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CHILD CARE BEHAVIOR HANDBOOK A helpful guide promoting positive behavior changes in young children in child care and early learning settings

PUBLIC HEALTH – SEATTLE & KING COUNTY CHILD CARE HEALTH PROGRAM Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

ACKNOWLEDGEMENTS This second edition of the Behavior Handbook builds on the first edition, copyright © 1994. We acknowledge and appreciate the work of those who made that first edition possible. Lenore Rubin, PhD Child Psychologist Child Care Health Program Public Health – Seattle & King County We would also like to thank those who shared their time, talents, and expertise to make this second edition possible: Child Care Health Program, Public Health – Seattle & King County Cathy Fritz, RN, BSN, Child Care Health Program Supervisor Nancy Couhig, MS, RD Anne T. Curtis, MSPH Adrienne Dorf, MPH, RD Ellen Flamiatos, RN, BSN Kari Fisher, MPH, RD Robin Kenepah, RN, BSN Robin Laurence, MS, RN Cheryl Nakagawara, Health Program Assistant II Shannon Roosma-Goldstein, RN, BSN, MPH

Community Partners Charlotte Jahn Donna Weston, PhD Cam Do Wong Linda Albert, PHN

We especially wish to thank the many child care providers and families who have shared their questions and concerns about children’s behavior with us.

Second Edition 2010

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

TABLE OF CONTENTS INTRODUCTION …………………………………………….…………………………………..….....9 THE BASIC CONCEPTS DEFINED Attachment and the Developing Brain ……………...………….…………...………..……12 The Importance of Play ……………………………………………………..…………..…..17 Classroom Environments ………………...……….……………….………………...……..21 Media Influence ……………………………………………………………..………...….....23 BEHAVIOR AND DEVELOPMENT Infants – Ages Birth to 12 Months ………...………………….…………..……..….….....27 Early Toddlers – Ages 12 to 24 Months ……………………………………............…....31 Toddlers – Ages 24 to 36 Months ……………………………………………………......33 Pre-school – Ages 3 to 5 Years …………………………… .……….……….................35 School Age – Ages 5 to 12 Years ……………………………..………….…............…..37 BEHAVIOR CHALLENGES Relationship Informed Discipline ……………………………………………………...….39 Reasons Children Might Misbehave ……………………………………………………...43 Challenging Behaviors ………………………………………………………………….….45 Aggressive Behavior ………………………………………..…………………..….45 Attention Deficit Hyperactivity Disorder (ADHD or ADD) .. …………………..…47 Autism Spectrum Disorders (ASD). ……………………….……………………...48 Babies Who are Difficult ………….…………………………………………….....49 Bi-polar Disorder ………………….………………………………………………..50 Biting ……………………………..……………………..……………………….....51 Cerebral Palsy ……………………………………………………………….….....54 Depression ………………………………………………………………………....54 Encopresis ……………………………………………………………………...….55 Feeding Challenges …………………………………………………………….…56 Picky Eating Habits ………………………………………………………..56 Emotional Stress …………………………………………………………..57 Emotional Eating …………………………………………………………..57 Pica ………………………………………………………………………….57 Mineral Deficiencies ……………………………………………………….58 Sensory Integration Issues ……………………………………………….58 Food Allergies and Exclusions ……………………………………….…..58 Hyperactivity and Sugar ……………………………………………….….59 Fetal Alcohol Spectrum Disorders (FASD) …………………………….………..59 Hearing or Vision Challenges …………………………………………………….60 Lying ………………………………………………………………………………...61 Whining ……………………………………………………………………………..61 Oppositional Defiant Disorder …………………………………………………....61 Sexual Behaviors ……………………………………………………………….....63

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

HELPING CHILDREN WITH PROBLEM BEHAVIOR Developmental Considerations ………………………………………..………………......69 How Children Develop Social Skills……………………………………………..……………..70 Problem Solving Guide………...….…………….……………………………………………...71 Tools – Useful Techniques ………………………………………………………………….….72 Transition Planning….……………………………………………………………….……….….73 Using a Structured Behavior Plan ……………………………………………………............75 SPECIAL CIRc*msTANCES Children at Risk ……………………………………………………………………………..…..79 Child Abuse ………………………………………………………………………..……79 Children in Foster Care …………………………………………………………..……80 Children Living in Shelters ………………………………………………………..…...81 Children Impacted by Trauma ………………………………………………….….....82 Disasters ……………………………………………………………………………..….84 Divorce ……………………………………………………………………………..……84 Grief and Loss …………………………………………………………………….…....85 Stress …………………………………………………………………………………....88 Effects of Stress Upon the Body …………………………………………..….89 How Do Children Show Stress ……………………………………………..…89 Sleep Problems ………………………………………………………..90 Eating Problems …………………………………………………….…90 Feeling Problems ………………………………………………….…..90 Thinking Problems ………………………………………………….…90 Military Families: The Stress of Separation …………………………….…...91 COMMUNICATING WITH FAMILIES All Kinds of Families ……………………………………………………………………………94 Parent - Teacher Relationships …………………………………………………………. …..95 English Language Learner Families ………………………………………………………….97 Working with Interpreters ……………………………………………………………………...98 Working with All Families ……………………………………………………………………...99 Working with Americans with Disabilities Act (ADA) Families …………………………….100 Working with individual Families …………………………………………………………….101 Infants and Toddlers …………………………………………………………………101 Pre-School Children ………………………………………………………………….102 School Age Children …………………………………………………………………102 TEACHER STRESS – TAKING CARE OF YOURSELF The Demands of Child Care ………………………………………………………………….104 The Importance of Your Feelings ………………………………………………….………...105 SEEKING HELP AND MAKING REFERRALS Professional Services …………………………………………………………………………111 Where to Find Help …………………………………………………………………….……...112 Washington State County Public Health Departments …………………………….……....113 Offering Continued Encouragement ………………………………………………….……..115

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

SAMPLE FORMS Child of Concern Check List ……………………………………… …………………..…119 Behavior Observation Tool …………………………………………………………….....121 Child Conference Summary ………………………………………………………….…...123 Sample Letter to Health Care Provider ……………………………………………….…125 SAMPLE HANDOUTS Coping with Traumatic Events 10 Tips to Help Children Manage When Disaster Strikes……………………………………………………………………….….127 Helping Your Children Recover from Stress - Advice for Parents …………………….129 Feeling, Thinking and Doing Go Hand in Hand ………………………………….……..131 REFERENCES ……………………………………………………………………………………....133 PARENT HANDOUTS Welcome To The Toddler Room …………………………………………………….……135 Sibling Rivalry ……………………………………………………………………………….141 Toilet Training ………………………………………………………………………………149

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Introduction Caring for children is complicated and important work. It is complicated because there are many parts involved in establishing relationships with children and their families. You are asked to promote the emotional well-being of the children in your care, help them be successful in school, make friends and work well with others. You are often a source of parenting advice for families. The goal of this handbook is to provide support for child care professionals by providing information that will enable you to address classroom concerns and establish a warm and nurturing environment for all of the children in your care. Beginning with infants, developmental needs and strategies for helping children with behavior challenges will be discussed. The theme of the handbook is about relationships - how to establish warm and supporting relationships with the children and the families you serve; relationships that promote emotional well-being for everyone. The child care centers of today “grew out of a welfare movement to care for immigrant and working class children while their impoverished mothers worked” (Scarr & Weinberg, 1986, p.1140)1. The Federal Government sponsored child care during WWII because mothers were needed to work and support the war effort, not because of interest in children’s development. Since that time, the number of children in care has risen. In 2006, 50% of Washington State children five and younger were in care outside their home. In 2000, The Committee for Children wrote “From Neurons to Neighborhoods” reviewing the body of literature on child development.2 This review highlighted the importance of early nurturing relationships in the development of children. Much of what children learn about themselves and the world comes from receiving warm, nurturing care from consistent caregivers who are responsive to their needs. From birth (and maybe before), infants form attachments to their close caregivers. Through receiving kind and understanding care, babies learn to think of themselves as able to socialize and get along in the world. Self-esteem, selfcontrol, and values all get their beginnings in those important early relationships. There is a growing body of evidence about the importance of connections in protecting children and families from the stress of poverty and other negative experiences. Child care centers are places where parents have the opportunity to be supported, make connections with other parents and their community, and to learn about how best to understand and support children. What is the role of those who care for children outside the home? Research indicates that quality childcare is very important especially for children who may have stress in their family life. In January 2006, the National Institute of Child Health and Development (NICHD) Study of Early Child Care and Youth Development released its findings from a major study on child care arrangements and children’s development. The report found positive connections between quality child care and cognitive and social development. Since the publication of this and other studies, stakeholders in the child care community have begun working to increase the number of quality child care programs. The work you do is of vital importance to the future of children and we at the Child Care Health Program value your contribution to children’s lives. 1

Scarr, S and Weinberg, M. The Early childhood enterprise: Care and education of the Young. American Psychologist, 41, 1140-1141. From Neurons to Neighborhoods: The Science of Early Childhood Development. National Research Council Institute of Medicine. Jack P. Shonkoff and Deborah A.Phillips, editors. National Academy Press, 2000.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

THE BASIC CONCEPTS DEFINED

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Attachment and the Developing Brain Attachment refers to the strong and loving bond established between an infant and his primary caregiver. This connection is established through warm and nurturing care that is responsive to the needs of the infant and allows for good communication between the adult and infant. We all form attachments throughout our lives but here we are focusing on early attachments that support the healthy development of children. Warm, supportive and nurturing attachments are very important to a child’s development. In 1978, a researcher named Mary Ainsworth began trying to understand an infant’s relationship with his primary caregiver (Mother). She developed a plan that would allow her to look at how a baby manages the comings and goings of his primary caregiver. Her plan was called the strange situation. After playing awhile, the mother left the room briefly and then returned. Ainsworth observed the baby’s reaction to his mother’s departure but also looked at the “reunion” behavior when the mother returned. She observed the baby’s ability to use his mother as a secure base from which to explore, his reaction to an unfamiliar adult, separation anxiety, his ability to be soothed by a stranger, and his reaction to the reunion. The baby’s behavior was used to assess the quality of the mother-infant attachment. Ainsworth classified the infant-mother pair as either having a secure attachment (55-65%), or an insecure attachment.3 Why were the findings important? Ainsworth’s findings were important because of the correlation between the quality of attachment and the child’s later development. Pre-school children who were securely attached as babies were rated as more socially and cognitively competent than their insecurely attached peers. Since Ainsworth’s work, other researchers have looked more in-depth at assessing and understanding attachment. It is widely accepted that quality early care and nurturing relationships are vital to a child’s well-being for the rest of their life. Infants and young children with secure attachments feel safe using their caregivers as a secure base from which to explore the world. This ability to explore, play, and interact with the environment promotes both intellectual and emotional growth. Can the quality of attachment change over time? Are there other things that impact attachment quality? The quality of a child’s attachment can change over time, especially if families are impacted by poverty, illness, or other events that cause major family stress. Likewise, attachment can improve as families become less impacted by stress or as a parent’s psychological well-being improves. Cultural conditions must also be considered when looking at the quality of attachment. For example, some cultures may value and support an attachment that encourages dependence while others encourage independence. The “dependant” attachment may appear insecure but is appropriate and normal in that culture.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

What role do child care professionals play in attachment with the children in their care? The National Institute of Child Health and Development Early Child Care Research Network (NICHD, 1997, 1999)4 looked at infant’s attachments as related to child care attendance. More than 1300 infants and their mothers participated in the study. The study found that attending child care did not contribute to the insecurity of a child’s attachment. However, infants who had insensitive care at home and then had poor quality child care, long hours in child care or more than one child care arrangement had more insecure attachments. Infants “at-risk” for insecure attachment that attended quality programs and were allowed to establish warm and nurturing relationships with their caregivers did better than their “at-risk” peers who did not have the benefit of quality care. Quality child care is especially important to infants with insecure attachments. The opportunity to establish a nurturing bond with a primary caregiver helps children become secure. Young children in poor-quality child care score lower in tests of cognitive and social skills compared to their peers in quality programs (NICHD Early Childcare Research Network, 2005).5 Child care providers, especially those caring for infants and young children must establish warm and nurturing relationships with those in their care. Child care providers must work to insure that children are receiving quality care. Reaching licensing standards is not indicative of quality child care. Child care providers can assess their program by using the National Association for the Education of Young Children (NAEYC) standards. Over the last ten years much has been learned about brain development. From the moment they are born, babies use their experiences to develop brain connections. These connections last a lifetime. By the age of 3 the weight of a child’s brain has almost tripled! (BrainNet)

“Experiences are like food for the brain. A rich diet of love and healthy stimulation

causes the brain to grow and flourish. A positive environment nourishes the child’s innate intelligence and allows her unique gifts to blossom.” (BrainNet)

Central to a baby’s development is its attachment to its caregivers. Warm, nurturing and responsive care fosters secure attachments. Babies who are securely attached learn to manage their feelings, cope with stress and see themselves as competent. Caregivers play an important role in supporting development by meeting a baby’s needs and establishing a nurturing relationship.

4 NICHD Early Child Care Research Network, The Effects of Infant Child Care on Infant Mother Attachment Security. Results of the NICHD Study of Early Child Care. Child Development 68:860-879. 1997 5 Child Care and Child Development: Results from the NICHD Study of Early Childcare and Youth Development. NICHD Early Childhood Research Network, 2005. Guilford Press.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Babies who are reliably nurtured begin to develop an inner way to understand their experiences. Loving attentive care helps babies establish good feelings about themselves. From those positive feelings and a regular pattern of nurturing care, babies also begin to develop a sense of regularity and an understanding of patterns, which allows for later ability to understand cause and effect. The groundwork for self-regulation begins with reliable nurturing care. What is self-regulation and why is it important? Self-regulation refers to a person’s ability to manage themselves with regard to feelings, behavior, and ability to pay attention. You can think of it as an internal thermometer that children regulate as necessary. The ability to selfregulate is important because it allows children to focus on learning cognitive as well as socialemotional skills. A child who is overwhelmed by feelings cannot control their behavior or focus on learning new information. Relationships are the most powerful teaching tool for learning self-regulation. If we think again about infants, reliable nurturing allows them to organize their inside experience. They can nurture themselves as they have been nurtured. When occasional frustration occurs they can self-regulate and cope with the frustration. Language is also important for helping children develop this ability to self-regulate. Before children can use words themselves, they are able to understand language. Sometimes, they cannot use language effectively to talk, but can put words to their actions. Self-talk helps children cope when their feelings are strong. For example, sometimes toddlers with aggressive behavior will gain more self-control as their language skills increase. They can better communicate with others and themselves. If children have been lovingly cared for and the words they hear about themselves have been positive, they are more likely to use positive self-talk and are more likely to develop the self-regulation skills needed for play with friends. Cognitive readiness to learn cannot be separated from social-emotional readiness. The kinds of skills that allow for school success are primarily good self-regulation skills. Kindergarten children must be able to control themselves so that they can follow class routines, get along with others and pay attention. These school readiness skills are much harder to achieve and much more important than learning the ABC’s or how to line-up. Supporting babies in child care Fostering secure attachments with the babies in your care is of primary importance. Keep attachment in mind when problem solving for babies who have difficulties. Babies require familiar and consistent care and do best with one primary caregiver. Contented babies play happily as they show their curiosity about the world. Insecurely attached babies spend little time engaged in play and may seem distressed much of the time.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Welcoming new babies into your program Babies 3 months and younger usually do not have visible stranger anxiety. However, it is best for all babies, even those that appear ‘happy’, to have a gradual introduction to care whenever possible. Set up a schedule with the baby’s parents. Over the course of at least 1 week allow the baby and parent to visit together. The baby will have a chance to become familiar with the child care provider and the environment before being left for an entire day. This will help ease adjustment issues. See page 27 for more information about babies.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

The Importance of Play How children learn and show others what they are thinking

“Play gives children a chance to practice what they are learning. They have to play with what they know to be true in order to find out more, and then they can use what they learn in new forms of play.” Fred Rogers of Mr. Rogers’ Neighborhood Many of us are familiar with the saying; “play is children’s work.” x

What does that really mean?

How important is play and why?

How can we use our observations of children’s play to get a better understanding of a child?

Can play help children with their social-emotional growth?

As we watch children play, we are watching children teach themselves many things about their inside and outside world. The infant, who watches her spoon as she repeatedly drops it to the floor and giggles as her parent makes a game of repeatedly picking it up, is giving herself a science lesson (gravity). Practicing back and forth interaction with her parent helps to build social skills. Toddlers, with their need to climb, give themselves a different perspective as they view their world from the top of the play structure. As they achieve success, up and down become real ideas. Pre-school children build tall towers and begin to understand the need for a strong base and balance so their structures don’t topple over. Building the tower with friends provides a lesson in how to work with others and the special pride of accomplishment that comes with working together. School age children play more highly organized games with complex rules, learning to work as a group.

The ability to spend time playing socially with others, using different materials and exploring one’s environment, is central to a child’s emotional well-being. A child who lacks the ability to play may be of concern. Consult your Public Health Nurse for ideas about promoting cooperative play.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Developmental Stages of Play This checklist can be used as a guide to identify behaviors that indicate a need for referral. Age limits are meant as a guide since children have individual differences. Hopefully, most play milestones will be reached by the end of the age limit given. For example, by age two a child should be reaching the play goals listed for age two. Items in bold type are particularly important as they may indicate a need for referral.

Birth to 4 months

Four to six months

Six to nine months

Nine to fifteen months

Fifteen to eighteen months

Interested in looking at your face. Looks toward you when you speak. Imitates (you stick out your tongue, baby attempts the same). Smiles at you when you smile. Follows toys and shows interest in bright objects.

Shows pleasure when interacting with you. Smiles easily during play with you. Coos and babbles. Reaches for toys.

Smiles and giggles during play. Coos and babbles in response to your words and face during play. Enjoys shaking a rattle to cause the sound.

Responds with smiles and laughter to playful actions. Enjoys playing peek-a-boo and other social games. Makes syllable sounds like “ma, da, ba, na, ga”. Turns toward you when you call them by name. Crawls, stops to play and explores. Enjoys handing toys back and forth with others. Points or uses gestures to get your attention. Begins to use and understand at least three words such as “mama, dada, or bottle”. Gives clear and understandable messages during play to involve you in the play. Can play “naming games” like show me your nose, eyes, mouth. Starts to enjoy simple pretend play like talking on a toy phone. Enjoys dumping toys and putting them back. Can roll a ball back and forth. Enjoys playing with a variety of toys. “Talks” during play.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Eighteen months to two years

Two to three years

Three to five years

Young school-age children

Older school-age children

Continues to enjoy pretend play. Enlarges their play area but checks back to see if you are paying attention. Enjoys playing with push or pull toys Enjoys imitating parent’s everyday behavior like talking on the phone or cooking. Gives clear understandable cues about how they want to play with you. Begins to enjoy scribbling with crayons. Begins to enjoy simple puzzles. Enjoys playing side by side with friends. Likes being read to and likes to hear the same book many times. Begins to play with blocks and other building materials. Likes to play pretend games that may include friends. Have ideas about their play, for example, “I am building a house”. Enjoys games and play with caregivers.

Play becomes increasingly social. May develop preferences for playing with particular friends. Imaginary play is more interactive and complicated. Use of building materials in play becomes more elaborate. Enjoys different kinds of play experiences. Uses words to give clear messages to adults and children about how they want to play. May feel sad if a friend does not want to play.

Enjoys playing organized games but may “forget” the rules. May start to have a preference for kinds of play. Still enjoys pretend play. Enjoys testing physical skills with races, climbing, etc. May become upset if they lose games. Most of their time is spent interacting and playing with peers.

Enjoys playing organized games with firm rules such as baseball or monopoly. Can play with peers for long periods of time without becoming upset. Can lose games without becoming upset. May dislike playing with younger children and sometimes may be unkind. May have trouble navigating groups of friends (excluding, etc.). Does not use age or size advantage to be unkind or “bully” other children.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Observing Children at Play Watching infants and children at play provides you with a window on the way they understand their inner and outer world. It gives you important information about their development. For example, children who have had a scary experience may play out the experience over and over again. After the collapse of the World Trade Center many children played by building towers and then crashing into them with airplanes. The children were trying to understand what happened and were showing adults what was on their mind. This play began to change and disappear as children were reassured about their safety and helped to understand what happened. Children who have had much trauma in their young lives often have trouble playing, or their play is limited to the same thing over and over again. You may notice older children who have an especially hard time playing with their peers, or infants who may seem withdrawn or too upset to engage in play. Observing problems with children at play lets you know that intervention is needed. Looking at the way infants and children play should be a routine part of your observations. When you are concerned about a child’s behavior it is important to observe their play. Play observations will help you make a plan to support their development.

Learn More: Children’s Play: The Rotts of Reading by Edward Zigler, Dorothy Singer, and Sandra J. Bishop-Josef A Child’s Work: The Importance of Fantasy Play. by Vivian Gussin Paley. The Power of Play: Learning What Comes Naturally by David Elkind Playful Parenting by Lawrence Cohen

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Classroom Environments Classroom environments are very important for both teachers and children. The word environment, used here, refers to both the physical space and the atmosphere that exists in the classroom. The physical environment provides structure that allows safe exploration, cognitive growth and challenge. The atmosphere or psychological environment of the classroom is made up of all the relationships and social interactions that occur. The physical and psychological environments go hand-in-hand. For example, if the physical environment of the toddler room has few opportunities for climbing or large muscle activity, the teacher may engage in more negative commentary as the toddlers try to climb on unsafe objects. Climbing is typical for this age group. A good environment is designed with the developmental needs of children in mind. When children’s needs are met through the environment or the curriculum, the teacher is better able to support a child’s social-emotional growth. Child care programs are communities. Communities thrive when everyone, adults and children, are respected and appreciated for their contributions and shared values as well as for their differences. All community members should expect kind and understanding words and help when they need help. For children this means that teachers are thoughtful and responsive to their needs. When children need help with behavior, relationship informed discipline (see page 39) strengthens the child’s relationship with caregivers. Here are some things an observer might see in a quality childcare class room: Physical Environment x

Age appropriate materials are available that reflect the child’s developmental needs.

Materials are accessible, checked for necessary repairs, and well-maintained.

The classroom has defined areas of interest such as a book area, a kitchen play area, etc.

New materials are introduced that build on the developmental progress of the children.

There are opportunities for outside play.

Lighting is pleasant and ample.

Psychological Environments x

Teachers spend time at floor/eye level with the children.

Teachers know and understand the children in their care.

. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Teachers work to have a warm relationship with both children and families.

Teachers engage in conversation about the child’s experiences.

Children know the teacher’s name rather than using “teacher.”

Voices are calm.

Teachers problem solve out loud to address concerns.

A problem solving approach is used with everyone.

Children feel safe because consistent routines are maintained.

Transitions are supported and go smoothly.

Children are able to play free of interruption and form close friendships with each other.

Children are comforted when they feel unhappy.

Discipline is relationship informed. (see page 39 Relationship Informed Discipline)

Learn More: Designs for Living and Learning: Transforming Early Childhood Environments by Deb Curtis and Margie Carter Environments for Learning by Eric. P Jensen (2003) Unsmiling Faces: How Pre-schools Can Heal. Lesley Koplow, Teachers College Press, 1234 Amsterdam Ave NY, NY. 10027 (2007)

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Media Influence

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Media Influence Television and its Effect on Children Many families are concerned about how television viewing affects young children. The first two years are important years in the life of a child, physically, mentally, and socially - a time the brain develops rapidly. During this time the specific brain connections associated with many skills are developing. Recent brain research and other studies provide evidence that television viewing affects children in many ways Television is a passive activity. Young children/ are not developmentally ready to benefit from even the best of television or video programs. American Academy of Pediatrics (AAP) research indicated that the fast-paced action features of children’s television programming may be a contributing cause of attention disorders in children. Overall, higher levels of television viewing correlate with lower academic performance in school, especially in reading. Children who sit in front of a television set are being deprived of the opportunity to engage in social play and interaction with others. They need sensory-rich experiences that will enhance their emotional and intellectual growth. Children need self-directed, imaginative play to develop problem solving abilities and an understanding of their world. Infants need an environment that is responsive to them. They need to bond emotionally with caregivers who smile, talk, sing and engage actively with them. Television can’t provide that kind of interaction. Television in an infant care setting is a distraction to both caregivers and infants. Young children learn best by doing and being active. This is the sensory-motor stage of learning. A well-rounded program of activities for infants and toddlers can be a rich experiential learning opportunity. Children need to investigate their surroundings using all five senses. They need to feel, see, hear, touch, and taste the world around them to make sense of it. Reading books, singing songs, or playing finger games allows children to explore and encourages creative play and curiosity. Story telling can be expanded to include events in a child’s life. A well-thought-out preschool program has little need for “television time.” If you do decide to show a video or turn on the television set, remember: x x x x x x

Select age appropriate videos and limit viewing. Children cannot distinguish between fact and fantasy. Talk about what the children have seen. Violent programming is never appropriate for children. Research has shown that viewing violent programs may encourage aggressive behavior in children. Too exciting or adult theme television is not appropriate for children. Television should not be used as either a reward or a punishment. News reports can be troubling for children even if they do not appear to be watching the adult news program.

Learn More: Parenting Well in a Media Age: Keeping Our Kids Human by Gloria DeGaetano and Diane Dreher (2004) www.truceteachers.org

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

BEHAVIOR AND DEVELOPMENT

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Infants – Ages Birth to 12 Months As caregivers of infants, it may be hard to imagine that little babies are beginning their education. What could babies be learning as they gaze at their caregiver and nurse, or suck on their bottle, or gently drift off to sleep? Recent advances in understanding the connection between infant experience and later development have allowed us to understand that learning begins in infancy. Important groundwork for development is laid during those early years. For example, when an infant is hungry, cries, and is fed, important messages are conveyed. The infant feels comforted as their feelings of hunger disappear. The infant begins to know that their cry brings help and comfort. Soon they will stop crying when they hear a caregiver’s voice reassuring them that food is on the way. Babies who are reliably nurtured begin to develop an inner way to understand their experience.

Loving, attentive care helps infants establish good feelings about themselves. From these positive feelings and the regular pattern of nurturing care, infants also begin to develop a sense of regularity and patterns which help them understand cause and effect. The groundwork for good self-control and social emotional health begins with reliable nurturing care. Over the course of 12 months most infants: x

Learn to roll over, sit up, and crawl. Some babies are walking while others are able to “cruise” as they hold on to a sofa. They can grab objects and explore toys and other things in their environment.

Start to babble. Their babble increasingly begins to resemble language.

Have a social smile by the age of 2 months.

Get increasingly better able to communicate their needs to caregivers. As they pass 6 months, they may protest when a toy is taken or when their caregiver leaves their presence. They can reach for something and use gestures to let you know what they need.

Love to engage in back and forth play with their caregivers. They enjoy playing “peek-aboo” and other games and can laugh and giggle.

Show a definite preference for their primary caregivers and may have ‘stranger anxiety’.

Do well with familiar routine and notice when routines change.

Use caregivers as a secure base as they begin to explore, often checking in for “re-fueling.”

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

What you can do: x

Establishing a welcoming ritual that may include receiving information about the baby’s evening/morning at home followed by a short welcome song.

Allow infants to be sad and say goodbye with your support.

Help parents develop goodbye rituals with their babies. For example, a goodbye song sung on the way to childcare followed by three kisses goodbye, or a wave out the window.

You can provide parents with a small book with pictures of the infant room, teachers and activities that parents can read to their baby at home.

Establish a goodbye ritual that can include giving parents information about the infant’s day and a goodbye song.

At the end of the day limit time infants spend in ‘containers’ so that when they transition to their car seat they are ready to sit with less complaint.

Interventions for infants: x

All intervention plans should begin with careful observation and connections with the child’s family. Let parents know that you are their partner in trying to work on a solution to improve the baby’s contentment in child care.

Gather information about the baby’s home life and schedule. Look for any patterns that may arise at home or in care. For example, does the baby have more difficulty or do better at certain times of day? What is happening at those times that might be affecting the baby’s well being?

If you notice patterns, try to make changes to reduce stress during those times. For example, if you notice the baby has an especially hard time when her primary caregiver goes on a break and the break occurs when the baby is sleepy, modify the break time to during the baby’s nap or before sleepiness becomes a factor.

Look at your environment. Is it quiet (no background music etc.)? Is the lighting harsh? Are there warm and inviting places to sit?

Look at staffing patterns. Does the baby have one primary caregiver most of the time? Does the caregiver feel ‘in tune’ with the baby? If not, might another caregiver be a better match? Can the caregiver be supported to better understand the baby’s temperament and cues?

Ask parents to bring comfort items from home. Even the familiar smell of a parent’s clothing can bring comfort.

Speak and sing to babies in a calming manner. Remember to talk with babies to let them know what is going on even if you think they don’t understand. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Do not try to distract babies from their unhappiness. Instead sympathize with their misery, let them know you understand they are feeling sad and you will be with them until they feel better.

Increase your knowledge of infant development and cues to better serve the infants in your care.

Enlist the aide of outside professionals like your Public Health Nurse or Infant Mental Health Specialist to make further suggestions.

Learn More: What to do for a fussy baby: A problem solving Approach, by Janet Gonzalez-Mena, Young Children, 2007 www.zerotothree.org

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Early Toddlers – Ages 12 to 24 Months The Shift to Toddlerhood Toddlers are explorers. Their bodies let them walk and their hands can pick up small objects, push buttons, and push their friends! Even though they show strong feelings, they don’t always know what they feel or why. Toddlers are a joy to be with because they are little “sponges” soaking up information about everything they see and experience. They are not as dependent as infants and are interested in making choices on their own. Toddlers still need the close relationship with their caregivers. Caregivers of toddlers need special skills. They must help toddlers feel safe and secure as they explore both the environment and themselves. Caregivers must be especially sensitive to toddler feelings, helping them cope with the disappointment and frustration that comes from the hard work of learning about their world and managing their place and themselves. Over the course of 12- 24 months most early toddlers: x

Begin to develop empathy.

Actively explore their environment as their general motor skills increase.

Expand their vocabulary from 1 word labeling to using 2 words together.

Use simple words to describe feelings.

Expand their understanding of the range of feelings they experience.

Need help with understanding their feelings.

Need help with angry or frustrating feelings.

Need help to cope with disappointment.

Make repeated attempts to understand their environment.

Are at a critical age and still require a nurturing caregiver who understands their particular needs.

Need caregivers who provide a secure base and who respond consistently in a kind and supportive way.

Like to point with their finger and have caregivers name things.

Make good eye contact with caregivers and let them know what they need.

Begin to have the ability to play symbolically, for example: they can “pretend talk" on the telephone; or, “eat” a play banana.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

What you can do: x

Review the suggestions for infants as many apply for this age group.

Since toddlers are “little scientists”, provide a safe environment they can explore and use to develop their newly learned motor skills. x Talk, talk, talk. Use language to talk with the children about what they are doing, what their friends are doing. Model yourself after radio sports commentators who provide minute by minute information about what is happening. However, make sure you listen when toddlers talk to you! x

Begin using a problem solving approach. Rather than give toddlers feedback like “It is not nice to hit your friends”, provide specific information about situations in a gentle way. For example, “Sam, I see you wanted the toy Isabella has. Let me help you solve that problem another way since we don’t hit each other.” Hold the toy while you comfort Isabella, commenting that you are sorry that Sam hit her. When she is calm, help Sam ask for the toy. Help Sam to understand Isabella’s plan to share the toy. Perhaps she will give it to him when she is finished playing. Help Sam find another toy while he waits.

Label feelings for the toddlers as they work on getting along with peers.

Be sure to keep working on establishing a positive relationship with the toddlers as they still need the closeness to feel safe and secure.

Learn More: The Happiest Toddler on the Block by Harvey Karp www.zerotothree.org Infants and Toddlers: Development and Curriculum Planning by Penny Deiner, 2008 The Emotional Life of the Toddler by Alicia F. Lieberman, 1995

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Toddlers - ages 24 to 36 months As toddlers move past 24 months to the age of three, tremendous development takes place. By the time they are 3 years old they will be speaking in sentences and capable of conversation, capable of naming preferences for foods or activities. After the age of 24 months toddlers are more organized in the way they play and their motor skills are more reliable. They are interested in watching adults and copying the things they see. For example, toddlers like to participate in making dinner by doing what they see their caregiver doing. They may want to cut vegetables, wash dishes and pour juice and they can manage many simple tasks. Like younger toddlers they still need a great deal of help understanding their feelings and controlling their behavior. However as they move closer to 36 months they begin to show greater emotional understanding and self-control. Older toddlers also gain pleasure from friends, beginning to share with others and may even have preferences for playing with certain children. They still require a warm and nurturing relationship with the important adults in their lives; however they grow increasingly able to play on their own for some of the time. Over the course of 24 - 36 months most toddlers: x

Can run competently.

Can build a 2 block tower.

Can speak in sentences.

Enjoy pretend play.

Want to imitate the adults in their lives.

Express their disappointments and can be consoled.

Insist that a toy is theirs and theirs alone!

By 36 months they can play and share. What you can do: x

Continue to provide an enriched environment that includes opportunities to pretend to be an adult.

Support toddlers self control by providing safe choices.

Support toddlers social skills by teaching problems solving strategies as things arise in the classroom (see page 70).

Remember that they are not yet pre-school children.

Stay out of control struggles.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Pre-school - Ages 3 to 5 Years By the time children are 3 they have many self-help skills and enjoy playing with their peers. Children in this age group are able to separate from their primary caregivers and participate in the routines of pre-school programs. Often they have strong feelings and their feelings may change from one moment to the next. They enjoy learning new skills and are hands on learners. This age group has been identified as ready to benefit from group activities because of their ability to “listen” and play with friends. Self-regulation skills: x

They are usually toilet trained.

They use physical solutions to solve problems less frequently.

They speak in clear sentences and can tell you a story.

Their play is more organized and includes fantasy/pretend play.

They have strong feelings that can change suddenly and can sometimes manage their own feelings.

They show empathy toward others.

They like to play structured games but can’t always follow strict rules.

They use self-evaluation and can compare themselves to others.

They have better understanding of cause and effect in regard to actions and feelings.

Three year olds sometimes can be harder to work with than toddlers as they assert their independence and autonomy. In just three short years children have learned to walk and run, have conversations and follow simple directions. This age group is developing self-help skills; they enjoy having some say in their clothing choice and other choices throughout the day.

What you can do: x

Use curriculum that develops from children’s interests and gives them opportunities to learn about their world.

Promote a feeling of community by having everyone contribute to the well being of the class through jobs. Have children clean the class together rather than only being responsible for their play area.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Set up times when children can work together in small groups. Provide them with the experience of being listened to by peers.

Emphasize a problem solving approach with the children so that teachers do not need to impose their solutions on problems between children.

Have established times for parent-teacher conferences so that information can be shared and any problems addressed.

Learn More: Unsmiling Faces: How Pre-schools Can Heal by Vivian Gussin Paley and Lesley Koplow Positive Discipline: A Teachers A-Z Guide. Solutions for Every possible Behavior Problem by Jane Nelsen, Roslyn Duffy and Linda Escobar

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

School Age – Ages 5 to12 Years Children age 5 to 12 are mostly reasonable, understand cause and effect, and use that understanding to get along in the world. This age group has managed to learn many self-control skills. Children in kindergarten through third grade should be able to focus attention on mastering new skills like reading and writing. Children in fourth, fifth and sixth grade are practicing their newly acquired skills and begin to develop interests in social activities outside school. This is a great time for children to develop interests and learn about themselves and their world. x

Children starting school face new challenges in dealing with the wider world. School age children need ways of coping with these challenges. Unlike young children, this age group has more internal ways of coping with life. By age 10, most children have an adaptive set of behaviors for managing emotion (Kliewer, Fearnow, & Miller, 1996). For example, if a friend gets mad and refuses to play, they may cope by doing some self-talk about what happened. They may tell themselves that they didn’t want to play anyway, or that they can find another friend, etc. This age group begins to better understand both their feelings and the feelings of others. Their ability to understand feelings and show empathy increases.

School age children can engage in games that have set rules (baseball, Monopoly) and may become quite angry when the rules are not followed.

They are very interested in being an accepted member of their peer group.

They have ways of coping with their feelings that go along with their increased thinking skills.

They have good self-control so that physical means to reach goals should not be necessary.

School age children may compare themselves to their peers and face self-esteem issues around comparisons. They need support around their own self- assessment.

They can do some problem solving on their own.

They are very interested in having “best friends”, being in clubs as social groups. These groups do not have to be exclusive.

This period of development is referred to as “latency,” partly because issues around sexual development are not especially prevalent.

One can observe boy/girl preferences in play choice and socializing.

Sometimes children in this age group have social difficulties that can be very upsetting such as deliberately excluding children or bullying. Some children have had long term behavioral difficulties such as using physical force to solve problems. They may not have received help, so by the time they are in school-age care, their problems are worse.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

What you can do: x

Get to know the programs and personnel of the school your children attend. Understanding the culture of the place where children spend their day is very important. Children come with expectations based on the culture of their school. For example, children who attend a school with an open concept and reliance on choice may have trouble with following rules in your after school program. Likewise, children who are in structured programs may expect rules.

Establish relationships with the school to facilitate the exchange of information about children. Inquire about the exchange of information and any parental permission needed so that you can talk with school personnel. You can also request an Individual Education Plan (IEP) from the parent if the child is receiving services.

Establish a culture in your program that makes it hard to be a bully or use intimidation or unkind behavior toward others. Role model kindness, never tease children and discuss feelings openly.

Have some activities that involve cooperation to be successful rather than competition. For example, work in teams to solve a math problem or play group games.

Review peaceful problem solving skills routinely. This may require repetition and modeling.

Although this age group is peer directed, they still need adults to be strong role models. Make sure you give each child some time to be close to you.

Children who have self-control problems and use physical means with others have probably heard a lot of advice about getting along with others. If they continue to have difficulties, the advice hasn’t worked. Use some of the tools listed on page 72. Find ways to say things differently. For example, if a child is usually reprimanded for hitting others, tell the child that their hand forgot the rules - then speak to the child’s hand. You may feel you are making light of the child’s bad behavior or not taking things seriously, but the truth is that the child has had the usual feedback and it has not helped. Try to give them information that doesn’t further their negative view of themselves.

Children with long histories of hearing “bad” things about their behavior live up to that expectation.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

BEHAVIOR CHALLENGES

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Relationship Informed Discipline Often when we hear the word “discipline”, we think of punishments like time-out or other negative tactics. The definition of discipline really means “to teach” and young children do need teaching about getting along with others and solving problems. The best way to help children learn to behave is through understanding and establishing a warm relationship. Here is an overview of ways to begin to support a child’s ability to learn good behavior and self-control. x

Take active steps to promote good social behavior in your classroom. These steps may include using a social skills curriculum, using language that supports selfunderstanding and role modeling positive problem solving.

Encourage children to solve their own problems and participate in classroom management decisions.

Establish pro-social behavior. For example, the children can be responsible for cleaning the general classroom rather than just cleaning up the area or materials they used.

Usual and customary discipline refers to current best practice in early childhood education.

Establish a classroom that has a developmentally appropriate and interesting curriculum that reflects the culture of all the children served.

Provide opportunities for choice and curricula that enhance the development of self-control and social skills.

Provide children with the comforts of routine and structure that are flexible in meeting the needs of a wide range of children.

Work to establish warm and nurturing relationships with each child in the classroom and with parents and colleagues.

Role model problem solving by letting children hear you negotiate with your peers and solve problems out loud.

Establish a relationship with the child’s parents by greeting them warmly every day. Let them know that you are working as a team with a plan to help the child improve in behavior. Do not ask parents to use punishments or rewards at the end of the day to help their child improve their behavior. Let them know that the best thing they can do is to create a warm and nurturing home life for their child.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Be honest with yourself about the challenges the child may present to you. Does it feel as if this child is “pushing your buttons”? Is there something that makes this child especially hard for you to like? Talk about your feelings with another adult. Ask another teacher to tell you about something they may like about the child. Write a list of 5 positive things the child can do.

Observe the child using the form provided on page 121 or develop your own observation form. Ask another teacher to complete an observation form. Use these observations to notice any patterns that occur in the child’s behavior. For example, are transitions stressful? What time of day does the behavior occur?

Develop a plan for helping the child learn better ways of behaving. For example, if transitions are a problem, support the child by planning transition time. Can the child stay behind to help the teacher and then join their peers?

Think about the possible reasons behind the child’s difficulties so that a responsive, effective plan can be made. For example, does the child seem to be trying to make friends but does not have the skills to join a group? Is the child sensitive to their personal space being challenged?

Monitor the child’s progress through continued observations. Continue making observations so you can see if your plan is helping the child.

Change plans as necessary after each review. Include parents in updating any plan.

When you think of correcting a child’s behavior, consider how your plan affects your relationship with the child. Children thrive when they feel understood not judged: sympathetic understanding of problems allows children to see themselves as capable of developing different ways of meeting their needs.

Always address children with respect and a calm voice.

Avoid physical interventions.

See yourself as a learning partner not a power figure.

Allow children to have a voice in solutions to their problems.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Reasons Children Might Misbehave Misbehavior in young children can be in the “eye of the beholder.” All of us have ideas about how children should behave and these ideas can vary from person to person and from one culture to the next. For example, adults have different tolerance for noise levels so raised voices may not be noticed by some but may be intolerable to others. We may have been raised to think that children should obey adults regardless of what they are asked to do, while others feel children should have a choice about what they do. Most of us agree that behavior that directly impacts the rights of everyone to be safe and secure requires intervention. Behavior that is selfinjurious also requires intervention. This section covers our current understanding about a wide range of issues that can get in the way of children using self-control. Understanding children’s behavior is the first step to creating positive solutions to problems. Developmental Misunderstanding Sometimes children’s behavior reflects their developmental stage rather than a problem in their development. For example, it is “normal” for toddlers to experiment with their environment and repeatedly do things they have been told not to do. As child care providers, we understand that they need an environment that is safe for them to explore. They use their caregiver as a safety base often looking back to reassure themselves that they are safe. Sometimes this developmentally appropriate “check back” is interpreted as trying to engage the teacher in a negative interaction, especially when the child is doing something they have been warned against. Rather than seeing the child as failing to listen, the child should be understood as wanting to learn more about her world. She is trying to understand if she will get the same information every time. So rather than saying “I keep telling you not to touch that”, the caregiver might say, “I see you there and I know you remember that we can’t play with that. Let’s read a book.” Other developmental misunderstandings happen when programs do not meet the developmental needs of the children in that age group, or have expectations that are not consistent with children’s developmental level; for example, a toddler room organized like a pre-school room or academic expectations of pre-school children that would be more appropriate in kindergarten. Understanding the developmental expectations of the children in your care is very important. Teacher knowledge about child development is associated with quality care. Temperament and Biological Factors All children come ready to learn, to be nurtured and to form close relationships with their caregivers. Children also come with a variety of temperaments or other biological factors (language delay, sensory motor integration disorder, and attention and hyperactivity disorder) that might make it hard for them to have positive interactions. Sometimes temperament causes a caregiver to have difficulty in reading a baby’s cues and, as a result, both the baby and caregiver withdraw. Some children are “slow to warm up” and need extra time and attention before they can function in a group setting. We all know children we describe as overly shy, children who are stressed if their routine is changed, children who are unpredictable, or children who seem to have their “motor running” all the time. Children’s temperaments can be an asset or create a problem depending upon how they are nurtured. In developing a behavior plan it is Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

important to take these issues into account so that you are not pushing a child beyond their capabilities. Two and half year old Samantha challenged her teacher because of her refusal to follow class routines. Even when given ample warning about a coming transition like cleanup time, Samantha responded by sitting down and refusing to speak. The teacher threatened a time-out for Samantha’s non-compliant behavior. This only made things worse as Samantha screamed and tried to run out the door. Samantha’s parents told the teacher that Samantha was always shy and slow to accept change. The teacher and Samantha’s parents developed a plan that addressed Samantha’s behavior and temperament. In addition to giving Samantha ample warning about transitions, the teacher would sit quietly by her side and describe the transition. She would let Samantha know that she could take her time if needed. Slowly Samantha began to participate in class room transitions. Unmet Needs Sometimes children come to child care as if they “woke up on the wrong side of the bed”. Nothing seems to go well; they are irritable, cry for little reason and seem generally unhappy. There may be immediate problems troubling the child. Are they sleepy, hungry, feeling ill or sad? Is something happening at home? Was there an unhappy experience on the way to child care? Before adding to the child’s distress by commenting on their misbehavior, take a moment to reflect and offer solutions like a snack, rest, quiet game or hug. Five year old George came to pre-school clutching a bag of potato chips. When the teacher asked him to put it in his cubby, he kicked the teacher. Rather than discipline George, the teacher said “George, I can see those chips mean a lot to you.” Through his tears, George told the teacher that his dad had given them to him. His dad was in the Marines and was leaving for Iraq that afternoon. The teacher let George know she understood that he missed his dad. George felt understood by his teacher. He gave her a hug and a heartfelt apology. George was able to have a good day at pre-school.

Difficult Life Experience Chronic, major stress causes serious problems for infants and children. Infants and young children are works in progress: their brains are developing circuitry and structures that are fundamental to their well-being for the rest of their lives. When they are raised in high stress situations like chronic exposure to violence (domestic or community) or poor nurturing, high levels of hormones are activated in their bodies to help them deal with the stress. This can impact their ability to have self-control, their memory skills, and other aspects of development. They require special understanding and planning. Even after the stress has ended, the memory of a challenging experience remains. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

If stress has been part of a young child’s life for long periods of time, the child may have behavior problems that are a result of the stress. For example, infants exposed to family violence or infants who are cared for by a mother who is a victim of violence, will probably not get the sensitive responsive care they need to develop good social-emotional skills.

Siblings, Denesh, age seven, Mareen, age five, and Leroy, age two were enrolled by their foster parents in child care. Their previous home life was troubled by serious domestic violence and neglect. Denesh seemed to be adjusting well to child care. However, he often asked to check in on his siblings, especially if he thought he heard them crying. Mareen had trouble with transitions, often running out of the class room. She also hit other children if they had a toy she wanted. Leroy seemed really tired, choosing to sleep most of the time. His play was limited to running a car back and forth on the table. Their teachers worked hard to form relationships with the children. They approached them with calm and reassuring voices. Denesh was allowed to visit his siblings throughout the day. Slowly the children adjusted to care and increased their participation in the class room activities.

What do I do when I suspect a problem? Child care providers are in a special position because they have experience with large numbers of children grouped according to age. When you have an infant or toddler who does not seem to be achieving the milestones described earlier or who seems “different” than or “behind” their peers, it is helpful to begin the observation and referral process described on page 109. Child care providers can provide observations about children’s behavior and information about developmental milestones to families. You are often one of the first to notice problems and to begin a process for help. However, it is not the child care provider’s responsibility to diagnose children. For example, even if you suspect the child is autistic because he is similar to another child with that diagnosis, it is not a good idea to share that with the child’s parents. Straightforward observations of the child’s behavior are your best contribution to the referral process.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Challenging Behaviors Aggressive Behavior Aggression toward others and “not listening” are two of the biggest challenges in child care settings. Safety is of primary importance in child care. Intervention is needed when the safety of children and teachers is threatened because of children who hurt others or have trouble following rules. As discussed throughout this handbook, there are many things that may be getting in the way of children behaving as we would like. You may have tried the usual interventions including talking with the child following an aggressive incident, time-outs, or leaving a play area. Often children with these problems do not respond to this type of discipline. It is better to try to understand the child and make a plan to help them gain the skills they need to have better self control. Teachers sometimes report that children only do things when the teacher isn’t looking at them. They assume the child is “manipulative” and does things he can “get away with”. In general, the idea that children are manipulative is not helpful. That is an adult way of thinking about children’s behavior and does not lead to building solutions. In fact, some children use their teacher as an “inside voice” and rule reminder. Eye contact with the teacher allows them to remember rules and use self-control. The teacher’s work is to help the children get an “inside voice” on their own to develop the skill we call self-control. Sometimes children who are aggressive toward others are interested in forming relationships and playing with friends but are unclear about how to make friends. They need support around social interaction. To help them learn how to play well with others you can: x

Set up play situations with the child and another child and support the children as they play. For example, Hank has trouble cooperating, which leads to aggression. Ask Hank and a friend to play with blocks. Position yourself close to Hank as he plays. Comment about how they are cooperating and working well together. If Hank begins to have problems, stay with him and suggest solutions. Comment on Hank’s feelings. Let him know you understand he feels disappointed when his ideas are not respected or if he doesn’t get the toy he wanted immediately.

Integrate cooperation and problem solving practice into your curriculum. Create a classroom atmosphere where everyone is respected and everyone works together to solve problems.

Use a social skills curriculum. Practice problem solving and getting along with others at circle time.

Use the Relationship Informed Discipline suggestions, page 39. Be careful not to reprimand children by calling their name across the classroom. Move to where children are having trouble and intervene.

Do “instant replay” about the problem. For example, John hit Gail because he wanted her to move out of his way. You can “replay” by asking John to practice asking you to move.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Work with children who have aggression problems and offer encouragement as they try to use their new skills. Sometimes children will try to use their “words” to solve a problem, but if the other child does not respond quickly, they may go back to aggressive behavior. Acknowledge the child’s try at a peaceful solution

Let parents know your plan to help their child be more successful. Ask them to do some role playing at home and practice problem solving skills. Ask parents to talk with their child about their school friends. Feeling familiar with their friends can help children be more comfortable. A homemade book about class routines can also help, see page 74.

Notice trouble spots during the day and make a plan for those times. You may notice that children with self-control problems sometimes have trouble choosing and sticking with an activity. They may do better with a structured activity. If you notice this happening, help the child stay within a play area by offering enthusiastic ideas about ways to extend the play. “Wow, I see you built a car, but how about a garage! I think this car needs a garage!”

Find the child’s strengths and help them contribute to the classroom. For example, one child who had trouble with self-control also was very interested in insects. Invite him to give a talk about insects at circle time and share his “bug” collection.

Children who have trouble listening and following classroom rules may have other difficulties. You may try many techniques for improving a child’s behavior without success. Children who have these troubles need caregivers who reach out and find the time to work on establishing positive relationships. Learn more: Unsmiling Faces:Pre-schools that Heal by Leslie Koplow Positive Discipline: A teacher’s A to Z guide, Revised 2nd edition Hundreds of Solutions for Every Possible Classroom Behavior Problem by Jane Nelsen, Roslyn Duffy and Linda Escobar Books for children: Andrew’s Angry Words by Dorothy Lachner Mean Soup by Betsy Everett The Chocolate Covered Cookie Tantrum by Deborah Blumenthal How Do I Feel? /Cómo me siento? (Good Beginnings (UN Buen Comienzo) Series) Editors of the American Heritage Dictionaries Hands Are Not For Hitting by Martine Agassi Alexander and the Terrible, Horrible No Good, Very Bad Day by Judith Viorst When Sophie Gets Angry, Really, Really Angry by Molly Bang

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Attention Deficit Hyperactivity Disorder (ADHD or ADD) This disorder is one of the most commonly diagnosed disorders in childhood. Most often it is diagnosed when children are in elementary school. In young children it is hard to diagnose because they are still learning self-control, how to get along with peers and how to manage the demands of a pre-school program. All children may sometimes have trouble focusing and behaving but, in children with this disorder, the behavior or inability to pay attention may be severe. Sometimes children are described as if they “have their motor running” all the time. Because of their inability to pay attention, they may miss out on learning both social and academic information. A child with ADHD or ADD may: x

Have trouble paying attention and day dream a lot.

Be easily distracted and seem not to listen.

Forget things.

Be in constant motion.

Squirm or fidget, or have trouble staying still.

Talk too much.

Have trouble playing quietly alone or with others.

Act or speak without thinking or remembering class rules.

Children with ADHD or ADD may be treated with medicine to help improve their ability to pay attention. They may also need additional classroom support to help them thrive. You can help them increase their attention span by enthusiastically showing them how to expand their play.

Four year old Derek was in constant motion, going from one activity to the next. After a brief time, Derek started to leave the Lego table. The teacher got his attention by saying enthusiastically, “Derek, I think we could add a tall, tall tower to your Lego building”. Derek returned to the table and played for a few more minutes. Over time, the teacher helped him increase his attention span and he was less likely to roam about the room.

Learn more: Young Children with Attention Deficits by Steve Landua and Cecile McAnich in Young Children, 1993 www.cdc.gov/ncbdd

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Autism Spectrum Disorders (ASD) Autism spectrum disorders are a disability caused by problems with the brain. It is called a “spectrum disorder” because it is seen as one disorder that can range from mild to severe. Asperger’s disorder is no longer a separate category on the spectrum and is used to refer to mild autism. The study of autism took a step forward when researchers were able to use magnetic resonance imaging (MRI) to look at the brains of children and adults with this disorder. Looking at brain functioning has allowed researchers to learn about how children and adults with autism process information compared to those without the disorder. What they have found is that the brains of autistic individuals have a hard time making connections from one area to the next. Connections between areas of the brain are very important since almost everything we learn relies on all parts of the brain working together. For example, children with Autism are programmed to learn language differently than typically developing children. Autistic children see each word as standing alone rather than together in logical sequences with meaning. Children with autism may have a period of time when they have “near normal” development and then seem to lose skills (between 12 -18 months), or they may seem to have trouble from birth. Infants and Toddlers with ASD may: x

Be unable to imitate movements; for example, sticking their tongue out in response to you showing them the movement, or clapping their hands after you illustrate how to clap.

Not reach up their hands to be lifted or seem stiff when you hold them in your arms.

Make limited eye contact.

Repeat actions many times, excluding the world around them.

Have unusual reactions to sensory experiences.

Be unable to point at objects or follow your gaze as you name things in the environment.

Be unable to respond to their name when called, even when looking in your direction.

Be unable to do pretend play like “talking on the phone.”

Have a language delay.

Find it difficult to understand the feelings of others or themselves.

Have extreme reactions to changes in the routine.

Children with mild autism, sometimes referred to as “high functioning autism” or a “non-verbal learning disability.” (Asperger’s syndrome is no longer used to describe this group of children.) Children with mild autism may: x

Have problems in social situations similar to those of children with autism.

Have language and cognitive skills that are usually within normal ranges.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Have interests in unusual topics and are overly involved with the topic (train schedules, whales, etc.), to the possible exclusion of other things.

Be interested in playing with peers but have poor social skills.

Have good language skills but are unable to have back and forth conversation.

Julia, an experienced infant caregiver, was concerned about 12 month old Rajeev. She was concerned because Rajeev was able to spend a lot of time alone, seemingly staring into space. When interrupted, Rajeev sometimes responded by looking at her face for a few moments. He rarely smiled though he did not seem unhappy. Unlike the other one year olds in care, Rajeev did not seem to notice or care when a stranger entered the room. He seemed happy to see his parents at the end of the day. His parents were not concerned about his development. With the parent’s permission, Julia consulted with the Public Health Nurse (PHN). Following the consultation, Julia, with the help of the PHN, wrote a letter to Rajeev’s medical provider describing Rajeev’s behaviors at child care. The parents agreed to share the letter at Rajeev’s 1 year check up. The medical provider diagnosed Rajeev with ASD and was able to refer Rajeev to early intervention services. Rajeev did very well over the next year with the help of his early intervention specialist and was later able to enter kindergarten without special services.

Learn more: www.firstsigns.org www.cureautismnow.org www.cdc.gov/ncbdd

Babies who are difficult Given the demands of group care, it is not always possible to hold one baby throughout the day. However, these babies have an important need to have that security. It is not because they are held “all the time” at home. Whenever possible, hold the baby or allow the baby to sit in your lap as you talk to her about the other teachers/children in the classroom. Let her know when you will be putting her down and what is going to happen next. For example, “I know you feel best when I hold you, and I will be back after I change your friend’s diaper, give him his bottle” etc. Talk to her during the separation. When you return, remind her that she was safe and that you are back. After one month if the baby continues to cry most of the time, further intervention may be needed.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Babies who seem irritable and inconsolable Cranky babies sometimes have issues around eating and sleeping that may need to be addressed to improve their mood. Work with the parents and the baby’s medical provider to gain an overall understanding of the baby’s physical needs and plan needed changes with the parents. These babies may benefit from environmental changes like less visual stimulation or lower noise level. The baby’s primary caregiver should approach the baby in a calm and thoughtful manner, letting the baby know what is going on around them. Try to identify possible soothing items like soft textured blankets or a pacifier. Ask the parents to bring in soothing things from home like a blanket the baby has used when being cuddled by a parent. Sometimes familiar smells can be soothing.

Babies who may not adjust to group care Some babies have a hard time being part of a group for long hours. These babies are irritable most of the time and spend very little time engaged in play. When you have a baby that has been unhappy for over one month, it is time to look more closely at the situation. x

Does the baby have one primary caregiver while in your care?

How long is the infant’s day?

Is there family stress?

Are there clues about the infant’s temperament that might help you make a supportive plan?

Follow the suggestions above for irritable and inconsolable babies. If the baby continues to feel unhappy, meet with the parents to explore other solutions. Some possible solutions are: shorten the length of time in care per day, change to a family home versus a center, or encourage family visits during lunch breaks. Learn More: www.zerotothree.org

Bi-polar Disorder Bi-polar disorder remains a somewhat controversial and uncommon diagnosis in children and will not be covered here. If you have concerns or questions, consult with your Public Health Nurse or medical provider. Learn More: Bipolar Disorder in Children and Teens: A Parents Guide www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Biting A young child who bites other children for little or no apparent reason can frustrate child care providers, upset the child who was bitten as well as the child doing the biting, and can anger the victim’s family. A parent may demand to know the identity of the "biter" and may even threaten to remove their child if the provider does not act immediately. This puts pressure on the provider to find a speedy solution. ` Biting occurs most often among toddlers (13 to 24 months old) and should be considered “normal" behavior. Toddlers use their mouth as a tool for exploring their world. They are learning to tell the difference between food and non-food items. Many of their teeth are in and they are starting to use words for the first time. Toddlers who bite may be trying to get a point across when they don't expect their words to work, or they may simply be expressing frustration. Toddlers may bite for many reasons: x

Because they are teething.

Out of frustration.

From loneliness and anxiety.

From lack of language.

A need for personal space.

Child care providers can help reduce the risk of biting by creating a calm and caring environment. Classroom activities should be developmentally appropriate and include several of each favorite toy. Over stimulation because of overcrowded spaces or high noise levels can contribute to stress in children and increase biting. One study found most bites occur early in the day and late in the afternoon. Children may be especially tired at these times and lose some self-control. Young children should be watched for signs of tiredness and restful activities planned. Reduce the risk of biting. Look at the environment: x

Bright lights, noise levels, or overcrowding can overwhelm toddlers.

Provide age appropriate toys.

Provide room to play and several of the same favorite toy. If a biter is teething, provide safe biting materials and opportunities to bite. Make a biting box with teething toys and offer them frequently. x Provide support to both the biter and the child bitten with extra hugs and understanding. x

Shadow children who bite. Help them make other choices when you see them attempt to bite. For example, if they lean over to bite a friend, stop the biter, and suggest they shake hands or touch their friend on the arm.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Add words as you show the child another behavior choice. “You can say hello to your friend by shaking hands”.

Help all the toddlers learn to say “no” to their friends when something happens that they don’t like. Occasional or first time biters should be treated in a calm and caring manner. Attend to the needs of the child who was bitten. Let the biter know that you understand he was trying to say something to his friend. Try to ease the situation by showing the child how people should treat each other. For example, a provider can enlist the biter's help in caring for the injured child. Providers should note the details of the incident in order to discover what may have motivated the child to bite. For example, does the child appear stressed, angry, or sad? Is there a time of day or activity when biting occurs most often? Toddlers who bite frequently need immediate attention. Tend to the children involved as you organize your observations about the child. Take time to observe the entire class. Consider not only biting incidents, but the child's general weIlbeing, range of expressed feelings and ability to play.

30-month-old Lily bit other children reportedly with "no warning". She appeared sad and lonely most of the time. Every attempt to stop the biting failed. The methods that were tried included ignoring her while tending to the victim, using time out, giving stickers for “no bites” and telling her that biting hurts others. The parents reported that Lily never bit at home and they shed little light on Lily’s child care troubles.

With help from their Public Health Nurse, the staff developed a plan to deal with Lily’s adjustment to child care. Her biting gradually stopped when the teachers began checking with Lily several times a day, asking her how she was feeling. The child care staff realized that Lily’s biting was the way she expressed sadness and frustration. Though the child care center was calm and not chaotic, ten-hour days seemed too long for Lily. The director suggested to the parents that they try to shorten her time at the center. When Lily bit, teachers comforted her along with the injured child and enlisted her help in caring for the injured child. She became less stressed, felt more understood and began to bond with the staff. Lily’s story shows the importance of understanding the whole child rather than focusing on one behavior. Biting, like all repetitive aggressive behaviors, is often the result of a child’s attempt to communicate. Young children may need more information. Picture books showing feelings with simple words might help a toddler understand their own feelings and also the effect biting has on others. Older children (3 - 5 years old) may be confused about the way others have previously reacted to their biting; so they bite, then wait to see the adult’s reaction.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

For children 4 - 5 years old, biting is more unusual and can indicate a range of problems. For some youngsters, it can be an aggressive act that has persisted because it makes the child feel momentarily “powerful” and safe. These children need to be helped to feel powerful and safe in other ways.

Ask for help from the Public Health Nurse if you are having difficulty with a repeat biter. Occasionally, the problem may require additional outside assistance.

Some warning signs that a child might need outside help: x

Biting persists for 1 month or more.

The child seems surprised that biting hurts his friends.

The child bites the same child repeatedly.

The child bites frequently and seems unhappy.

Children who hurt others need understanding, support, and kindness most when they behave in a most unlovable way. Providers sometimes feel they will be rewarding hurtful behavior if they tend to the biter as well as the child bitten, but that is an adult viewpoint. Children are not interested in hurting others. They appreciate understanding and compassion when they are showing their more troubled feelings. Share any plans with the biter’s family so that they can reinforce behavior choices at home. Tips for preventing biting: x

Provide sensory/motor experiences and teething toys.

Teach acceptable ways to express frustration and the use of assertive skills.

Use children’s books or puppets to teach positive social behavior.

Play picture games of things okay to bite and not okay to bite.

Provide activities that calm and relax children such as water/sand play, back rubs, relaxing music.

Learn More: For Children: Teeth Are Not For Biting (Best Behavior Series) by Elizabeth Verdick and Marieka Heinlen www.zerotothree.org/chewonthis

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Cerebral Palsy Cerebral Palsy is used to describe a “group of disorders that affect a person’s ability to move and keep their balance and posture as a result of an injury to parts of the brain, or as a result of a problem with development”. Cognitive (thinking) skills remain intact. Sometimes the ability to speak is affected because of motor skills, but this is not a sign of lower intelligence, just difficulty with the motor expression of words. Children with cerebral palsy can be delayed in reaching motor or movement developmental milestones. Six month old Samantha entered child care at 3 months of age. Samantha’s parents did not indicate to her caregivers that anything was wrong with Samantha’s development but her caregivers were immediately concerned. When held in their arms, Samantha had trouble keeping her head up - her head would fall to one side. When offered a rattle, Samantha reached with one hand while her other hand was balled up into a fist. When her caregivers mentioned their concerns to Samantha’s mom, she immediately scheduled an appointment with her pediatrician. This was her first baby and she did not know Samantha’s motor skills were a concern. Samantha was enrolled in an early intervention program to help her reach her full potential.

Learn More: www.cdc.gov/ncbdd

Depression Infants and young children can suffer from depression. In infants it may be harder to identify because they cannot talk about how they are feeling. However, in both infants and children who are depressed, you may see the following: x

Frequent sad expression, crying or tearfulness.

Increased irritability.

Physical complaints (head or stomach aches).

Changes in sleep or eating patterns.

Tiredness or low energy.

Children, even pre-school children, may talk about self-destructive behavior and even wanting to die. Though a rare occurrence, pre-school children can be at risk for suicide and “threats” cannot be dismissed. Even if a suicide attempt is unlikely, children who express feelings about wanting to die need immediate intervention. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

For the past two weeks three and a half year old Grace seemed especially unhappy. She no longer played enthusiastically with friends, cried when little things went wrong and complained of various body aches. As her teacher thought about Grace, she realized that Grace had become increasingly withdrawn over the past six weeks. She remembered that Grace had said, “I wish I was dead”, when a picture Grace had made tore. Her teacher thought it was just a childish over-reaction to a small event but reported Grace’s comment to the center director. Grace’s mother was called immediately. The director provided the mom with resources for Grace, including a letter to Grace’s medical provider describing the behavior observed, as well as contact information about local mental health service providers. Grace was given an immediate appointment because of her statement about wishing to be dead. Grace and her family started treatment with a mental health provider and Grace began to improve. Her teacher noted that Grace seemed more playful and less tired. She stopped complaining about her physical symptoms and made no mention of wanting to hurt herself. Accommodations to the program were made to support Grace until she felt better.

Learn More: www.aacap.org Facts for Families: American Academy of Child and Adolescent Psychiatry Encopresis Encopresis is a word used to describe the problem of leaking stool. When the bowel becomes impacted with stool the child is constipated and unable to go to the bathroom, so loose stool leaks out. Most children with encopresis are school age. Sometimes children have this problem before they are completely toilet trained. The child may fear using the toilet because of painful bowel movements and may lose the ability to know when they have to use the bathroom since the usual cues are not there. Children with this difficulty may be unaware about stool leaking into their underwear and not know what to do. They may use “denial” to try to cope by refusing to acknowledge a problem, use the toilet or change clothes. Children with encopresis are most often treated with a regimen that includes stool softeners and diet. Depending on their age and psychological issues, various behavioral approaches may be tried. With support and the appropriate regimen, children improve. When the children entered their after school program Ms. Celia noticed that 8 year old James smelled of poop. Some of the children were holding their nose and pointing at James but James appeared not to care. He sat at the snack table as if he was carefree. Ms. Celia asked James to wash his hands before snack and as he went to the sink, Ms. Celia asked him to change his clothes. He complied. The teachers felt that James was refusing to use the toilet and “pooping in his pants” as a result. They were puzzled by his seemingly uncaring attitude toward the problem and toward being teased by other children. James went to see his medical provider who explained that James was not really “pooping” in his pants but rather had leakage because he was constipated. Severe constipation was a problem for James and he had learned to put off going to the bathroom since he experienced pain. His medical provider started him on a regimen to help his constipation and James gradually improved.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Feeding Challenges Children who are hungry may display symptoms that are mistakenly referred to as “behavior problems”. When a child hasn’t eaten for a while, his blood sugar level drops, resulting in a child who may appear sluggish, inattentive, or light-headed. A hungry child will have trouble following directions and may act irritable and fussy. Programs that offer breakfast to children who arrive without having eaten, and that offer snacks or meals every few hours, provide important fuel and nutrition to rapidly growing children and may avoid some potential behavior problems. Longterm hunger and food shortages may lead to decreased activity and a sense of apathy among children. Chronic food shortages may also lead to unusual eating behaviors among children, such as hoarding food or taking large portions of food that are eaten quickly. Support for a child who is hungry and food insecure: x

Offer reassurance that enough food is available and that there is time to eat until he is full.

Remind him that meals and snacks are offered every few hours throughout the day.

Watch carefully as he eats so that he doesn’t choke when eating or stuff his mouth with food.

Establish rules about food taken away from the table if hoarding or pocketing food is a problem.

Allow him to place some non-perishable food in a container to be stored in his cubby if he is extremely insecure.

Provide the family with referrals to food assistance programs in the community.

Picky Eating Habits It is normal for young children to develop picky eating habits at certain stages in their development. It showcases their increasing skills of discrimination between types of food and their increasing autonomy and independence. Toddlers may also go through a period where their rate of growth slows and they don’t need to eat as much as they did previously. Some children are also extremely sensitive to tastes and textures or may even be “super-tasters” and have an increased ability to detect bitter tastes in certain foods. A child’s temperament may also play a role in his or her willingness to try new foods. It is important to have clear rules and a division of responsibility in feeding young children. Division of responsibility means the adult provides the food and the child is responsible for how much, or even if he chooses to eat. The adult should not beg, badger, reward, or threaten a child to eat. Offer a variety of food choices, not just those that a child likes or will eat. Young children may need 10 - 15 exposures to a new food before it is accepted. x

Provide meals and snacks at regular intervals.

Offer a variety of foods at each meal or snack time.

Keep negative emotions out of the eating environment.

Maintain a positive eating environment so that meal times do not become a battleground Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Negative emotions around eating can have life long consequences.

Emotional Stress Even children suffer from emotional stress. Family problems, violence, death of a pet or family member, or disaster are just a few of the issues facing children today. Unfortunately, there are no magic foods that will relieve stress. The “fight or flight” response to stressful situations increases a child’s need for energy in the form of calories. Providing a balanced diet will help ensure adequate nutrients are available to support the increased energy needs. Stress may affect a child’s appetite in different ways: one child may lose his appetite whereas another child will develop a voracious appetite. Even during stressful situations for a child, it is important to be consistent in using the division of responsibility at meal and snack times. Allowing children to determine the amount and what food, or even if they choose to eat eliminates the battles for both the child and the provider about how much the child “must or should” eat. After the stressful time has passed, the child usually reverts to a more normal intake.

Emotional Eating During times of stress, parents and caregivers often promote emotional eating by providing sweets and other treats to entice the child to eat or as a means of “comforting” them. Usually this food is a concentrated sweet or favorite food high in fat such as fast foods. Food may also be used as a reward for “good” behavior. Using food as a reward or coping mechanism may contribute to obesity. Providing emotional support and reassurance to the child during stressful situations is a healthy alternative to focusing on food as a way to cope and may help the child learn other ways to meet his or her emotional needs and to develop healthy eating habits.

Pica Pica is defined as the practice of eating non-food items. Children with pica may eat dirt, clay, paint chips, chalk, coffee grounds, sand, toothpaste, or other items. Pica is sometimes associated with mineral deficiencies, such as iron or zinc. Pica is also more common with other conditions such as mental retardation, autism, or other developmental disabilities. If a child consistently eats non-food items, it is important to talk with the family about a referral to their health care provider who may want to check the child for iron deficiency or run other tests.

It is important to carefully supervise all children and teach them to distinguish between food and non-food items.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Mineral Deficiencies Some mineral deficiencies can influence a child’s behavior. Iron deficiency affects 2.4 million US children and is associated with behavioral and cognitive delays. An anemic child may act tired, irritable, sleepy, or cranky. Anemic children are also more susceptible to infection and more likely to become ill. Iron deficient children have a harder time concentrating on tasks and may perform poorly on tests. Iron deficiency also puts children at higher risk of lead poisoning. High lead levels cause neurodevelopmental disorders. It is extremely important to diagnose and treat iron deficiency anemia in children to improve their health and to offer protection from the affects of lead poisoning. A health care provider is in the best position to diagnose and treat iron deficiency in children. A deficiency of zinc may also have a negative affect upon a child’s attention span and development. Since the mineral zinc is found in highest amounts in foods of animal origin, it is seen more often in children who don’t eat meat and have a diet high in milk and fiber, which both inhibit zinc absorption. Zinc plays a role in many systems in the body involving digestion and metabolism. A zinc deficiency has far-reaching affects, especially for a rapidly growing child. Having adequate zinc stores in the body adds protection against the possibility of lead poisoning. Sensory Integration Issues Some children have difficulty integrating the sensory input from the environment into their lives because of differences in the way their neurologic systems work. These children may include those with autism or other developmental conditions. For these children, eating may present huge sensory challenges because they get overwhelmed by the smells, textures or flavors of food, or because they cannot handle the physical tasks associated with eating. Some of these children have been fed only from a tube or bottle and need a lot of help learning to chew and swallow solid foods. These children benefit from a team of specialists who can assess the problem and find solutions that provide adequate nourishment and help expands that child’s sensory experiences. Consultation with a Public Health Nurse or Nutritionist may be helpful for children who exhibit challenging eating behaviors. Food Allergies and exclusions Sometimes a parent will say that their child’s food allergies include behavior changes - “he gets hyper when he eats wheat”. If they ask you to avoid serving certain foods to their child, it is important to get a written statement from the child’s health care provider that lists the medical reasons for avoiding a particular food and suggests appropriate substitutions. There are some situations in which a child’s body is highly sensitive to certain food components - “my child can’t eat anything with yellow food dye #5”, for which they need an exclusion diet. Be sure to get proper documentation so you have complete information about how to follow the special diet that may be required.

Child care rules prohibit offering special diets for food allergies to children without documentation from both a health care provider and the parent or guardian.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Hyperactivity and Sugar In the 1970’s much attention was given to the connection between hyperactivity and sugar in “Why Your Child is Hyperactive” by Dr. Ben Feingold. The Feingold diet was one that eliminated the use of sugar and many additives commonly found in food. Most of the research studies on this diet have not found a link between the diet and improved behavior in children. Some studies even found that sugar had a calming affect upon children! Many health experts believe that the excitement around the event in which sugary foods are served is responsible for the behavior changes that some children exhibit. It is wise to limit sugary foods because they often are low in nutrient density and contribute little, other than calories, to a child’s diet. There may be no reason to completely restrict them from a child’s diet. Remember to brush teeth after meals or snacks, especially when they include a concentrated source of sugar Fetal Alcohol Spectrum Disorders (FASD) Children exposed to alcohol before they are born are at risk of a range of problems known as fetal alcohol spectrum disorders. Fetal alcohol syndrome (FAS) is a severe disorder that causes abnormal facial features, growth problems and central nervous system problems. Children with FAS may have a range of serious learning problems that lead to difficulties in school and with peers. You may also hear the terms fetal alcohol effect (FAE), or alcohol related birth defects. Children with these diagnoses have been impacted by pre-natal alcohol exposure but do not have all the problems of FAS. FASD are fully preventable - a baby will not have FASD if their mother does not drink alcohol while pregnant. Children with FASD may have: x x x x x x x

Poor coordination. Hyperactive behavior. Learning disabilities. Developmental problems. Mental retardation. Poor reasoning and judgment skills. Sleep and sucking disturbances in infancy.

Eight year old Sam was having trouble getting along with peers and following directions in his school age program. Sam had a diagnosis of FASD and was receiving additional help in his class. Teachers were frustrated by Sam’s seeming inability to remember the class rules even though they had repeated those rules many times. The school age program staff asked for permission from Sam’s parents to speak with his primary classroom teacher. The teacher was familiar with the challenges of teaching a child affected by fetal alcohol, knew the strengths Sam showed and was able to help the after school teachers make a plan to help Sam. Rather than rely on verbal information given when Sam had done something wrong, the after school staff made a series of picture cards showing the daily routine and expectations. For example, one card showed children lining up, one showed them washing their hands, etc. Sam was better able to follow routines using the cards and visual reminders. The after school staff also helped Sam by giving him practice partners during free play times. These older children practiced problem solving with Sam as issues came up during unstructured time. Understanding Sam’s strengths was central to helping Sam learn. Learn more: www.cdc.gov/ncbdd Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Hearing or Vision Challenges Hearing and vision loss can be caused by many things. Again, since early intervention is so helpful in assisting children to reach their full potential, early identification is important. Sometimes children experience hearing loss because fluid gets in the middle ear from allergies or colds. This can cause delay in learning language. A child may have a hearing loss if she: x

Does not turn to look at where sounds are coming from by 3 - 4 months of age.

Does not say single words like dada and mama by one year of age.

Looks at you when she sees you but not when you call her name.

Seems to hear some sounds but not others.

Infants and young children are examined by their medical providers for signs of vision loss. The signs of vision loss you may see with children in your care include: x

Closing or covering one eye.

Squinting.

Complaints about things being blurry or hard to see.

Blinking frequently.

Eyes that appear red, watery or swollen. The PHN was asked to observe two and a half year old Dajohn because he “had trouble listening”. His language skills were somewhat behind but seemed within the normal range for his age. His teachers described him as only “listening when he felt like it”. The teachers felt his difficulty in following requests was in part a function of his age, but they also felt something was “wrong”. When the PHN observed Dajohn, she noticed that he failed to follow directions that were given to the general class but did well when teachers approached him directly. The PHN referred him for a language and audiology (hearing) evaluation. Dajohn had a partial hearing loss that affected his behavior. Once this was understood, and teachers accommodated for his loss, his behavior improved.

Learn more: www.cdc.gov/ncbdd

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Lying Most childcare professionals become concerned about lying when children are in pre-school and beyond. Pre-school children may have confusion around reality and fantasy, between their thoughts and true events. Often when young children tell a “lie”, all that is necessary is to question the information and the child can clarify what they are presenting. In fact, it is not even meaningful to label pre-school children as lying. When school age children repeatedly present false information, it is a cause of concern. Challenging the child directly about the truth of their comment may not be the best idea. For example, if a child says they have a puppy after hearing about another child’s puppy, rather than saying ”I know you don’t have a puppy”, you can say “ I know puppies are wonderful and we all wish we had a puppy”! Children who continually give information that you know is not true may be young in their thinking, may be unsure about their social skills and may think poorly of themselves. They may also have other behavioral challenges. Rather than a judgment about their morals, they need behavioral intervention. Whining Parents and childcare providers have all experienced children who use a whining voice to communicate a need. Many of us remind children to use their “grown-up voice” if they want to be heard. This usually works in the moment, however, the child may soon return to using whining. It seems that children who whine may have the idea that they will not be heard so they immediately choose a nagging style of communication. Thank the child for letting you know what they need. Reassure them that you heard what they said and that you will listen. Five-year-old Jo was a frequent whiner. She stopped when prompted to use her grown up voice but would soon whine again. The next time Jo whined the teacher said: “Jo, thank you so much for telling me you need more glue. Were you worried I wouldn’t hear your words? I hear you.” Jo immediately stopped whining--she even looked startled. The teacher continued to respond to Jo in this way and her whining decreased and her social skills increased. Oppositional Defiant Disorder You may have children come to your program and be told they have Oppositional Defiant Disorder (ODD). This diagnosis is most often used with school age children. All children, and for that matter all of us, can be uncooperative and disagreeable. However, children with this disorder frequently behave in a hostile and defiant way. They have a pattern of hostile, uncooperative, and defiant behavior in relating to the world. Children with ODD may: x

Have frequent temper tantrums and angry outbursts.

Argue with adults frequently.

Refuse to follow rules. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Relate to others with upsetting or annoying behavior.

Seek revenge.

Exhibit mean behavior especially when upset.

Blame others for their problems.

Children with these problems may be especially hard to have in your program as they are used to relationships fraught with tension and unpleasantness; thus bring those feelings with them. Their oppositional behavior makes it very hard to enforce rules and make sure every one is safe. If you have children in your care with this disorder, avoid power struggles and giving negative feedback. Take a break if you feel stressed by the tension-filled interaction. Sally, a fourth grader in the Happy Valley after school program was described by the staff as a “handful”. From the moment she entered the after school program she challenged every rule. Sally refused to wash her hands, refused to sit at community meetings, and blamed other children when she was reprimanded for not following the rules. Sally had similar problems both at home and in her school program. She was recently diagnosed with ODD. The after school staff decided to make a plan to serve Sally as she had been asked to leave two previous programs. First, Sally would be greeted with a choice list like; (1) wash hands and eat snack, (2) go outside and play, (3) design your own choice. The staff thanked Sally for making a choice, even if the choice was (3) design your own choice. The staff refused to engage in negative conversations with Sally and used humor to moderate any discussion. When Sally blamed others for something, the staff supported her by saying “of course you would never want to ……, so I understand why you think your friend is to blame.” Sally and her parents were receiving additional support at home and gradually Sally’s behavior improved.

Learn More: www.cdc.gov/ncbdd

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Sexual Behaviors Physical closeness is essential for all humans, especially young children. Hugging, stroking, gently tickling and kissing help infants and young children learn how to love and express affection. Touching also helps build positive self-esteem and healthy sexual development. Appropriate touching helps the child experience pleasure and body acceptance in a trusting relationship. Children’s interest in sex is a normal part of development. They are curious about genital functions as they learn about body control and toileting. Sexual behaviors include the following: x

Grasping their own genitals.

Peeking at others and games of “show me.”

Touching another’s genitals.

Sexual Development

Birth to age one Babies explore and discover their body and genitals through play. They can experience pleasure. Boy’s penises have erections and girl’s vagin*s lubricate.

One to two year’s of age Children continue to explore themselves and to recognize gender identity. They learn the terminology for genitals and functions.

Two to three year’s of age Children are aware of genital difference between genders and can confirm gender identity. They start to imitate parental model.

Three to five year’s of age Children sex play with children their own age, e.g., playing doctor, house, or a game of “show me”. They experiment, through play, with different gender associated roles. They touch their own genitals frequently. They develop an attachment to the opposite-sex parent.

Five to eight year’s of age Children start to want more privacy. The degree of modesty depends on family values. They form strong attachments to same gender classmates and friendships become important.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Guidelines for all families and caregivers: x

Give children appropriate physical affection e.g., hugs, backrubs, and kisses.

Answer questions in simple accurate terms. Talk about feelings, values, and the facts.

Help children understand where babies come from, how boys and girls are different, and why people love and care about each other.

Teach children the correct names and functions of body parts, including genitals.

Wait until children show an interest before toilet training. Children are usually not able to control their bladder or bowels until they are 2 or 3 years old. Boys usually gain this control later than girls. Be gentle and patient in this process so children will learn that their genitals are a good and healthy part of their body.

Helping children understand that their body is a source of pleasurable feelings contributes to the formation of a positive sexual identity.

Set guidelines for public and private behaviors.

Teach children their private parts are those covered when they are wearing a swim suit.

Teach children to say ”no” if someone touches them in a way they don’t like.

Prevent children from seeing sexual acts of adults or watching it on television or video.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Guidelines for specific concerns: x

Grasping their own genitals, masturbation Tell the child you know it feels good but private body parts are only to be touched when you are in a private place.

Peeking at others Tell the child who is peeking that this is the private body part of another person and that their privacy should be respected.

Games of “show me” Tell the child who is doing the “showing” to keep his private body part to himself.

Touching another’s genitals Tell the children involved that this is the child’s special body part and is to be kept private. Teach children to say “no” if someone touches their private areas.

Use of bathroom words Set an example. Have clear rules about the use of obscenities, curses, or loaded language (name calling or “street” talk). Teach healthy expression of feelings and acceptable words to use. Accept feelings of frustration or anger but state that we do not use those words. If the child continues to use “bathroom” words then try using humor. When the child uses the word, pretend to “mishear” the word. For example, “did I hear you say duck? I like ducks”. Then move on to something else.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Indicator of possible sexual abuse Some indicators of possible child sexual abuse are listed below. Consult with your Public Health Nurse or other health care professional if you have questions. Consultation with Child Protective Services (CPS) is advised if you see any of these behaviors. Immediate reporting of suspected abuse is required by law in Washington and in most other states.

Physical Indicators x

Pain, itching or bleeding in genital or anal area. These symptoms could also indicate a medical problem such as a urinary tract infection, pin worms, etc.

Torn, stained or bloody underclothing.

Bruises on the inside of the thighs, legs or buttocks.

Behavioral Indicators x

Unusual or adult sexual behavior or explicit sex act knowledge. Unusual or inappropriate interest in person or animal genitals. Play-acting sexual behaviors such as oral-genital or genital-genital contact.

Sexual acts used as aggression, threats or bribes, “come on, let me do it and I’ll give you…..”

Talking about specific situations, “Uncle Joe told me not to tell, it’s our special secret,” or “Billy’s dad wears funny underwear.”

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

HELPING CHILDREN WITH PROBLEM BEHAVIOR

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Developmental Considerations To understand and encourage positive behavior it is necessary to be familiar with the developmental stages of children. You can then structure your program to provide positive learning experiences at each child’s developmental level. Age-appropriate materials and activities can actually prevent many behavior difficulties by reducing a child’s frustration or boredom. Hitting, biting, shoving and shouting are typical ways children use to express strong feelings. Over the ages of two and seven most children develop self control. A two year old may try to settle a dispute by hitting another child with a toy. A four year old is more prone to argue with the other child, e.g. saying “It’s mine!” As a provider, you help each child learn to share, recognize and understand their feelings, and play cooperatively. By eight or nine most children develop the social skills needed to help them play successfully in groups. Intervention may be necessary, however, when a child is overly aggressive, impulsive, or frequently engages in shoving, hitting, or biting. This is the time to develop a partnership with the family and work together to help that child develop positive social skills. Children identified with a special behavioral need (e.g., ADHD, ODD) should have a care plan to help them be successful in group care. Developmental landmarks do not occur at the same time for every child and can overlap. For example, a four-year old can have great small muscle control but be less mature verbally and socially. The Washington State Early Learning and Development Benchmarks divide development into five broad domains: x

Physical well-being, health and motor development (height, weight, health, ability to engage in daily activities)

Social and emotional development (emotional competence and ability to self-regulate and form positive relationships)

Approaches to learning (enthusiasm for becoming involved in learning, curiosity)

Cognition and general knowledge (ability to understand and think about the physical and social world around them)

Language, literacy and communication (understanding and use of language, ability to communicate needs)

Development is sometimes also assessed using the following areas; physical growth (weight, height, etc.), large and small muscle coordination, personal/social skills, emotional understanding, and language/thinking skills.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

How Children Develop Social Skills Understanding how children learn to behave and noting their reaction to the environment and the people around them can help you effectively teach social skills such as caring, honesty, cooperation, responsibility, etc. Young children learn through their senses. They learn by moving, listening, touching and feeling. Watching, listening, and relating consequences to actions helps children understand their world. Through the repetition of their own behavior, and the responses of others to that behavior, they learn what works for them. Learning styles are partially determined by ethnicity and culture. A child’s behavior should be viewed in a cultural framework. How is the child disciplined at home? Is aggressiveness reinforced because strength is valued? What are family goals? Does the family value passive behavior rather than active intervention? The term “social learning” describes the many ways people influence and change each other’s behavior. For instance, three-year old Susan learns that if she throws a toy and then herself on the floor in a tantrum, she will get some support. The provider has a choice about responding: She can say, “Pick up that toy. You know better than that”. Or she can say, “When you pick up the toy I will be over to help you,” and ignore Susan until the toy is picked up. The third way and the most helpful way is for the provider to respond by going over to Susan and talking about feelings and suggesting other ways to manage her feelings. The provider offers positive reinforcement when Susan’s behavior changes. All three responses get Susan what she wants adult support; but in the third response, the provider is helping Susan learn more appropriate ways to manage her strong feelings. Behavior management is primarily a teaching process rather than a control problem. In the example above: x

The provider identifies a problem (throwing the toy and tantrum).

The provider lets Susan know she understands how she is feeling.

The provider helps Susan discover other ways to “solve” the problem.

The provider notices when Susan’s behavior changes.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Problem Solving Guide x

Define the behavior or problem in a short sentence. “Jerry throws the blocks at Sarah whenever she comes into the block area.” Include only one behavior in the sentence.

Gather information: when, where, what is happening before, during, after the behavior occurs. Track the behavior for two or three days looking for patterns of behavior.

Create Ideas. Brainstorm possible solutions to the behavior or situation.

Invite the family to be a part of the solution. Respect their ideas about what would help their child the most.

Choose one or two ideas to try both at child care and at home.

Communicate the plan. Make sure everyone involved understands their role. Have a written statement of the plan to give to the parents and to the teachers (a summary of the child conference, decisions made, and everyone’s role in the plan).

Set a clear beginning and ending date. Monitor the plan.

Evaluate the plan. Meet with the family again. “How did the plan work?” “What was successful?”

Helpful Questions to Ask x

Why is this specific behavior a concern?

Where else does the behavior occur?

How long has it been happening and when did it start?

When and where does it happen? Is there a specific time or place?

Does it involve certain people?

What is the result of the behavior?

What has been done to help the child change his behavior?

Why do you think the child is acting or behaving this way?

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Tools – Useful Techniques When the usual ways of helping children improve their behavior fails, it is time to address problems in a different way. If you find yourself correcting the same behavior over and over again, it is time to think creatively about helping the child learn the skills they need to develop better self-control. The following section discusses some general tools for helping children learn and develop self-control and social skills. Role Playing and Practicing: A tool for helping children Sometimes we ask children to “use their words”; sometimes we intervene by letting children know their behavior is not “acceptable”. This is often not helpful and leaves children feeling distressed and confused. Young children learn by active participation and by watching adults. You can help children learn social behaviors like kindness and sharing by practicing and modeling. Here are some examples: x

Three-year-old Mary attempts to get a toy and hits her friend. You think Mary may be trying to play with her friend but does not know how to be social. She also does not know how to take a turn with a toy. Say, “Mary, I see you want to have a turn with your friend’s toy. Let’s practice what you can do. Say,’ friend can I have a turn when you are done’?” Help the other child respond to Mary’s question and support Mary if she waits for a turn by suggesting a waiting plan like another toy or activity. Praise Mary for her good solution to a problem. Help Mary make connections to her peers.

During morning choice time you find yourself struggling to keep the classroom running smoothly. Many children have social troubles and fight with their peers. You decide to do some role-playing at circle time. Using puppets, you re-play some of the troubles you noticed during choice time. As the puppets have problems sharing, you ask the children to make suggestions about how they can get along. Let the children role model solutions to the problems. Make this a part of circle time at least two times per week.

Two four year olds are struggling over using special game pieces that are in short supply. One child tells you he had the piece first and wants it back. Instead of telling the child to return the piece to his friend who had it first you say, “I see you both want to play with this piece. How shall we solve this?” Allow the children to design their own solution and practice the solution.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Transition planning Participating in child care requires that families and providers work together to help children master separation successfully. When separations are handled well, infants and young children gain a greater sense of security and trust. They are better able to participate in their day, form relationships and learn. Separation times include much more than the morning drop off. They include daytime transitions (from playtime to cleanup, lunch to nap, staff changes and end of day pick-up). The process of closing one activity and moving to another can represent a “loss” and increase feelings of insecurity for some children. Sensitivity to shifts in the day can be the result of a child’s past experiences with loss and separation, insecure relationships or even temperamental differences. You can help children having problems during transition times by providing understanding and support. Here are some examples: x

Four year old John often refuses to clean up after free play; and if asked to do so, begins flinging toys around the room. You have observed that John has great trouble during transitions throughout the day. You develop a transition plan for John. You let John know that you noticed it is hard for him to clean up and that he can watch you put things away. Ask John for advice about what to put away first, engaging him in the activity. Talk out loud about what you are doing, “I am putting the blue blocks here.” If part of the problem at cleanup is a child’s unhappiness about putting away something he worked on, try taking a picture or using nametags to put on their work (saving shelf, name labels).

Naptime can be a nightmare for staff. John refuses to rest on his mat, frequently calling out and disturbing the other children. He requires one-to-one care. Give John an after lunch job that he completes while the teachers settle down the other children. John enters a room of already settled children. During morning snack have a discussion about naptime with John and the other children. Brainstorm some ideas for having a peaceful time. Experiment with different sensory input for John - does he like gentle back rubs, no touching etc.

John does not keep his hands to himself during the transition to outside play. Give John something to keep in his pockets to feel (textured item) and remind him to use his hands to feel that. John can practice defining his need for personal space by practicing with other children about optimal distance. Children can stand on pictures placed on the line-up area so they are distanced from one another. Plan a transition activity that lessens wait time. Use a group activity so that the children do not need to line up at all. Toddler teacher Eileen is having difficulty with transitions. The toddlers become irritable and unhappy during routine transitions. The Public Health Nurse is asked to observe the program. The PHN notices that the toddlers have a great deal of trouble with transitions but also observes that there are far too many transitions throughout the day. Toddlers should have few transitions or changes in their day. They do best with an open-ended schedule where circle time is a choice, and cleanup is limited to two times per day at most. Reducing the number of daily transitions reduced the classroom stress and the toddlers’ behavior improved.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Learn More: 101 Learning and Transition activities by Bradley Smith and Adam Smith Homemade Books Most children in child care are exposed to stories and books. Sometimes it is useful to make a book for a child on a topic that might be a challenge. For example, if a child has particular trouble with routines, you and the child can work together to make a book about “My day in school”. Make a copy of the book for the parents so that the child can read about their day at home, reinforcing routines. You can make homemade books with children on any topic like getting along with friends, or how I share. Homemade Books to Help Kids Cope by Robert G. Zeigler, M.D. The Child Care Center as a Village When developing an individual behavior plan for a child, it is important to look at the resources around you, not only the resources in an immediate classroom. Home providers can also think about resources that may be helpful in supporting the children in your care. Routines and Rituals All of us rely on routines and rituals to provide structure and comfort in our lives. We know the days of the week by the appointments we have. We look forward to routines to reassure us that all is well. We rely on ritual to help us through difficult times and provide a “road map” for how to cope with life events. Infants and children also benefit from routines and rituals. Consistent daily routines allow children to be reassured that their parents will pick them up after afternoon snack. Rituals like “three good-bye kisses” help them to manage strong feelings when saying goodbye. If children are suffering with behavior issues, are there class routines that could be modified or added to help them? Are there any rituals that could be used to make things easier for them? For example, a first grade student began to have difficulties in her after school program as soon as the first parent came to pick up a child. Her anxiety about being picked up increased so that she became angry and fought with teachers and peers. The teachers developed a routine and ritual that allowed her to cope with her feelings. Following afternoon snack (as parents were then likely to start picking up children), this child was asked to keep a list of parents as they entered, checking off each child as they went home. She was taught how to greet parents and to remind them of any important information. This routine gave her a way to cope with afternoon transitions. Her parent was asked to have a going home routine that could be repeated every day. The mother chose to read one book with the child before they left for home.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Using a Structured Behavior Plan Teachers often do not have time to organize an entire behavior modification plan for their classroom. “Star Charts” are not especially effective in changing children’s classroom behavior. Develop a plan that supports children with concerns and helps you build relationships. Let the parents know that you are making a plan to help their child develop new skills and plan to include them in the process. Share the plan you develop, ask for their input and keep them informed about how things are going. Remember, young children cannot benefit from discipline that happens long after the problem behavior occurred so parents cannot effectively discipline their child at pick-up time. The best thing parents can do is to have a loving, low stress and supportive home environment. Parents can role play with their children and help them gain new skills and ways of coping. x

Choose one behavior you would like to see change. For example, if you are most concerned about a child’s aggression toward others, choose that behavior.

Let the child know you are going to help them learn how to get along better with their friends. Tell them you will help them by reminding them every half hour about getting along without hitting friends.

For every half hour they remember to use their hands for playing, not for hitting, you will give them a token (Poker chip, star). When they earn 3 tokens, they may choose from a list of rewards they design.

The rewards list must have things that are relationship building and cannot include food or toy treats. Here are some examples of relationship building rewards: a game with the teacher and friend of choice, a special job, a visit to the director’s office or another classroom, choose a book at circle time, have increased outside time with a small group. You and the child develop the reward list together.

Never take a token away. If the child hits, let the child know you can’t give them a token now but you can later when they remember the rule. Do try to have the child experience success. If you notice the child in a situation that sometimes ends in his aggressive behavior, give the child a token before any negative behavior occurs and thank the child for remembering the no hitting rule. Young children will not pay attention to the half hour limit. Use your judgment about timing to make sure children are successful and get rewards.

After three tokens, allow the child to choose from their reward list. Rewards lists must be changed every week to be effective.

Remember to work on some of the problems that underlie the child’s behavior. For example, if the child has poor social skills, be sure to spend time playing with the child and helping him play with others.

If other children question the reward plan, let them know you are helping their friend remember the “no hitting” rule. Tell them you would be glad to help them if they need some special help.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Keep observation records so you can have an objective measure of the frequency of the child’s behavior. Is the number of aggressive incidents decreasing? Hopefully, the combination of this plan with attention to teaching better social skills will have a positive impact.

Consistency and follow through is very important for the success of the plan. Before you implement a plan, make sure all teachers are in agreement and understand the plan.

Try the behavior plan for one month. If you do not see a change in the child’s behavior or an increase in their ability to play and get along with peers, then it is time to ask for consultation. If the child’s behavior improves, you can let the child know that they have learned the rule and you are proud of them. You can end the formal behavior plan; however, it is a good idea to continue checking in with the child and rewarding them from time to time because of learning the rule. When beginning a referral conversation with families about your observations: x

Set up a quiet time to meet away from the classroom.

Come prepared with past observation sheets, child of concern check lists, and behavior plans.

Ask the parents for their observations and feelings about how things are progressing. Incorporate their suggestions into your recommendations. Make sure the family understands your concern and that you are offering to be a "partner” with them.

Set a definite time to meet again.

Be prepared. Find local resources that might be available to serve the family. Your Public Health Nurse can help by suggesting resources and connecting the family to those resources.

Choosing a Referral Pathway Many referrals can be made directly to the appropriate health care provider. You may want to call ahead to the referral agency or provider to find out their appointment procedure. You can then provide the family with the necessary forms or information in preparation for their visit. Some parents may feel more comfortable consulting the child’s health care provider directly, who can then provide information and referrals. Referrals can generally be made directly to: x

A child’s health care provider (see letter, page 125) for concerns about a child’s general health, developmental level, or behavioral concerns.

A speech and hearing center or audiologist for language and speech concerns.

A mental health provider or clinic for behavior concerns.

Child Find for academic or developmental concerns.

Often problems overlap and the best referral is the one most trusted by parents.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

SPECIAL CIRc*msTANCES

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Children at risk Child Abuse In your role as child care provider, you may have concerns about the health, welfare and safety of a child in your care and may need to contact Child Protective Services (CPS) to discuss your concerns. As a mandated reporter you are required to report instances of suspected abuse or neglect. The role of CPS is to investigate those reports to insure the well-being of children. Types of maltreatment and possible symptoms Type of Maltreatment

Possible Symptoms

Neglect

Signs of malnutrition. Poor hygiene. Unattended medical needs.

Physical Abuse

Unexplained bruises, burns or welts. Child is afraid of caregiver. Child’s stories do not match injuries.

Sexual Abuse

Exploitation

Pain, bleeding, redness or swelling of genital or anal area. Sex play with toys, self or others that isn’t in line with developmental age. Knowledge of sexual activities that isn’t in line with developmental age.

Extremes in behavior from overly aggressive to overly passive. Delayed physical, emotional or intellectual development.

Washington State Department of Social and Health Services 2007 Children’s Administration performance report

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Children in Foster Care If children are in foster care it usually means that they have suffered loss in their young lives. Even if the children are safer, they have still suffered the loss of their familiar caregivers. If the children were abused or neglected, they will need special care to heal from the traumas that they have experienced. Pay special attention to establishing warm and reliable relationships with these children. Establish routines they can count on. Make sure the child has a main teacher who is responsible for their care. Follow relationship informed discipline procedures on page 39. What you can do: x

Learn about the child’s past experience so you can better understand their background. Clarify with the foster parents who is responsible for making decisions on the child’s behalf.

Be prepared to hear troubling information. As a child feels more comfortable they may talk about some of the hard things they have experienced. If that happens, remain calm and let the child know you are very sorry about what has happened to them. If they continue to talk about upsetting information in front of other children, let them know they are talking about important things and you will talk with them later. When you can, check-in with the child and talk with them separately. Let them know you understand that scary/sad things have happened to them. If the child often brings up unsettling things, let the foster parents know and recommend counseling.

Advocate for the child when you see that the child has an unmet need. For example, if the child is talking a lot about upsetting things or has behavior problems, consult with the foster family about a referral for counseling. Advocate for the child around other issues and document what you may notice. A 9-month-old infant boy was picked up three times per week from child care by a social worker who took the infant to visit his biological mother. The pick-up time interfered with nap and mealtime. The social worker picking up the infant was often a person unknown to the infant and resulted in the infant’s inconsolable crying. He was often hungry and tired. When the infant returned to child care he seemed listless and disconnected for the remainder of the afternoon. The Center Director, with the support of the Public Health Nurse, contacted the infant’s caseworker and changes were made. The infant was picked up after his nap, was sent with a familiar adult, and with food in case he got hungry.

Make sure the child has the opportunity to form close attachments to a teacher who will likely remain at the center for an extended period of time.

Be sensitive to the needs of siblings to check on each other. Help children who may feel responsible for their siblings know that there are adults available to provide care.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Children’s books on Foster Care: The Star: A story to help young children understand foster care by Cynthia Miller Lovell Maybe Days: A book for Children in foster care by Jennifer Wilgocki, Marcia Kahn Wright and Alissa Imre Geis

Children Living in Shelters (homeless children) Children living in shelters, most often with their mother, are stressed. Many have been exposed to domestic violence or other trauma and their parent is likely overwhelmed with being homeless. Shelter life may have its own stresses such as small living quarters, little choice about mealtimes and a variety of rules about behavior. x

Follow the relationship informed discipline suggestions on page 39.

Do not ask the child to share if it is hard for them to do so. They may have had to give up many of their personal belongings because of homelessness. They may have to share all toys at the shelter. Make sure you have multiples of favorite toys.

Offer reassurance about the availability of food. If you notice a child hoarding food, rather than setting fixed limits, reassure the child that they can have more if they need more. Then ask the child to ask their “stomach “if they are still hungry. If so, provide more food. Once the child gets used to the routines of child care, concerns about food should lessen. If eating is about hunger for other things like stability and support, give the child additional attention throughout the day.

Families living in shelters are stressed. Often the path to the shelter has been paved with trauma for everyone. Sometimes parents themselves have been homeless as children or placed in foster care. Be non-judgmental about the family’s situation. Offer help and support where you can, but do not make assumptions about the families’ needs without asking the parent. Parents may feel guilty about their situation and the impact it has on their child. Go out of your way to let the parent know how much you enjoy their child and how much you would like to be their partner in caring for their child. If parents have complaints do not get defensive. Thank the parent for letting you know the concerns and brainstorm together to come up with ideas about making things work better. Never meet a parent’s anger with your own. If you find yourself feeling upset, let the parent know you need to think about what they are saying and you will get back to them later. Then enlist help from another child care provider about possible answers. If a child who is homeless has behavior challenges, follow the guidelines outlined in this handbook. You may need to take extra care with the parent because of the ongoing stress of being homeless. Do not give time line ultimatums about accessing services for their child. They may be overwhelmed already by too many mandatory appointments. Instead, ask for permission to speak to someone who is working on their behalf, like a shelter caseworker or Public Health Nurse. Offer support and information about community services. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Children’s books: Fly Away Home by Eva Bunting; Clarion books, 1991 Uncle Willie and the Soup Kitchen by Dyanne Disalvo-Ryan Learn More: www.nationalcenteronfamilyhomelessness.org Children Impacted by Trauma Trauma is used to describe an experience that is emotionally painful and frightening. Trauma can include neglect, exposure to domestic violence, abuse or any potentially life threatening event (earthquake, serious car accident). Children who have experienced trauma may have behavior problems that require special understanding and support. Children’s response to trauma is affected by many things: x

The age of the child.

The nature of the trauma (exposure or direct involvement).

How long the traumatic situation lasted.

How they were cared for following the trauma (availability of parent for support).

The child’s own personality.

Children are also impacted by the negative effects of racism and community violence. Anxiety and ongoing fear causes stress for children. It may produce some of the same behaviors seen when trauma is easily identifiable. Children neglected or abused in early childhood (birth to three years or age) may have real differences in brain development. The parts of the brain that involve memory and emotional self-understanding are especially impacted. Domestic violence is used to describe violence between intimate partners. Children are impacted by not only witnessing violence, but by having caregivers who are the victims or perpetrators of violence. Children may also be the victim of violence, including sexual abuse and neglect. Traumatized children can show a range of behaviors that reflect how the traumatic experience has impacted their development. Infants and children may show many of the signs discussed in section on challenging behaviors. In addition, they may have: x

Trouble paying attention and following directions both because of memory problems and/ or anxiety. x Feelings of helplessness or be unable to act, become passive. x Hyper-vigilance and hyperactivity. x An over-reaction to small things. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Overly aggressive behavior.

Withdrawal, appearing “in another world.”

Problems learning new information.

Problems getting along with peers.

A lack of a belief about self-worth.

It is important to remember that many of children’s responses to trauma are adaptive and have helped them live through the trauma. They need special support to help them learn to cope differently. When you have children in your care that have experienced trauma, it is important to do the following: x

Allow the child to have a primary caregiver who works hard to establish a trusting relationship with both the child and his parent.

Use relationship informed discipline (page 39), but keep in mind that traumatized children may require more time to respond and recover.

Keep the child company when they withdraw and make efforts to include the child in group activities even if you are only describing what the class is doing while the child looks on.

Check in with the child throughout the day about how they are doing.

If the child has safety concerns, review the safety procedures you have in place. Pretend practice dialing 911 so they can gain some sense of control.

Allow them to work or play with materials meant for younger children so they are comforted by their success and then can move on.

Do not punish regressive behavior like toileting accidents. Let the child know you understand and will wait until they are able to use the toilet again.

Enlist the entire community to support classroom teachers who are trying to accommodate traumatized children and their families. Child care family home providers may benefit from ongoing consultation with other providers or natural helpers in their community.

Healing and Compassion Witnessing the suffering of others, especially children we care for, can be quite stressful for childcare providers. It is important to be able to share concerns and feel connected to our childcare community. Feeling connected and supported by one’s community is vital to healing from trauma and supporting those who are helping trauma victims.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

“As we become fully aware of the pain of others, we paradoxically gain a deeper appreciation for living. If we can be gentle and caring for ourselves as well as others, we can learn to laugh in the face of tragedy, hope in the midst of hopelessness, and create collaborative communities rather than working in isolation.” Barbara Bennett, private correspondence, April 2008 Books for Children: Something is Wrong at My House by Diane Davis Smokey Night by Eve Bunting and David Diaz A Terrible Thing Happened by Margaret Holmes Resources for adults: National child Traumatic Stress Network Trauma Center

www.nctsnet.org www.traumacenter.org

Disasters Prevention is the key word when it comes to disasters, children, and mental health. To a great extent, children take their emotional cues from the adults around them. Children often do not have the life experience that tells them that an earthquake or other incident can be dangerous. Teachers and other adults who react calmly to an emergency situation give children a great gift. Given education and training around such events, as well as calm role models, children react competently and recover faster. Studies have shown that children, like adults, who have experienced a frightening event are more likely to suffer lingering effects after additional traumatic events. Protecting our children from unnecessary exposure to traumatic images through the media and promoting healthy and supportive environments greatly contributes to children’s resilience after a disaster. Psychological reactions of children to disasters can range from nothing noticeable or mild shortlived stress to severe post-traumatic stress disorder. Various factors contribute to this response, including gender, resilience, and, as noted above, social support and experience of the event. Emotional and behavioral responses correspond to developmental stages. Generally, children’s reactions to trauma will fade over time. If reactions persist or return often, parents or guardians may want to seek professional help for their child. Divorce Children whose families are changing may be stressed, both by the change in the family and the upset of the adults in their life. Young children may not understand what is happening but they can feel sad and frightened about the changes. Older children sometimes feel responsible for their family’s troubles. Pay extra attention to infants and young children whose families are experiencing the stress of divorce. They may cry more easily, seem irritable and have more behavior problems than usual.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

What you can do: x

Do not add to the child’s stress by using harsh discipline measures or adding extra demands on the child.

Ask the parents to let you know what is happening in the family. For example, make sure you know who may be picking up the child from child care so you can reassure the child if they worry during the day.

Make a calendar for the child (with the parent’s support) that lists “mommy days” or “daddy days” so the child has a visual reminder about what will happen.

Let the children know that you understand that they miss their parent. Give them opportunities to write or draw pictures for their parents.

Do not take sides with either parent. The child will benefit most from having two loving parents who get along with each other. Provide educational material about divorce for the parents so they can best support their child.

Ask the parents how they would like you to communicate about general child care arrangements or other issues that may arise. Do they both want the information separately or can you inform one parent who will inform the other parent?

Read books about divorce to children and make book suggestions to parents.

Books for Children: Why Are We Getting a Divorce by Peter Mayle Dinosaur Divorce-A Guide for Changing Families by Laurene Brown and Marc Brown Grief and Loss For many of us, worries about loss or feelings about past loss affect our behavior. Loss is a very important issue and something we need to understand. All of us face loss in our lives, whether it is a disappointment about something we hoped for or the death of a loved one. We sometimes think children, and perhaps even other adults, do things because they want to be in “control”. Often we do not really think about why this need for control is so important and what might be behind the need. Children also react to loss with anger. Anger is an emotion that is easy to observe in others and even in ourselves. Sometimes anger and control are behaviors we use to deal with feelings of loss and sadness. Feelings of loss and sadness can be overwhelming. When feelings are too hard to deal with, children may try to manage these feelings by becoming very controlling or becoming angry. Children with major loss issues may have trouble with transitions, following routines and controlling anger. They may have trouble moving from one activity to the next or putting things away. They may have trouble when limits are set or when teachers say “no”. For many of these children having to be part of a group raises issues of loss. Children who have had a major loss or trauma in their lives, especially children who have entered the foster care system, may need special attention. If you know that a child has experienced a loss in their life you can try to help them by keeping loss issues in mind. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Give children extra time and advance warning about classroom transitions.

Keep a consistent routine and add rituals to classroom activities.

Use pictures to make a visual daily schedule to help children follow routines more easily.

Have a “saving shelf” or allow children to use a nametag to label things they are working on so that they do not have to clean up things and put them away.

Rather than say no directly to children who become upset when hearing the word “no”, find other ways to set limits. For example, if a child asks to use a toy but that is not possible, rather than say “no, you can’t have that toy now”, say “now you can help me find the play dough and we can use that toy later”.

If the child keeps arguing and becomes upset about a limit, let the child know you are sorry to see how upset they are and that you will stay with them until they feel better.

Have a “later box” and put things in the box that a child wants now but cannot use until later. Make sure when you take things out of the “later box” he knows now is the time to use them.

Play Simon Says so children can practice leading and following.

Let the child know that you will take care of them and all the children in the class so they don’t have to worry.

Include books about loss in your curriculum.

Loss is a major issue that brings up strong feelings for everyone. When an infant or a child dies teachers may first feel shock and disbelief. When a teacher or parent dies, it can be just as upsetting. Shock then gives way to sadness. The death of a child is tragic and can bring up sadness, especially for the teacher that directly cared for that child. The loss of a child may also remind some of other losses they have suffered. Families losing loved ones can also impact the child care community. Teachers must balance help for the children and families in their care and managing their own feelings. Some things to consider when thinking about how to help your community cope with loss: x

Remember to respect the privacy and wishes of the bereaved family. Ask the family what information they would like you to share with the community and honor their wishes.

When talking with a parent whose child has died, refer to the child by their name.

If you feel it is an imposition to contact the family more than once, ask for the name of a person who can represent the family. It may be useful to call the emergency contact listed by the family on your child care forms.

Gather your childcare community. Make a plan to offer support and condolences to the family. Teachers should be encouraged to attend funerals as appropriate. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Consider a staff meeting for child care providers to discuss their feelings about the death of a child attending their child care. This is especially important if the child has died of Sudden Infant Death Syndrome (SIDS) while attending child care. Your local Public Health Nurse may be available to provide SIDS grief support for the child care program staff. Offer local grief resources.

Organize any plans to contribute to the family with meals, car pools or making lunches for other children in the family around the family’s wishes.

Everyone grieves in different ways. Sometimes the way a person deals with his or her grief may be misinterpreted as uncaring or insensitive.

Children will follow the lead of the adults so it is important for teachers to remain calm and provide simple and direct information and answer questions as they come up. x

Let children know that you are sad because of the death. Be available to answer any questions they may have. For example, young children may wonder if the person is coming back later or is in heaven. Let the children know that the person is not coming back even if you wish very hard. You can then listen to their ideas about heaven. You can tell them that many people think that heaven is the place where people go when they are no longer alive. You do not need to discuss views about death except to acknowledge that people have many different ways of thinking about death. Just listen.

Help the children put together a memory book or card about the person who has died. The children can all contribute pictures and things they remember about the person. Let the children know that the family will receive their memory card and that they are helping the family feel better.

Be aware of children’s developmental level and how children of different ages understand death. Children younger than 3 pick up cues from the adults they are close to and react if those adults are upset. Pre-school children can feel sad and then return to normal play and then feel sad again. They may have questions about the death, especially if the death was someone close to them. Answer questions as they come up. School-age children understand that death is permanent. They may worry about something bad happening to them and may need reassurance about the cause of the person’s death, especially if it was another child. Avoid referring to the child or loved one’s death as going to sleep but not waking up. You can say something like “Most children grow up and most people die when they are very, very old. Sometimes bad things do happen and that is why we are sending this card to the family.”

Young children can be very direct. For example, following the death of 4 year old Tom’s father, his friend Sam stated ”Tom, your dad died, so you don’t have a dad”. Rather than telling Sam not to say such things, the teacher calmly said that Sam was correct about Tom’s dad, but added that he did have his dad even if he can’t see him anymore. He could remember a lot about his dad. She added some things she had remembered about Tom and his dad and named the other important people in Tom’s life as well.

Observe the children for signs of distress and be ready to help with support and information if necessary. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

If children other than those most directly impacted by the death remain upset after 1 month, then you may want to ask your Public Health Nurse for ideas on how best to help them manage their feelings.

Children and families who have suffered a significant loss should receive additional support for a very long time and may be upset for a very long time. Their lives and the lives of their families have been permanently altered and there is no timeline for healing. However, if you notice that the family is having trouble coping with the demands of everyday life, or if you have concerns that the family lacks a support system, ask your Public Health Nurse for additional resources.

Some members of the community may be very uncomfortable with loss and death and will feel as if they don’t know what to say. They may fear saying the wrong thing and adding to a family’s sad feelings. Provide some coaching for the adults in your community by letting them know what teachers and administrators are doing and saying to help. If you have permission and information from the bereaved family, let other parents know what the family would find supportive.

Death is never easy. The loss of a young loved one is tragic and an important part of healing is the support of a loving community.

Stress Spending your day away from familiar surroundings and the people you know and love best is stressful. Stress is something we all experience to some degree every day. Even things we think of as positive, like getting married or getting a new sought after job, can be stressful. For adults stress might be sitting in traffic, delayed for an important appointment. For infants in childcare, it might be wondering who will be taking care of them as they gaze at unfamiliar caregivers. Young children and school age children are asked to cope with the challenges of all day group participation. Will they be included in games with their friends? Will parents really remember to pick them up? Will they be understood and helped when things go wrong? There are everyday stressors like those described above as well as long term stressors like living with financial worries, divorce or chronic illness. The families and children in your care may face a range of stress. Stress impacts everyone’s well being. How we manage stress is dependent on many things. Infants and young children rely on the important adults in their lives to help them manage stress. Older children may be able to withstand distress better depending upon their early experience and other protective factors in their lives. As discussed on page 14, infants and young children are especially vulnerable to the effects of long term stress. Extreme stressors like exposure to abuse and neglect negatively impact a child’s development and behavior into adulthood. 6

6 Adverse Childhood Experience Study Felitti V.J., et al. The relationship of health status to childhood abuse and household dysfunction. American Journal of Preventative Medicine. 1998: 14: 245-258

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

The effect of stress upon the body Stress tells your body to prepare for “battle”. That means that all one’s efforts are aimed at dealing with the stressful event to insure survival. The ‘fight or flight’ response is activated so that chemicals are released into the body that prepares the body to manage the stressful event. In the short term this is useful for survival. The heart rate increases, digestion slows, pupils in the eyes dilate and the rate of glucose metabolism increases. Cortisol is released into the blood stream and a feeling of tension and anxiety may occur. If there is long term stress, the body is not able to function in the usual health promoting ways. That is why stress is associated with heart problems, digestive problems, muscle tension and even a weakened immune system. Children impacted by long term stress have additional health problems because of the impact of stress hormones on developing body systems. The following is a list of behaviors you may see when children are experiencing stress. Many of these behaviors are also experienced by adults who are stressed. Children may: x

Be irritable and cranky.

Cry over small things.

Be overly sleepy or have trouble sleeping.

Lack focus or be forgetful.

Lose some skills - like forgetting to use the toilet when already toilet trained or return to thumb sucking, request a long gone pacifier.

Be clingy or whiney.

Have physical complaints (stomach aches, headaches, etc.).

Have behavior problems.

Be withdrawn.

Children impacted by long term stress may have serious behavior challenges because they respond quickly and over react to others. They may have trouble learning because of memory and attention problems. Children in this situation need counseling and special educational support to help them overcome their stressful experiences. How do children show stress? Stress is hard for both children and parents, especially if the stress goes on for a long time. Children can feel stress from their parents, so even if you think children don’t see or understand what is happening, they can tell when you are stressed. Taking care of children is hard work and stress makes it even harder to take good care of children. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Some of the ways children show stress can be the same as for grownups. As you read how stress impacts your children you may find it has impacted you in some of the same ways. But, since you are an adult you probably have some ways to help you with your stress like talking with friends, using relaxation techniques such as yoga or meditation, counseling or medication prescribed by your doctor. Young children need help from their caregivers to find ways to manage their stress. The problems you see can be in any or all of these four areas: Sleep Problems Babies and toddlers may sleep too much, or have a hard time falling or staying asleep. Preschool children also have problems going to sleep and they may also awaken from nightmares. They may seem tired but can’t fall asleep. Bedwetting can reappear in children who were dry at night. Eating Problems Babies and toddlers may have trouble eating, lack of appetite or eating all the time. They may also have problems with spitting up, constipation or diarrhea. In addition to the above, preschool children may complain of stomach aches or headaches. Feeling Problems Babies and toddlers may look sad or withdrawn and be hard to play with. They may also seem nervous, always looking around their environment. Separation from parents or trusted teachers may be very hard, causing a lot of tears and upset. Temper tantrums can be expected for children this age, but stressed children may have frequent temper tantrums that go on for a long time. Pre-school children may look sad and withdrawn. Sometimes they may get upset over something very small and be generally irritable and often cry. They may talk about worries and do a lot of whining. Very stressed children can have “habits” like nail biting or pulling on their hair or eyebrows. Thinking Problems Babies and toddlers may seem confused and unable to focus on play or back and forth games with caregivers. While it may be “normal” for toddlers and pre-school children to show independence and disobey, stressed children appear to “not listen” a lot of the time. They may quickly go from one thing to another without really stopping to enjoy an activity. They may break toys rather than use them in the intended way. Following simple directions is challenging, as their anxiety makes it hard for them to keep on track. Children may forget routines, like putting their toys away or washing hands. Children may even “forget” some of the things they had learned before they were affected by stressful events. For example, they may have been toilet trained but stop using the toilet and require diapers again. Or, they may seek the comfort of their bottle or pacifier even if they had given them up months before. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Military families: The Stress of Separation Children whose parents are deployed face the stress of missing their parent plus the family changes that result from that. The remaining parent likely feels stressed and misses the support of their spouse. If the deployed parent is in a life threatening situation, the stress increases. Children and families in this situation need additional support and understanding. The support of other families, especially those in the same situation, is invaluable. Other issues arise when families are reunited. Books for Children: While You Are Away by Eileen Spinelli In My Heart by molly Bang; Little Brown Books for Young Readers, January, 2006 How Many Stars in the Sky by Lenny Hort Learn More: National military family association Military Child Education Coalition

www.nmfa.org www.militarychild.org www.militaryonesource.com

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

COMMUNICATING WITH FAMILIES

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

All kinds of Families Child care providers care for children from many kinds of families. The children in your care may live with one parent, grandparents, two parents, or have two moms or two dads. All families have their own heritage and ways of taking good care of their children. No matter what the family constellation, most parents do their best to provide their children with the care they need to grow and thrive.

“Culture influences every aspect of human development. Culture prescribes how and when babies are fed, as well as where and with whom they sleep. It affects the customary response to an infant’s crying and a toddler’s temper tantrums. It sets the rules for discipline and expectations for developmental attainments.” From Neurons to Neighborhoods, The Committee for Children. Sometimes when we hear about “culture” we think of identifiable ethnic groups or immigrants from another country. In fact, culture shape’s everyone’s behavior. Because culture is so much a part of us, it may seem hard to identify those parts of our thoughts, feelings or actions that relate only to our own culture. We may think that everyone shares our viewpoint unless they are obviously and visibly different than us. Then, if they are different than us, we may assume they cannot share any of the same ways of thinking. Given the wide range of circ*mstances and cultures of the children who may be in your care, how can you help families feel comfortable and understood? x

First, do not make assumptions about how families function based on what limited information you may have. This will help you avoid using stereotypes.

Ask for information you need to best take care of the child. For example, parents may have eating or sleeping practices that vary from the child care way of doing things.

Make sure your program and classroom incorporates aspects of the culture of the children in your care.

If you are uncomfortable with another family’s culture, consult with your Public Health Nurse or Child Care Resources about how to understand your discomfort.

Children are best supported when parents and providers have a positive and warm relationship that allows them to work as a team.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Parent-Teacher Relationships Families today face many challenges in child rearing and often feel guilty about the lack of time and energy they may have for their child. Stress, guilt, and unhappy life experiences can sometimes make parents behave in ways that make it hard to establish a positive relationship with them. A parent may react to a concern raised by criticizing the child care program or provider. Others may ignore the concern you raise or disagree with you about the nature or seriousness of the concern. In these situations, try not to become defensive or frustrated.

As a parent, when I heard the word ”evaluation” I panicked. The teacher was helpful but “early intervention” meant something was not right with my child. I stopped listening and started arguing with myself: had I done something, was this my fault? My child was ok. The teacher just didn’t understand.

There are several things you can do to improve the situation. The first thing you can do is continue to work on establishing a positive relationship with the family. Start by examining your own feelings about the child’s situation. Discuss the child’s problems with your colleagues. Use the Behavior Observation Tool, page 121, to note the child’s strengths along with your concerns. As you share information with the child’s parents try to be objective. If you are feeling either judgmental or uncomfortable, you might want to practice what you are going to say with a co-worker, deciding which words to use and which words to leave out. Or, you might choose another staff person who has daily contact with the child and feels comfortable being the main communicator with the family. Try not to establish a daily “negative report” to the family. Parents find it very difficult to repeatedly hear negative feedback about their child, even if they ask for “daily reports”. This undermines their ability to pay attention to the important issues that need intervention. Young children need supportive solutions and understanding of their difficulties rather than delayed and often punitive responses that they might receive from frustrated parents. Rather than a daily “negative report”, let parents know you have made many observations and you would like to share them so that together, you can make a plan that benefits the child. Be sure to include positive information if a parent insists on hearing about the child’s day. For example, you could say:

“I noticed that John was very involved in building a tall tower and really worked hard. He did a great job! Around naptime he seemed to have some trouble settling down and began throwing things around. We would like to give a little more thought to making the transition easier for him. Perhaps you have some ideas? Let’s talk.”

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

When you have a meeting with the family, use your observation sheet to describe the behavior of concern. Describe your observations objectively. If you have a videotape of the child playing or interacting with others, view the video together. Describe the behavior (what is happening) as you and the family view the tape. Let’s take the case of Sam, a child who does not play successfully with his peers and responds with aggression:

I observed Sam playing alone in the block area, using the blocks to build a road. When another child entered the area ,Sam screamed “get out, these are my blocks.” That child refused to leave. Sam did not return to his play but began kicking blocks at the other child. The teacher intervened and reminded Sam that we don’t kick the blocks. Sam continued to kick the blocks for a few seconds more. Then he stopped and moved to another area. Let the parents know you have observed similar behavior at other times. Your goal is to help Sam play peacefully with his classmates and interact positively with others. Work with the family to map out a plan to help Sam reach the goals you have set. Use the Child Conference Summary, page 123. Be sure to include a time and date for a follow-up meeting so Sam’s progress can be followed. Then, if problems continue, referral suggestions can be offered. Here are some suggestions for open-ended questions that might encourage discussion. Try to ask questions that can’t be answered by a simple “yes” or “no,” such as: x What things have been most helpful to Sam when his behavior has been a problem? x

What kinds of things does Sam do that leads you to put him in time-out?

How do things go when Sam plays at home with children his own age?

What are Sam’s favorite things to do with you as a family?

Learn more: www.handinhandparenting.org This is an excellent resource with articles and advice on a variety of parenting topics and childcare dilemmas.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

English Language Learner Families When families are English language learners, some additional preparation may be needed before the meeting: x

It is very important not to have the children in the family act as the interpreter. It can change the family dynamic, giving the child more power over the situation. If the child is in trouble, he or she may not interpret what is said accurately.

Ask the family if they want an interpreter present and if they have a preference in gender. Also ask about what language they prefer to use. Many English language learners speak multiple languages.

Ask about language preferences in translated written materials. They may prefer written material in a different language than they use verbally.

Find out who is the “decision maker” in the family and be sure that person is present at the meeting. For example, the mother may attend the meeting, but if the father is the final decision maker in the family, then he should attend as well.

Again, try to avoid professional jargon. It may be difficult to understand and may not translate well.

Don’t assume that all cultures have the same customs, values and beliefs regarding child rearing or that all people in a given culture have the same beliefs.

Talk with the family to find out more about their culture and what they want their child to learn and practice. Respect differences, especially in ideas and practices. Try to discover what will work best for the child. Meeting the child’s needs is more important than a discussion about who is right or wrong, who has the last word, or who is winning in a conflict of ideas.

Talk with the family about things that you are unsure about or that might cause disagreements. Work toward solutions that satisfy both you and the family

Be available for informal conversations about their concerns, values and expectations.

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Working with Interpreters x

Use certified interpreters if possible.

Meet with the interpreter five to ten minutes before the meeting. Explain your expectations and the help you need from him or her. Make certain the interpreter understands that the conversation will be confidential.

Ask the interpreter to tell you everything the family says and not just give a brief summary. For example, the interpreter may talk with the family for five minutes then simply say “the family is doing fine.” In long conversations it may be helpful for the interpreter to make short notes so everything that is said is included in the interpretation.

Ask the interpreter about any culturally sensitive issues or taboos.

Let the interpreter know it is important to ask you questions if your questions, information, or content is unclear. Again, avoid professional jargon as the meaning can be difficult to translate if the word is not a part of that language.

Try to speak slowly and clearly, using short sentences and short pauses. Speak directly to the parent. Never use the third person “tell her that…”

Pay attention to non-verbal communication. Look for body language that looks uncomfortable or puzzling. If you sense something is going on, ask the interpreter for clarification.

Make sure the family understands that the interpreter is neutral and is there only to help translate, not to offer suggestions or “coach.”

Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Working with All Families When you decide to meet with a family there are several steps you can take to make the meeting successful: x

Before meeting with a family, record your observations documenting the events or behaviors that concern you.

Describe what you see in an objective manner. Avoid using adjectives such as busy, hyper, noisy, or aggressive and adverbs such as always, never, etc. Avoid labeling the child as out of control, abnormal, ADD or ADHD. Try not to describe the behavior in terms of motive (why), “he does it for attention” or “to get his own way.”

Make a definite appointment to meet with the child’s family. Drop off and pick up times when parents are harried might not be the best times for a meaningful discussion.

Before the meeting, gather your Observation Tool, page 121, narratives, documents, some possible solutions and resources available.

Talk with the family in an area away from the child’s hearing.

Ask open-ended questions to gather more information and understanding about the family, such as, “tell me about your evening, morning, or weekend routine” or “what kind of things do you like to do together?”

Avoid using professional jargon that the family might not understand such as “age appropriate” or “developmentally appropriate”.

Believe that families are sincerely concerned and interested in all aspects of their child’s development.

Share the child’s strengths first before you discuss the challenges.

Involve the family in the decision making process. Ask the family for suggestions and refer back to them when you make recommendations.

Offer suggestions about changes your program can make that might also help. Agree on an action plan with the family.

Consider any special circ*mstances – hospitalization, unemployment, homelessness, etc.

Have a list of referral resources available if needed.

Set a date to review the plan. This is a time to check-in with the family about how the plan is working and for you to provide feedback about the success of the action plan.

Make yourself available for informal conversations, allowing time for the family to voice any concerns or unmet expectations before the review date. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

Working with Americans with Disabilities Act (ADA) Families The importance of early intervention For all disorders, early intervention is important so children can develop and reach their full potential. Also, children with some of the problems discussed earlier are vulnerable to having other serious problems. For example, a child with FAE who has learning challenges and social difficulties is at risk for school failure and social isolation. Both can lead to delinquency or depression in adolescence. Children with disabilities benefit from early educational support and warm, supportive relationships with others. Infants and children with physical and/or mental disabilities benefit from attending child care. The Americans with Disabilities Act (ADA) is designed to give families and children with disabilities the opportunity to be included in child care programs. The basic requirements of the ADA ask that child care providers: x

Make reasonable modifications to policies and procedures to integrate children with disabilities.

Provide auxiliary aids and services if it does not constitute an undue burden.

Include children with disabilities in their programs unless their presence would pose a direct threat to the health and safety of others, or require a fundamental alteration of the program.

Challenges Children and Families may Face Sometimes children in your care are receiving treatment for a developmental or behavioral problem diagnosed by their health care providers. If a child in your care has a diagnosis, or is given a diagnosis while in your care, it is important to learn about the diagnosis and what it means for the child and family. Sometimes you may think that a child has a specific disorder and that the family should seek help. It is not your role to make specific recommendations to parents, but rather to encourage them to seek outside help from their medical provider or other community partners when there is a concern. Each child is more than their diagnosis, more than the problems and challenges they face. Each child impacted by a disorder needs warm and loving accommodations to support their success in your program.

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Working with Individual Families Infants and Toddlers Referring young children for services may be especially challenging as some people have the idea that babies can’t really have problems, or that they will “grow out of it”. However, early intervention is so beneficial that it is in the best interests of the child to refer when there may be a question or problem. Providers working with infants often have a pattern of close responsive communication with parents. They need to share information since babies can’t “talk.” The infant-provider ratio also allows time to talk with parents. Hopefully, this makes it easier to raise issues with parents and suggest the need for outside referrals. Here are some guidelines that might suggest a baby should be referred for further evaluation: General Concerns: x

Is the baby able to separate from her parent and allow herself to be comforted by her caregiver?

Is the baby fretful most of the time and unable to play in a joyful way?

Does the baby look away from his parent when his parent arrives at the end of the day?

Does the baby take several short naps, is she easily awakened or does she never really seem rested?

Does the baby have any eating problems (refuses feeding, eats all the time, never seems satisfied)?

Developmental Issues: x

Is the baby/toddler generally reaching expected developmental milestones?

Does the baby/toddler appear interested in hearing language and communicating with adults?

Does the toddler make her needs known easily, using either gestures or language?

Refer to section on play, page 17.

Parent Issues: x

Does one parent often make comments suggesting that their relationship with their baby/ toddler has been difficult? For example, here are some comments moms have made about their babies:

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Baby Johnny seems to want to nurse all the time. Sometimes I think he will nurse so much I might disappear. Baby Sally is just like my sister, always making me feel that whatever I do is never right. This baby started kicking me in utero and he is still out to get me.

It is important to recognize depression in mothers and make a referral. If mom complains about extreme exhaustion, worries about hurting her baby and/or shows little positive emotion, it is vital to offer additional support and refer her to her obstetrician/gynecologist or other health care provider.

Pre-school Children When children enter pre-school, they are able to use language to communicate, are interested in playing with their friends, and can follow most routines. Pre-school children may benefit from referral if: x

They have trouble playing peacefully with their friends and often use physical means to cope with difficulty.

Their speech is not easily understood.

They withdraw from others and do not seem interested in playing with everyone.

They appear angry, upset, or sad much of the time.

They do not meet developmental milestones.

Their parent feels they are very difficult and hard to parent.

Sometimes parents do not have an understanding of developmental expectations. Like parents of infants, they feel their child may be going through a phase and will grow out of the problem. Sometimes they feel that they had the same problem as a child and they did ok. School Age Children Many of the principles already described also apply to working with school age children and their families. It is important to partner with the child’s school (as well as the family) to address concerns. If new approaches are tried with the child, it is more effective if everyone involved uses the same approach. This is also an excellent way to find out what has or has not worked for the child at school and at home. There may be resources within the school that can be used, such as family support workers or school counselors. Additionally, because a school age child may have a longer history of problems than a younger child, resolving an issue may require patience and persistence. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

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TEACHER STRESS TAKING CARE OF YOURSELF

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The Demands of Child Care Providing quality care for children can be very demanding work. Young children are often in your care for long hours. You may play multiple rolls as educator, social skills trainer, and peacemaker, among others. Teachers also partner with parents, colleagues and other systems that care for children. Caring for children is a big responsibility and does not necessarily receive support from others. What does research tell us about job stress? Teacher burnout is related to a variety of factors: x

Insufficient recognition and support for the demands of the job.

Challenges that make a person feel ineffective.

Lack of opportunity for personal growth and education.

Physical factors, like long hours or poor pay.

Lack of job flexibility

Problems outside of work that impact one’s capacity to function well.

Lack of social supports at work.

Symptoms of burnout include irritability, lack of motivation, depression, loss of memory, and poor functioning at work. Good communication of one’s needs to colleagues or supervisors is important so that problems get solved and workers feels supported and connected in the workplace. Building relationships is one step toward making positive changes and is a buffer against stress. Consider increasing the amount of exercise you are getting or doing something you find relaxing. Christine was in her 14th year of teaching in the child care setting. Lately she felt extremely tired much of the time and couldn’t wait to get home. However, home life was stressful as well since Christine was raising two children on her own with little support from the children’s father. Christine used to enjoy the pre-school children she taught but lately they seemed to be demanding and difficult. One day Christine heard herself yelling at a child and knew that something needed to change. She met with the center director and discussed her feelings about her work. The director called a meeting with Christine and her assistant teacher to discuss how best to share responsibility in caring for the children. Changes were made to the schedule and responsibilities clarified. The needs of two children in the class with serious behavior concerns would be addressed. Christine decided to join a single parent support group. She also got a family membership to the local YMCA so that she and her children could take a variety of classes. Christine found a neighborhood “walking group” and began to walk for at least 1 mile everyday. Christine felt better.

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What can you do? x

Work on communication skills. Good communication of one’s thoughts and feelings to colleagues or supervisors is very important so that problems are solved, and you feel supported and connected.

Take a break! Read a book or do something that is not focused on difficulties. You need to re-charge your energy to find solutions.

Eat well and exercise. Both these things will help you feel better and better able to cope with stress.

Incorporate stress reduction activities in your everyday life. This can be exercise, but also make sure you have time for at least ½ hour of an activity you enjoy. One teacher worked on crossword puzzles each day, another gardened, etc.

Learn something new. This can apply to both your professional work life and personal life. Gaining competency as a teacher feels good and is a stress reducer. Learning new skills opens up possibilities and also feels good!

The Importance of Your Feelings It is three o’clock and almost time for you to go home. It has been a tiring day filled with activity. Four year old Sam, a child who you feel is very difficult, suddenly begins screaming at another child about taking his car. Sam’s face turns red with anger and, as you try to help, he runs away and starts throwing things around the classroom. You take a deep breath as you realize that the situation is out of your control and you are feeling very angry.

Should teachers be angry? Should teachers have any feelings about the children in their care? Is it OK to like Jenny better than Sam because Jenny always follows your directions, unlike Sam? What role might a teacher’s feelings play in the care they provide?

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Everyone has feelings and it is healthy to be able to have feelings. After all, in our work with children we help them experience and understand their feelings. We need to be in touch with our own thoughts and feelings. This is especially important in working with children because very often the feelings we have are directly connected to the feelings of the children in our care. If we can identify our feelings, we can identify the feelings of children. In the example above, Sam’s teacher feels very angry about an out of control situation. The teacher’s out of control and angry feelings are the very same feelings that Sam is experiencing. The teacher can use her own feelings to understand Sam. This can help in finding solutions to Sam’s problems. x

If you feel disconnected from a child, or find a child hard to relate to, it is likely the child feels the same way toward you.

If you feel frustrated with a child’s behavior, it is likely the child feels frustrated.

If you feel annoyed by a child’s inability to follow directions, it is likely the child is annoyed with himself and even is feeling anxious.

If you feel sad about a child’s situation, it is likely the child feels sad.

If you have trouble liking a child, it may be because that child generally does not feel liked or appreciated.

Use your own feelings to try to understand the feelings of children in your care.

Reach out to children who may have problems making connections and feeling appreciated. If they “push your buttons”, give some thought to exactly how the child makes you feel. Use your feelings to try and understand the child’s feelings. This will help you make a plan to support the child. In the example earlier, the teacher describes Sam as difficult. In thinking about what is meant by “difficult,” the teacher realizes that Sam is very stubborn and refuses to follow routines. He often makes the teacher feel helpless because she does not know what to do when Sam refuses to do as she asked. The teacher realizes that Sam also feels helpless. She makes time to check in with him throughout the day, to build their relationship and finds many ways to give him choices. Sam has been able to follow routines better as a result of the teacher’s intervention. On the now infrequent times when he refuses to follow routines, the teacher recognizes his feelings and lets him know he has time to make a choice. Talk over your feelings with your colleagues. Sometimes it helps to get other teachers or the director’s ideas about children. You can share feelings and information with your colleagues. You can even do some problem solving and role modeling. If you find yourself frequently feeling frustrated, angry, or generally unhappy with your work situation and the children in your care, you may be experiencing “burnout”. Caring for children and being central to the lives of many children and their families is hard work. When your home life is stressful, it can be especially difficult to feel good. Worries can directly impact your ability to have the energy necessary for working with children. Do not hesitate to contact your Public Health Nurse for assistance. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

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Stress for all seasons It is 7:10 AM - five children have arrived and are quietly entertaining themselves while you begin to get breakfast organized. All appears to be going smoothly, so why are you feeling worried? Could it be that a necessary staff member has called in sick? Or a particularly challenging child is expected at any time? Or has your morning been off to a rough start? Are you thinking about all you need to accomplish before the day is over?

For most of us, the everyday stress we experience is connected to real (or sometimes imagined) worries. The kinds of things that worry people depend upon the individual, as does the amount of time spent worrying. For all of us, worrying can be a useful signal to ourselves that we need to take a time out and evaluate our circ*mstances. Any library or bookstore has shelves full of books on the topic of stress-reduction, relaxation how-to, and dealing with trauma. There seems to be an "epidemic" of stress related problems. The traumatic events of 9/11 and its aftermath have caused underlying stress for many of us. We may feel a generalized lack of security and safety that can increase worries and interfere with our ability to accomplish our everyday tasks as well as long term goals. The financial uncertainty many of us face due to layoffs and the general economic downturn can undermine our well-being in important ways. The extra challenges of holidays can overwhelm an already stressed person. Certainly children can have their own set of worries and concerns. However, children often take cues from the important adults in their lives. For example, many young children could not grasp the gravity of the events of September 11, but they could understand that the adults were upset. Serious financial worries and job loss are among the top ten stresses for adults. Children in families experiencing tremendous stress are bound to be impacted. Financial demands add extra stress to families facing an uncertain future. What behavioral changes might you see in stressed children or adults? In many ways the reactions of children and adults are similar. You might see or experience increased irritability, moodiness or angry outbursts. Children may show an increase in their activity level and a decreased ability to concentrate and pay attention. The usually enjoyable activities may hold no interest. Signs of serious stress include changes in appetite or sleep, increased physical complaints and extreme sadness. What are some things we can do to take care of ourselves and the children in our care? x

Incorporate stress reduction activities in our personal lives and in our programs. Yoga and meditation are just two of the many stress reducing techniques that can be integrated into programs.

Be an active listener and encourage children to talk about their worries and confusing feelings. Understand that troubling behavior is a possible reflection of the inner experiences of the child.

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Use strategies that build community and support the development of group cohesion. All of us feel better when we feel the support of a larger community. Realize that the stress felt by adults impacts the children who rely on them. Establish supportive relationships with families and with staff to enhance a support network.

Flexibility is central to coping with worries that arise from things out of our control. Be flexible enough to change expectations and adapt to new information. Fewer financial resources may mean a less expensive holiday: it doesn't have to be a less meaningful or pleasurable holiday.

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SEEKING HELP AND MAKING REFERRALS

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Understanding and Dealing with a Family’s Refusal to Seek Help Sometimes a family may refuse further help or even a request for a joint conference. They may feel uneasy and fear that their child will not be treated fairly due to cultural or ethnic differences. The family may be overwhelmed with personal, medical, or psychosocial problems and not have the energy to face “one more crisis”. They may have sought help in the past and were told their child did not need outside help. They may be worried about financial costs. They may be concerned about CPS. They may respond by criticizing you or your program. Try not to react defensively if this happens. If you and the family can’t establish some common goals for helping their child, a stalemate can occur that may lead to an unhappy ending. Either the child is suddenly removed from the facility or, as a provider, you may decide that you cannot continue to serve the child and will refer the family elsewhere. Brainstorm with the family about the kind of program that might meet the needs of their child. Consult with your Public Health Nurse or other community child care agency for ideas about making a “smooth” transition. Smooth transitions are important whenever a child leaves. You, the family, and your staff may feel angry and hurt, or suffer from a feeling of failure or rejection. Both the child who is leaving and the children who remain may experience sad, scared or angry feelings. If the child was not liked, the children may feel both relieved and guilty. Encourage the family to make a “leaving” plan that allows a smooth transition process and time for saying goodbye. Continue to support the family in any way possible. The family might, after thinking things through, decide to follow your suggestions to seek further help.

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Professional Services Audiologist – An audiologist is a professional who diagnoses, treats, and manages individuals with hearing loss or balance problems.

Child Psychiatrist – Child psychiatrists are medical doctors who diagnose and treat children/ adolescents with behavior disorders. Because they are medical doctors, they can prescribe medication.

Family Counselor – A Family Counselor has a Master’s degree in counseling and is trained in family therapy.

Family Practice Doctor – A medical professional who provides continuing general medical care for the individual and family - can be a Primary Care Provider.

Nurse Practitioner – A Nurse Practitioner is a Registered Nurse who has graduate level training in assessment and diagnosis skills. Their training allows them to provide basic medical care, treat children with behavior problems, and prescribe most medications.

Occupational Therapist – An Occupational Therapist helps people with disabilities manage every day life activities, and treats sensory motor integration problems. Pediatrician – A Pediatrician is a medical professional who provides general continuing medical care to children - can be a Primary Care Provider.

Physical Therapist – A Physical Therapist promotes recovery or rehabilitation by physical and mechanical means (e.g. massage, regulated exercise, heat, etc.).

Primary Care Provider (PCP) - A PCP is a medical professional who provides routine health care for a patient and who may refer the patient to a specialist for further treatment.

Psychologist – A Psychologist is a licensed doctoral level practitioner who is trained in the psychological and developmental testing, diagnosis, and treatment of developmental and mental health disorders.

Public Health Nurse (PHN) – A Public Health Nurse is a registered nurse with special training in community health. A PHN can help with health concerns and is knowledgeable about resources in your community. PHN’s work with child care programs, families, and communities to promote health and safety.

Social Worker – A medical social worker arranges care for the child and family. A psychiatric social worker evaluates and provides therapy for children and families with mental health issues.

Special Education Teacher – A Special Education Teacher is trained in educating children with developmental or behavioral challenges.

Speech/Language Therapist – A Speech/Language Therapist provides therapeutic treatment of speech problems. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

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Where to Find Help Listed below are some of the more general resources available: x

Child’s health care provider (pediatrician, primary care provider, family physician) Provide the family with a letter outlining the concern in general terms. See sample letter to health care provider, page 125.

Child Care Health Program - Your Public Health Nurse can assist the family in connecting with services. You can reach a Public Health Nurse by calling your local health department.

Child Protective Services (CPS) – Mandated reporting when neglect or abuse is a concern (1-800-609-8764).

Parenting/child development classes – Check the websites of the technical/community colleges in your area.

Hospital education/counseling departments – Often offer parenting support or classes.

Mental health clinics – May be able to take medical coupons to cover some or all of the costs of behavioral health services.

Churches – Sometimes offer family counseling or classes.

Libraries – Offer books on many topics, divorce, death, etc. and can help in finding materials translated into many languages.

Family service organizations – Check with the United Way or Family Support Centers in your area for possible help. They may be able to help locate services that meet the family’s need.

Local school district’s early childhood special services department – All school districts have Child Find services. Call the local school district office for a list of services and contact information. Include the name of the person to call in the information you provide the family.

Child Care Resources (CCR) –CCR provides assistance to families in locating child care for children with special needs. Contact your local CCR office.

Private Practitioners - Professionals who take private pay/private insurance clients.

WithinReach Family Health Hotline (1-800-322-2588), www.withinreach.org provides assistance in finding parenting and family health resources

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Washington State County Public Health Departments Adams 210 W. Broadway Ritzville, WA 99169 (509) 659-3240 Phone

Asotin 431 Elm Street Clarkston, WA 99403 (509) 758-3344 Phone (509) 758-8454 Fax

Benton-Franklin Kennewick 7102 W Okanogan Pl Kennewick, WA 99336 (509) 460-4200 Phone

Benton-Franklin Pasco 412 W Clark Pasco, WA 99301 (509) 547-9737 Phone

Benton-Franklin Prosser 310 7th Ave. E. Prosser, WA 99350 (509) 786-1633 Phone

Chelan Douglas 200 Valley Mall Parkway E Wenatchee, WA 98802 (509) 886-6400 Phone (509) 886-6478 Fax

Clallam Clallam County Health & Human Services 223 East 4th Street, Suite #14 Port Angeles, WA 98362 (360) 417-2000 Phone

Clallam – Forks 140 C Street Forks, WA 98331 Phone and Fax (360) 374-3121 Phone (360) 374-5418 Fax

Clark 1601 E Fourth Plain Blvd., Vancouver, WA 98661 (360) 397-8000 [emailprotected]

Columbia 341 E. Main St. Dayton, WA 99328 (509) 382-4541 Phone

Cowlitz 1952 9th Avenue Longview, WA 98632 (360) 414-5599 Phone (360) 425-7531 Fax

Colville 240 East Dominion Colville, WA 99114

Garfield 121 South 10th St. P.O. Box 130 Pomeroy WA 99347 (509) 843-3412 Phone

Grant Ephrata Office 1st and C St. NW, PO Box 37 Ephrata, WA 98823 (509) 754-6060 Phone (509) 766-0419 Fax

Grays Harbor 2109 Sumner Avenue Aberdeen, WA 98520 (360) 532-8631 Phone (360) 533-6272 Fax

[emailprotected] Moses Lake Office 1038 W. Ivy St. Moses Lake, WA 98823 (509) 766-7960 Phone (509) 766-6519 Fax [emailprotected] Island 1791 NE 1st Ave Oak Harbor, WA 98277 (360) 240-5554 Phone

Jefferson 615 Sheridan Street Port Townsend, WA 98368 (360) 385-9400 Phone

King Child Care Health Team 401 5th Avenue, Suite 1000 Seattle, WA 98104 (206) 263-8262 Phone

(206) 205-6236 Fax Kitsap 345 6th Street, Suite 300 Bremerton, WA 98337 (360) 337-5235 Phone

Kittitas 507 N Nanum St Suite 102 Ellensburg WA 98926 (509) 962-7515 Phone (509) 962-7581 Fax

Klickitat 228 W Main St, MS-CH-14 Goldendale, WA 98620 (509) 773-4565 Phone (509) 773-5991 Fax

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Klickitat 501 NE Washington PO BOX 159 White Salmon, WA 98672 (509) 493-1558 Phone (509) 493-4025 Fax

Lewis 360 NW North Street Chehalis WA 98532 (360) 740-1223 Phone

Lincoln 90 Nicholls St. Davenport, WA 99122 (509) 725-1001 Phone

Mason 415 N 6th ST Shelton WA 98584 (360) 427-9670 Phone

Okanogan 1234 South 2nd Avenue P.O. Box 231 Okanogan, WA 98840 (509) 422-7140 Phone

Pacific South Bend Location: P.O. Box 26 1216 W. Robert Bush Drive, South Bend, WA 98586 (360) 875-9343 Phone Long Beach Location 7013 Sandridge Road Long Beach, WA 98631 (360) 642-9349 Phone

San Juan 145 Rhone St. Friday Harbor, WA 98250 (360) 378-4474 Phone (360) 378-7036 Fax

Skagit 700 South Second, Rm. 301 Mount Vernon, WA 98273 (360) 336- 9380 Phone [emailprotected]

Skamania See Clark County Contacts

Snohomish 3020 Rucker Ave. Suite 306, Everett, WA 98201 (425) 339-5200 Phone (425) 339-5263 Fax

Spokane 1101 W College Ave Spokane, WA 99201 (509) 324-1500 Phone

Tacoma Pierce 3629 South D Street Tacoma, WA 98418-6813 (253) 798-6500 Phone

Thurston 412 Lilly Rd. NE Olympia, WA 98506-5132 (360) 867-2500 Phone (360) 867-2601 Fax

Wahkiakum 64 Main Street Cathlamet, WA (360) 795-6207 Phone

Walla Walla 314 W. Main Street Mail - P.O. Box 1753 Walla Walla, WA 99362 (509) 524.2650 Phone (509) 524.2678 Fax [emailprotected]

Whatcom 1500 N. State Street Bellingham, WA 98225 (360) 676-6762 Phone

Whitman Colfax Office: N. 310 Main Street Colfax, WA 99111 (509) 397-6280 Phone (509) 397-6239 Fax

Yakima 1210 Ahtanum Ridge Drive Union Gap, WA 98903 (509) 575-4040 Phone or (800) 535-5016 (509) 575-7894 Fax

Pullman Office 1205 SE Professional Mall Blvd Pullman, WA 99163 (509) 332-6752 Phone (509) 334-4517 Fax Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

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Offering Continued Encouragement Once the child’s family has been able to establish a connection to services and is on the way to resolving the problems, they will still need your assistance. Now is the time for you to offer ongoing support and encouragement as they work toward a solution. Continue to work closely with both the family and service provider to provide consistent and appropriate care for the child. Provide updates on both positive and negative behaviors, and especially on any changes and improvements you observe. With strong support and communication, the family may be able to address the concerns you initially identified, giving their child a good foundation for future success. Some concluding steps These are some steps child care providers can take to help promote a quality learning experience for all children on a continuing basis. Suggestions for child care providers: x

Provide mandatory training for all new staff on normal growth and development and age appropriate behavior management strategies.

Schedule periodic classroom observations by an outside person (peer-teacher, community trainer, Public Health Nurse).

Develop an on-going training plan based on the needs of the children enrolled in care, (asthma training, working with a special needs child, etc.), including theory and hands on techniques and information.

Make sure your parent handbook includes information about discipline policies, communication pathways, and a partnership statement.

Encourage early identification of behavioral, developmental or health concerns with a plan of “next steps”.

Use a parent information board to distribute educational materials on parenting issues, discipline, and developmental charts.

Teach social skills throughout the year; i.e., handling feelings, healthy ways to express anger, problem solving, how to make friends, etc

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SAMPLE FORMS

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CHILD OF CONCERN CHECKLIST

Complete the Behavior Observation Tool (page 121).

Check for any patterns or similarities in your observations.

Use your observation and understanding of the child to develop hypotheses about the meaning of their behavior. Then develop a plan to support the child to build skills and change behavior. For example, if you hypothesis that the child’s aggressive behaviors are a result of poor social skills, make a plan to teach social skills to the child. Use the information on page 70 to help.

Talk with the family about your observations and your plan to support their child in your program. Make sure to listen to their feedback about their child and the child’s experience in care. Include ideas about how parents can support their child’s development. Use the information on pages 119 and 121 to help parents.

Set a review date so progress can be measured. Use the observation tool again to measure progress.

Before meeting with the family, think about the following: Is your program a good match for this child? What developmental issues are involved?

Have referral resources ready (page 109).

Set another date for follow-up with the family so progress can be monitored.

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Behavior Observation Tool Observer

Date ____________________

Child’s Name

Time

Behavior

Room activity/ with whom

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Child Conference Summary (To be filled out with family) Child’s Name_______________________________

Date_____________

Conference Participants ____________________________________________ Identified Concerns:

Action Plan: (can include environmental changes, activities, staff intervention, etc.)

Action Recommended

Results/Behavior Changed?

At the Child Care

At Home

Follow-up plans (meeting, telephone call, in writing, etc.)

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Sample letter to Health Care Provider Dear Dr. Smith, I am writing to share our observations of your patient, Jimmy Johnson, age 3. Jimmy attends our child care program Monday through Friday for approximately 10 hours each day. He is in a classroom with 20 other children ranging in age from 3 ½ to 5 years of age. We offer a varied curriculum that includes both structured and unstructured times. Our teachers have made the following observations:

Jimmy enters the classroom with a smile on his face and immediately begins building with small blocks. Two children attempt to engage him in play. Jimmy responds by moving his body away from the children. He remains in solitary play at the block table until clean-up time. When a teacher comments on Jimmy’s block building, “I see you built a tall tower”, Jimmy repeats her sentence but otherwise does not respond. This is typical of Jimmy’s behavior in our classroom. During clean-up time, Jimmy begins throwing blocks randomly. When the teacher intervenes, he stops and walks around the room in circles. We have not observed Jimmy using language for communication with either peers or teachers. He often parrots what is said by others. Jimmy has excellent fine motor skills and spends most of his time using small manipulatives for construction. He appears to enjoy coming to child care as he smiles frequently and plays with the materials. He rarely makes eye contact with others. We look forward to hearing from you so we can be sure we are providing the kind of care that meets Jimmy’s needs during the time he is in our program. Or We are concerned about our capacity to meet Jimmy’s needs and feel he might be better served in a specialized program. Sincerely,

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Coping with Traumatic Events - 10 Tips to Help Children Manage when Disaster Strikes All of us experience fear and anxiety for reasons that range from watching upsetting images on TV to direct involvement in traumatic events from natural disaster to the recent terrorist attacks. Our own past histories and experience dealing with trauma and uncertainty affects our response to traumatic events. Usually, children directly exposed to frightening experiences are likely to suffer with greater anxiety and fear than children whose experience is limited to TV viewing. It is important to note that children who exhibit dramatic changes in behavior, including non-stop worrying, excessive clinging to parent or teacher, or loss of appetite and moodiness, might require professional intervention. The following general suggestions address ways to support children who have been exposed to trauma in varying degrees: 1. Children turn to adults whom they trust when scary things happen. Adults need to role model good coping skills in spite of upsetting events. Be sure to attend to your own feelings so that you can talk with children in a calm and responsive manner. When talking with children, help them get a realistic age appropriate picture of what occurred. 2. Children need information that lets them know that adults are thinking about ways to insure their safety. They may need to be reassured many times throughout their day especially if something happens to remind them of the event (police sirens, loud noises). Patience is important and calming activities can help children feel less anxious and upset. 3. Children benefit from reassurance about community helpers who help to keep children out of harm’s way. You can talk with children about the work of the President, firefighters, etc. to insure our safety. 4. Children need to participate, even in small ways, in community efforts for safety and support. For example, children can make cards for those affected by the trauma. Even if the cards are never mailed, the children have made a positive effort on behalf of healing trauma. 5. Planning for emergencies can include input from children. Even young children can help assemble emergency kits or label emergency supplies. 6. Routine emergency drills may cause added anxiety in some children. Reassure children that there is nothing frightening happening, but practice is important to help with everyone's safety. 7. Avoid re-exposing children to visual images (T.V.) or information about the event. Children need time to work out their feelings, thoughts and fears. Repetition of the event delays their ability to recover from the trauma. 8. Maintain family or school routines as much as possible. Adequate rest and a good diet allow us all to cope better with stress. 9. Children may express strong feelings of anger as they try to understand the "cause" of the trauma. In the event of a natural disaster, children may direct anger at "God" or even worry that they did something wrong to bring about the event. If the event is "man-made", anger may generalize to an entire group of people. For example, following the 9/11 attack it was important to understand that all Arab people were not responsible and that generalizations about groups of people are hurtful. After acknowledging children's strong feelings it is

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important to help them sort out these issues. Understanding natural or man-made disasters by getting factual information is important. Help children separate thoughts from feelings, facts from fears.

10. Find ways to let children know you care about their well being. Grant yourself and children patience and spend time together doing pleasurable activities.

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Helping Your Children Recover from Stress – Advice for Parents x

Reduce your stress and take good care of yourself.

Think about the kind of parent you want to be and your goals for your children: If you need support to reach these goals get help.

Learn and pay attention to your baby’s cues so you can respond and meet their needs. Try different ways to comfort your baby until you find what your baby likes best.

Remember that toddlers can be especially challenging. Create a living space that is “toddlerproof” so you have less need to say “No!” and your toddler is safe from accidents.

Provide comfort for your baby/children through kind words and physical affection.

Respond to your baby/children’s feelings by helping them name their feelings.

Include the stress reduction activities you learned into your daily schedule.

Give children positive ways to solve problems.

Set up routines and rituals that will provide structure and security for your children.

Talk to your children about any changes before they happen. Let them know when it will be time to leave or change an activity so they have some time to adjust.

Provide your children with a predictable and safe environment.

Educate yourself about children’s development so you can understand their point of view and respond.

Avoid yelling and punishing your children. Think of your self as their first and best teacher. If something goes wrong, try to work with your child to fix the problem.

Allow your children to make some choices. Let them know you notice and appreciate the work they do and they choices they make by giving praise. Avoid criticism and negative words.

Read, talk, dance, sing and play with your children. Even 15 minutes a day of focused attention spent enjoying family time will bring rewards for everyone.

Learn how to advocate for your children so they can have positive experiences in childcare/ school.

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Feeling, Thinking and Doing go Hand in Hand As parents of newborns, it is hard to imagine that little babies are already beginning their education. What could babies be learning as they gaze at you, nurse or suck on their bottle and gently drift off to sleep? Recent advances in understanding the connection between infant experience and later development have allowed us to understand that learning begins at birth and that important groundwork for development is laid during those early years. For example, when an infant is hungry, cries and is fed, important messages are conveyed. The infant feels comforted as their feelings of hunger disappear. The infant also learns that their cry brings help and comfort. Soon they will stop crying when they hear a caregiver's voice reassuring them that food is on its way. Babies who are reliably nurtured begin to develop an inner way to understand their experiences. Loving, attentive care helps infants establish good feelings about themselves. From these positive feelings and the regular pattern of nurturing care, the infant also begins to develop a sense of regularity and understanding of patterns which allows for later ability to understand cause and effect. The groundwork for self-regulation begins with reliable, nurturing care. What is self-regulation and why is it important? Self-regulation refers to a person's ability to manage their feelings, behavior, and ability to pay attention. One can think of it as a child having an internal thermometer that they are able to regulate as necessary. Capacity for self-regulation is important because it allows children to focus on learning cognitive as well as social-emotional skills. A child who is overwhelmed with feelings cannot control their behavior or focus on learning new information. Relationships are the most powerful teaching tool for developing self-regulation. Consistent, reliable nurturing allows infants to begin to organize their inside experiences. They learn to nurture themselves as they have been nurtured. When they experience frustration, (for example, delayed feeding), they can self-regulate and thus cope with the delay. Language is also important for helping children develop the ability to self-regulate. Before children can express themselves with words, they are able to understand spoken language but they may not be able to use language effectively to talk with themselves. This "self-talk" helps children when feelings are strong and interfere with their capacity for self-regulation. Sometimes toddlers with aggressive behaviors will become less aggressive as their language skills increase. They can better communicate with others but they can also use "self-talk" to further their self-regulation. For example, a child would resist the impulse to grab a toy from a friend because they are able to remind themselves that grabbing is not a good idea. If they have been lovingly cared for and the words they have heard about themselves have been positive, they are more likely to use positive self-talk and then are also more likely to develop the self-regulation skills required for playing cooperatively with friends and mastering new information. Cognitive readiness to learn cannot be separated from social emotional readiness. Good self-regulation skills allow for success in school. Kindergarten children must be able to control themselves adequately so that they can follow class routines and get along with their peers. They must understand routines and have a basic understanding of cause and effect relationships. The ability to pay attention and to tolerate some frustration is also an important part of school success. These school readiness skills are much harder to achieve and much more important than learning the ABC's or how to stand in line. So, the next time you lovingly comfort your baby or have a pretend meal with your toddler, remember that you are helping lay the groundwork for their later development and school success.

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REFERENCES Family Help Line: 1-800-932-HOPE Referrals for family resources in all 39 counties, 24-hour stress line with tips for handling stress; 24-hour Parent information line; Speak to a parenting coach, available in English and Spanish. www.parenttrust.org Free downloads with parenting tips. www.circleofsecurity.org Parenting information . www.maginationpress.com Books on a variety of topics for children including anxiety, depression, foster care, divorce etc. www.cdc.gov The Center for Disease Control/Federal Government has a variety of mental health related fact sheets. www.naeyc.org National Association for the Education of Young Children has a variety of material for child care providers; Publishes Young Child Magazine, an excellent resource for teachers. www.waeyc.org Our state chapter of the National Association, 800-727-3107. www.zerotothree.org Probably the best resource for information on serving infants, toddlers and their families in child care. www.schoolsoutwashington.org Resource for school age providers on a range of topics to enhance services to after school children, 888-419-9300. www.childcareexchange.com Many articles and resources for childcare providers including a magazine with pertinent articles. www.cfchildren.org The Committee for Children published a violence prevention curriculum called Second Step. www.mentalhealth.org/child/childhealth.asp This is a SAMHSA (Substance Abuse and Mental Health Services Administration) website that provides information on children’s mental health. www.wcpcan.wa.gov Has information about establishing good relationships with parents and supporting parents in your program. Click on the strengthen families link for information. www.strengtheningfamilies.org This site has information for childcare providers on working with parents and having a program that supports families and children in your care. www.medicalhome.org This site provides information on a variety of health related topics including autism and provides good information on working with health care providers. www.doh.wa.gov/cfh/mch/cshcnhome2.htm This will access the Children for Special Health Care Needs Website, information on accessing services for children and the ADA. www.healthychildcare-wa.gov Information on accessing local Public Health child care consultation and info on health and safety issues in child care.

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WELCOME TO THE TODDLER ROOM

A helpful guide for families about toddler biting

CHILD CARE HEALTH PROGRAM Public Health – Seattle & King County

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Welcome to the Toddler Room This is a very exciting time for you! Your toddler is walking and is starting to use words to communicate. Toddlers are filled with energy and love to explore using their newfound abilities to run and jump and climb! They like to make choices for themselves; though of course, they still need a lot of warm encouragement and support from the important adults in their lives. Our classroom environment is designed to support your toddler’s natural interest in exploration and activity. We always have books and puzzles in our classroom and a choice of materials for building and making things. Because many toddlers still experience the world by using their mouth, we make sure all materials are too large to be swallowed. Our daily schedule includes both group time and outdoor time. One of the most important things we are teaching toddlers is self-control and how to make friends. We do this by helping toddlers learn about their own feelings. For example, we may notice that they seem sad or frustrated and we let them know we noticed by describing or naming the feeling; saying things like “Sara, you look very frustrated. Did you want some help with the puzzle?” We try to model empathy for all the children since that will help them develop empathy themselves. Second, we try to help them connect their feelings to their behavior. For example, Sara hits John and we comment: “Sara, you are upset because John grabbed your puzzle pieces. Let me help you and John solve this problem without hitting.” Sometimes, because toddlers are just learning about their feelings, just learning language, and just starting to be social, they turn to biting as a way to communicate. In fact, biting is not uncommon for toddlers in group care. When a child is bitten, we immediately apply first aid. We calmly remind the biter that biting hurts our friends, and if we notice a possible reason for the bite, we help the biter make the connection between what they are feeling and their behavior. For example, if Johnny bites Sam because he wants him to move, we would say: “Johnny, it seems you wanted Sam to move. You can say ‘Sam, please move’.” Even when children do not have a lot of spoken language, it helps to connect their behavior to their feelings in this way. During group time and throughout the day, we remind children about gentle touches and practice gentle touches with our friends. We also teach children how to say no to their friends if something is happening that they don’t like. Usually, as children acquire more language and become familiar with the other toddlers, the biting stops. In the unusual event of a child who bites frequently, we observe the child to identify events that trigger the biting episodes and then develop a plan to help the child stop biting. We will share our observations and plans with you. Sometimes we ask for help from outside resources like our Public Health Nurse. We cannot tell you the name of the biter or discuss the issues pertaining to any child other than your own. However, we assure you that whenever a child is hurt in our program, we take immediate steps to fix the situation and will let you know if your child was involved. We are committed to providing safe, warm, nurturing and responsive care. Please share any information or concerns you have that will help us in providing excellent care for your child. We look forward to working together with you. Thank you for entrusting us with the care of your precious toddler. Sincerely, Your Toddler Room Teachers

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Understanding Biting Behavior When there is biting behavior in the classroom it can be upsetting to all involved: the child who was bitten, the child doing the biting, their families, the toddler room teachers, and other children in the room. Biting occurs most often among toddlers (13 to 24 months old) and should be considered “normal” behavior. Toddlers use their mouths as a tool for exploring their world. They are learning to tell the difference between food and non-food items. Many of their teeth are in and they starting to use words for the first time. They may also be getting new teeth. Toddlers who bite may be trying to get a point across when they don’t expect their words to work, or they may simply be expressing frustration. Toddlers sometimes also bite from loneliness and anxiety or a need for personal space. Children who hurt others need understanding, support, and kindness most when they behave in a most unlovable way. Adults sometimes feel that they will be rewarding hurtful behavior if they tend to the biter as well as the child bitten, but this is an adult viewpoint. Children are not interested in hurting others. They appreciate understanding and compassion when they have shown their more troubled feelings. It is important to understand the whole child rather than focusing on the one behavior. Biting, like all repetitive aggressive behaviors is often the result of a child’s attempt to communicate. In the toddler room we try to reduce the risk of biting by creating a calm and caring environment. Over stimulation because of crowded spaces or high noise levels can contribute to stress in children and increase biting. One study found most bites occur early in the day or late in the afternoon. Children may be especially tired at these times and lose some self-control. You can help your toddler adjust to the transition between home to child care and child care to home by taking a few minutes to make these transitions peaceful and calm and by establishing routines and rituals.

If Biting is a Concern One way you can help is by reinforcing the classroom activities at home. You can teach acceptable ways to express frustration when your child “acts out” at home. You can play picture games of things that are okay to bite and those that are not. You can use children’s books to help teach positive social behavior. Your local library is a great source of picture books showing feelings with simple words that help a toddler understand their feelings and the effect biting has on others.

When to Seek help Please let us know if you have any concerns about your child’s behavior. We will let you know of any troubling behaviors we see in the classroom and work with you in developing a plan. Our Public Health Nurse is available to help with those plans. You might also discuss your concerns with your health care provider, especially if your child is surprised that biting hurts his friends, your child bites the same child repeatedly, or bites frequently and seems unhappy.

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Lenore Rubin, PhD, Child Psychologist, CCHP, 2011

FOR MORE INFORMATION PLEASE CONTACT:

Child Care Health Program Public Health – Seattle & King County 401 5th Ave Suite 1000 Seattle, WA 98104 (206) 263-8658

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SIBLING RIVALRY A helpful guide for families about promoting harmony between siblings

CHILD CARE HEALTH PROGRAM Public Health – Seattle & King County

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Sibling Rivalry Many of us who have taken on the pleasure and responsibility of raising children find that it is a harder challenge than we had imagined. Our children’s behavior can be hard to understand and seem even harder to change. When children are away from us in child care it may feel especially hard to cope with difficult behaviors at either the beginning or the end of the day. One of the challenges parents face is sibling rivalry. Most parents look forward to seeing their children at the end of the workday and are not ready to be confronted with squabbling, unhappy children. Why do siblings sometimes have a hard time getting along? You may notice that sometimes brothers and sisters get along better then at other times. Like everyone, being hungry and tired, feeling unwell or upset can impact a child’s ability to tolerate frustration and their use of coping skills to get along. Children may feel that they are missing out on the attention that their sibling is receiving. They may feel that they are treated unfairly (disciplined differently, rewarded differently) when compared to their sibling. Children may want to play with their sibling but don’t know how to engage them in a positive way.

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Stress Parental stress may decrease a parent’s ability to spend time with their children, increasing rivalry as children vie for the limited attention available. Stress in children’s lives can also hamper their ability to use self-control thus increasing fighting. Sometimes a child’s temperament or personality makes it more difficult for them to get along. Sometimes our own life and family experiences make it hard to relate to our children. For example, your child may remind you of a relative with whom you did not get along. Your child then may feel rejected. What can you do to help your children get along? x

Do not compare your children to each other or anyone else! Every child is an individual. Children need to be supported in identifying their interests and strengths. There is no reason to assume siblings will be the same or should be the same as each other.

Do not label children. For example, statements like “Sara is the quiet one, Jane is the wild one” are not useful. Children are works in progress. Describing them in absolute ways especially when compared to siblings, is limiting and increases sibling resentment.

Establish a household and family life where problems are solved through discussion and everyone’s feelings are considered and respected.

Rather than ask siblings to compete (who can be the first) set up situations where they are rewarded for working together (lets see how fast we can clean the room together).

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All children need some space of their own and the ability to choose how they spend their playtime. Do not force siblings to play with each other or share toys. Often parents ask older siblings to accommodate to the needs of their younger brother or sister. Rather, help younger siblings understand that their big brother or sister is not available at that moment. Teach younger siblings how to ask their sibling to play. If the younger child is a baby or toddler help the older sibling set gentle and kind limits.

Ask the older sibling if they can pick a time when they can play with their sibling. Let them know that sometimes their younger brother/sister wants to be with them but doesn’t know how to play “like a big kid.” Help the older sibling choose some toys that he would consider sharing.

Refrain from lecturing older siblings about their unkind behavior toward a younger sibling: “you’re older, you should know better.” Do not take sides in sibling arguments. Even if big brother hits little sister it is best to comment: “I see you are both upset, let’s sit down together and figure this out.” Offer big brother other nonphysical options for solving problems.

Sympathize with children and reflect their feelings back to them: “It sounds like you got very angry with your sister.”

Have fun as a family. Shared positive experiences help children form positive relationships with their siblings and cut down on fighting.

Make an effort to spend individual time with each child. Even fifteen minutes a few days per week of alone time with each child can make a difference.

If your children attend the same child care program, ask if they can have brief visits during the day. The child care program can support the sibling bond, making it special to be a sibling.

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What about welcoming new babies into the family? To help you understand what it may be like for children when a new baby arrives, consider this: your partner brings home another husband/wife and says, “you will love having him/her here. They can play with you.” Most of us would not be very happy with that situation! We might even become angry and leave. So, how can parents be sensitive to their older children when a new baby arrives? x

Prepare your child for the arrival of a new baby. Enlist their help, if they are interested, in getting things ready for the baby. They may give the baby some of their old toys or clothes. Be prepared if they decide to take them back. They can practice taking care of babies by playing with dolls.

Don’t expect your child to immediately love their new sibling. Let your child know you understand that they may not find their sibling enjoyable right now but that will likely change.

Reminisce with your child about when they were born. Spend time looking at any baby pictures you may have. Let your child know about how you took good care of them when they were small.

Make sure you allow one-on-one time daily with your child. Especially if this is a second sibling, it can be especially shocking to a child to have to share your parents.

Be self-observant and notice if you find yourself having a greater number of negative interactions with your older child/children. Taking care of an additional family member can be stressful and may shorten tempers and increase demands placed on other family members. Incorporate some stress reduction activities into your schedule even if only for 10 minutes a day.

Offer your child emotional support by understanding and supporting their feelings and behaviors. For example, if they become angry with the baby because you are unavailable, rather than asking them to be reasonable and wait, sympathize with their unhappiness about the situation. Let them know you understand that things have changed and that they are unhappy. Remind them that you will always be there even if they have to wait awhile.

Don’t emphasize their new status as a “big boy/girl” as a way to let them know they cannot have what the baby now has. For example, if they cry because of some disappointment rather then comment “you are a big boy now, only babies cry”, comment, “I see you are upset. Come sit with me until you feel better.” Sad feelings of being displaced may make a child feel small. They may go back to behaviors they had long passed by.

Do let them know that they now have special status as a “big brother or sister.” Identify some tangible benefits and let them know what they are. Some examples are: staying up while baby goes to sleep, helping with cooking or other important chores that might be fun.

You can also follow the suggestions for helping children get along listed earlier.

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When children spend their day in child care, family time is limited to evenings and weekends. Family time can thus be more precious, not only for children and their parents, but between siblings. Your children have spent much of their day getting along with other children, following directions, and being part of a group. Adult attention may be especially important.

When to seek help Please let us know if you have continuing concerns about your child’s behavior. We will let you know of any troubling behaviors we see in the classroom and work with you in developing a plan. Our Public Health Nurse is available to help with those plans.

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Lenore Rubin, PhD, Child Psychologist, CCHP, 2011

FOR MORE INFORMATION PLEASE CONTACT:

Child Care Health Program Public Health – Seattle & King County 401 5th Ave Suite 1000 Seattle, WA 98104 (206) 263-8658

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TOILET TRAINING Helping children master a major developmental milestone!

CHILD CARE HEALTH PROGRAM Public Health – Seattle & King County

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Toilet Training A partnership between families and providers Leaving the world of diapers behind and “graduating” to using the toilet is a major developmental milestone for children. Often, toilet training is begun when children are still toddlers. The toddler stage of development is one of transition to greater independence. Using the toilet can be part of that transition. Toddlers are learning to have self control in many areas, and, along with that, is a strong interest in independence and self-actualization. Though no longer infants, toddlers need to maintain the same strong attachments with caregivers that they had in infancy. But, unlike infants, toddlers are interested in asserting their new found skills. The relationship between a toddler and parent may have different kinds of challenges - challenges around control and selfdetermination. When you begin the toilet training process it is important to think about how to maintain that positive nurturing attachment that is so important. Keep in mind that toilet training should not be a power struggle or a struggle that leaves both you and your child feeling upset. Most children are at least 18 months old when they indicate an interest in using the toilet. The child’s developmental level will help determine their readiness to learn. To determine if your child is ready to be toilet trained consider the following: x

Can your child follow simple directions?

Can your child sit and play for at least five minutes?

Does your child signal (grunts, pulls at diapers, facial expressions, etc.} before a bowel movement or wetting incident?

Does your child seem interested in using the toilet (pretending to use the toilet, sits, squats down, etc.)?

Are there any major family stresses (moving, new baby) that might interfere with toilet training? Some suggestions for families

If you decide the time is right to begin toilet training, include your child care program in your plan. There are different recommendations about how to best toilet train your child ranging from training children in 24 hours (foxx) to reward systems. You can review the programs available and make a choice about what may be best for your child. Most programs follow guidelines which include: x

Role modeling, letting the child watch adults/siblings or peers use the toilet.

Reading your child’s cues about the need to use the toilet and offering encouragement to try when the cues are noticed. Child Care Behavior Handbook 2010 Public Health - Seattle & King County, Child Care Program

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Making the toilet feel safe and comfortable for example, by making sure your child’s feet touch the floor, or are on a bench, or using a potty chair.

Some times are scheduled to use the toilet for example, after lunch.

The child is praised when successful.

The child is reassured if not successful about trying again next time.

The importance of positive interactions between parent and child - avoiding a “power struggle” where toileting becomes “child controlled” because of upset.

Some suggestions for child care providers Toilet training is a major milestone in a young child’s life. Because children spend much of the day in child care, you may recognize the signs (listed above) that a child is ready to begin toilet training. As a provider, you can share you observations with the family and offer suggestions and emotional support. Working together with the family, you can help make toilet training a successful and positive one for their child. x

Follow the same procedure in child care as in the home. Use the same words (peepee, poop, etc.) so the child doesn’t become confused about what is required. Pretend play with a doll using the same vocabulary and talk through expectations.

Develop a detailed written plan of communication between child care and family. Keep daily records concerning successes and concerns to share with the family.

Encourage the family to dress the child in easily removable clothing. Keep an extra set of clothing on hand in child care for accidents.

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before going out to play, after lunch, etc. x

Expect relapses and treat them matter-of-factly. Praise the child’s successes, stay calm and remember this is a learning experience leading to independent behavior.

Some children may be frightened by the noise made by flushing. Try to flush after the child has left until he becomes accustomed to the noise

Take time to offer help to the child who may need assistance in wiping, etc.

Most children are interested in pleasing the important adults in their lives so if toilet training becomes stressful and interferes with maintaining a consistently warm and positive relationship with your child, it may be best to let the child know they can try again later when they feel better. Don’t be discouraged or disappointed: allow your child the time they need to master this important developmental accomplishment.

When to seek help In general, girls are ready to learn at a slightly earlier age than boys. Bowel control can precede bladder control. It can take a while before a child stays dry both during the day and at night. If you are concerned about how toilet training is progressing the Public Health Nurse is available to offer help and support. Families might also check with their health care provider for advice.

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Lenore Rubin, PhD, Child Psychologist, CCHP, 2011

FOR MORE INFORMATION PLEASE CONTACT:

Child Care Health Program Public Health – Seattle & King County 401 5th Avenue Suite 1000 Seattle, WA 98104 (206) 263-8658

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[PDF] CHILD CARE BEHAVIOR HANDBOOK - Free Download PDF (2024)

References