Boundaries

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Boundaries are essential to healthy relationships and, really, a healthy life. Setting and sustaining boundaries is a skill. Unfortunately, it’s a skill that many of us don’t learn, according to psychologist and coach Dana Gionta, Ph.D. We might pick up pointers here and there from experience or through watching others. But for many of us, boundary-building is a relatively new concept and a challenging one.

Having healthy boundaries means “knowing and understanding what your limits are,” Dr. Gionta said.

Below, she offers insight into building better boundaries and maintaining them.

Name your limits: You can’t set good boundaries if you’re unsure of where you stand. So identify your physical, emotional, mental and spiritual limits, Gionta said. Consider what you can tolerate and accept and what makes you feel uncomfortable or stressed. “Those feelings help us identify what our limits are.”

Tune into your feelings: Gionta has observed two key feelings in others that are red flags or cues that we’re letting go of our boundaries: discomfort and resentment. She suggested thinking of these feelings on a continuum from one to 10. Six to 10 is in the higher zone, she said.

If you’re at the higher end of this continuum, during an interaction or in a situation, Gionta suggested asking yourself, what is causing that? What is it about this interaction, or the person’s expectation that is bothering me?

Resentment usually “comes from being taken advantage of or not appreciated.” It’s often a sign that we’re pushing ourselves either beyond our own limits because we feel guilty (and want to be a good daughter or wife, for instance), or someone else is imposing their expectations, views or values on us, she said.

“When someone acts in a way that makes you feel uncomfortable, that’s a cue to us they may be violating or crossing a boundary,” Gionta said.

Be direct: With some people, maintaining healthy boundaries doesn’t require a direct and clear-cut dialogue. Usually, this is the case if people are similar in their communication styles, views, personalities and general approach to life, Gionta said. They’ll “approach each other similarly.”

With others, such as those who have a different personality or cultural background, you’ll need to be more direct about your boundaries. Consider the following example: “one person feels that challenging someone’s opinions is a healthy way of communicating,” but to another person this feels disrespectful and tense.

There are other times you might need to be direct. For instance, in a romantic relationship, time can become a boundary issue, Gionta said. Partners might need to talk about how much time they need to maintain their sense of self and how much time to spend together.

Give yourself permission: Fear, guilt and self-doubt are big potential pitfalls, Gionta said. We might fear the other person’s response if we set and enforce our boundaries. We might feel guilty by speaking up or saying no to a family member. Many believe that they should be able to cope with a situation or say yes because they’re a good daughter or son, even though they “feel drained or taken advantage of.” We might wonder if we even deserve to have boundaries in the first place.

Boundaries aren’t just a sign of a healthy relationship; they’re a sign of self-respect. So give yourself the permission to set boundaries and work to preserve them.

Practice self-awareness: Again, boundaries are all about honing in on your feelings and honoring them. If you notice yourself slipping and not sustaining your boundaries, Gionta suggested asking yourself: What’s changed? Consider “What I am doing or what is the other person doing?” or “What is the situation eliciting that’s making me resentful or stressed?” Then, mull over your options: “What am I going to do about the situation? What do I have control over?”

Consider your past and present: How you were raised along with your role in your family can become additional obstacles in setting and preserving boundaries. If you held the role of caretaker, you learned to focus on others, letting yourself be drained emotionally or physically, Gionta said. Ignoring your own needs might have become the norm for you.

Also, think about the people you surround yourself with, she said. “Are the relationships reciprocal?” Is there a healthy give and take?

Beyond relationship, your environment might be unhealthy, too. For instance, if your workday is eight hours a day, but your co-workers stay at least 10 to 11, “there’s an implicit expectation to go above and beyond” at work, Gionta said. It can be challenging being the only one or one of a few trying to maintain healthy boundaries, she said. Again, this is where tuning into your feelings and needs and honoring them becomes critical.

Make self-care a priority: Gionta helps her clients make self-care a priority, which also involves giving yourself permission to put yourself first. When we do this, “our need and motivation to set boundaries become stronger,” she said. Self-care also means recognizing the importance of your feelings and honoring them. These feelings serve as “important cues about our well-being and about what makes us happy and unhappy.”

Putting yourself first also give you the “energy, peace of mind and positive outlook to be more present with others and be there for them.” And “When we’re in a better place, we can be a better wife, mother, husband, co-worker or friend.

Seek support: If you’re having a hard time with boundaries, “seek some support, whether that’s a support group, church, counseling, coaching or good friends.” With friends or family, you can even make “it a priority with each other to practice setting boundaries together and hold each other accountable.”

Consider seeking support through resources, too. Gionta likes the following books: The Art of Extreme Self-Care: Transform Your Life One Month at a Time and Boundaries in Marriage (along with several books on boundaries by the same authors).

Be assertive: Of course, we know that it’s not enough to create boundaries; we actually have to follow through. Even though we know intellectually that people aren’t mind readers, we still expect others to know what hurts us, Gionta said. Since they don’t, it’s important to assertively communicate with the other person when they’ve crossed a boundary.

In a respectful way, let the other person know what in particular is bothersome to you and that you can work together to address it, Gionta said.

Start small: Like any new skill, assertively communicating your boundaries takes practice. Gionta suggested starting with a small boundary that isn’t threatening to you, and then incrementally increasing to more challenging boundaries. “Build upon your success, and at first try not to take on something that feels overwhelming.

“Setting boundaries takes courage, practice and support,” Gionta said. And remember that it’s a skill you can master.

 

Beautiful Girls

Beautiful Girls

How could I raise confident daughters if I didn’t get comfortable in my own skin first?

                Beautiful. That was the word my 8-year-old daughter Chloe used to describe herself. “I am beautiful,” she wrote, meticulously underlining the word and then smiling up at me, proud that she’d completed her second-grade spelling-word sentences. In disbelief, I read it again. It was number-two-pencil proof that a daughter of mine not only had good handwriting but a positive self-image. I glanced over at her twin sister’s paper. Without pausing to ponder whether her teacher might think she was conceited or seeking my opinion first, Willow had written, “I am a beautiful girl.” I was elated: Low self-esteem wasn’t hereditary.

                But was it inevitable? I sadly wondered, realistically, how long their confidence would last. Even if my daughters managed to retain a strong sense of self in the face of future recess rejection, tween tumult, and size-zero celebrities, a major obstacle remained: me, their supposed role model. Feeling good about myself was a daily challenge.

                When my girls were born, I vowed not to infect them with the guilty-about-every-bite madness I’d been struggling to shake since my teen years as a ballet dancer. I knew it was my maternal obligation to keep the negativity in my head and out of my mouth, so it couldn’t cream into their heads and out of their mouths. Even if true internal change wasn’t possible yet for me, self-criticism, at least in my daughters’ presence, wasn’t an option.

                I kept my promise. If I had a bad-scale day, I kept the disappointment to myself. When I was overwhelmed by pizza-gorging guilt, mum was the word. I proudly told friends I never used the word fat with my girls, as if that were a noteworthy feat. But to me, reining in the inner ramblings that unconsciously but continuously haunted me was an accomplishment. I was the picture of restraint.

                Unless, of course, nonverbal communication counted. When we dined out, did my daughters notice that I ordered what I thought I should have – never what I wanted – and then enviously eyed their father’s more appealing (and less healthy) meal? During all those trips to the restroom, did they watch me lift my shirt, look in the mirror, and examine the relative flatness of my mid-meal stomach? Did they see my palm press against my abdomen when I was finished eating? I clearly remembered seeing my own mom smooth her hands along her hips and sigh.

                My daughters begged me to wear no makeup (“We like your true self better”), but I felt naked without it. When we went shopping, they brought colorful, clingy dresses and skirts to the dressing room for me and I said, “Maybe next time” while trying on yet another pair of black pants. At the pool, they yelled, “Swim with us, Mommy!” But I remained safely clothed on a chaise lounge, preferring the company of a good book to the discomfort of exposing my body in a swimsuit. What was I really revealing?

                I have a picture of myself at age 5 that I’ve always loved. I’m in the backyard wearing only a pajama top and underwear, my long blond hair tousled from the night’s sleep, my cheeks the color of the pink rose cupped in my hands, my eyes bright an happy. Even as a teenager, I yearned to be that little girl in the photo again, fresh from joyfully running and playing in the yard, unburdened by concern that my thighs looked chubby in the natural light. I wanted my daughters to be the carefree girl I once was: to smile, twirl, and admire themselves. And so, I complimented their mismatched outfits even when they bore little resemblance to the coordinated ones I carefully chose in the store. I embraced their pudgy bellies protruding from too-tiny but cherished bikinis. I dropped them at school with kisses and tried hard to ignore their unkempt “but Mommy, I like it” hair. I encouraged their hard work, generosity, and empathy, and reminded them to always love themselves first and forever.

                Was it enough? And could I keep it up as my daughters grew and their smooth skin and baby teeth transformed into blemishes and braces? I cringed to think that I might see my own awkward past self reflected back at me. I worried they’d sense disapproval in my eyes or in my words, even if I did my gushing best to conceal my doubts.

                I asked my one truly together friend, Nancy, how she’d become so well-adjusted. She told me that her mother was neither over-complimentary nor critical of her and her three sisters. Instead, she demonstrated what she – and by extension, they – were capable of achieving: Her mom climbed trees and played baseball. She definitely jumped into the pool.

                “I am awesome. I am awesome,” one of my daughters repeated no long after that homework incident. First she said she was beautiful; now she was awesome too. “Did someone at school say that to your today?” I asked her. “No,” she said. “It’s just how I feel inside.”

                Then, it hit me. Despite my best intentions, I hadn’t been the perfect role model, but so far my girls were doing just fine. Maybe I could abandon the goal of acting like a superconfident mom – she’d be too hard for my daughters to live up to anyway. Would I start whining about my weight and hurling too-small skinny jeans across the room? Nah. Instead I’d take a page from Nancy’s mother’s playbook, and show my daughters the things I do well. Not tree-climbing, but listening, emphasizing, and sharing my stories of survival (think eye patch and thick glasses at summer camp). And yes, I could even drop my towel, say a silent “I’m awesome,” and dive into the pool.

Kids Who Feel Too Much

JANE: Shot July 8

 

Children with sensory processing disorder sometimes overreact or underreact to touch, sounds, and food textures. Doctors debate the condition, but parents say it’s real, and therapists say it’s treatable.

                Playdates, parties, meals at kid-friendly restaurants are the types of activities you’d expect to fill the days of a typical 3-year-old boy. But that’s not the case for Charlie Phelps of Raleigh, North Carolina.

                “We usually avoid restaurants,” says Charlie’s mother, Katie Phelps. “I don’t do playdates because he could pitch a fit – it’s not unusual for him to throw himself into walls – or wander off by himself. I don’t want something to go wrong and for people to start seeing him in a different light.”

                She is thinking specifically of a Christmas party that ended in tears – both Charlie’s and hers. Her son, then 2, couldn’t keep his eyes off the Polar Express train chugging around a miniature track. He had no interest in decorating cookies, playing with other kids, or doing anything that involved leaving the train. After about an hour, Phelps thought that stopping the train might encourage Charlie to join the party.

                “All hell broke loose,” she remembers. Charlie screamed with an intensity that most kids save for shots at the doctor’s. Phelps tried explaining that the train was tired and needed a nap. She tried distracting her distraught son by telling him about the other fun activities. She took him outside, hoping the cool air would help. When Phelps was out of options and Charlie couldn’t settle down, she decided it was time to leave. “He screamed and kicked like a bucking bull all the way home,” remembers Phelps. He was still crying as she carried him into the house, but he managed to look up at her and say, “Mommy, you rock baby,” referring to a calming ritual she’d created. Phelps brought her son to the recliner, held him tight and whispered “Rock, baby” in his ear repeatedly as they settled into the comforting motion of the chair.

                “We did that for 45 minutes, and then he put his hand on my face and said, ‘I so sorry, Mommy,’” says Phelps. “I put him to bed, went to the front porch, and bawled my eyes out.”

                Of course, every mom of a toddler could tell similar tales, but for Phelps this particular story is not an isolated incident. Charlie has these kinds of outbursts often: when the wheel he’s watching on the grocery store cart comes to a stop, when another child gets near the toy he’s playing with, or when Phelps tries to trim his fingernails or take him for a haircut.

                Though frustrated by his behavior, Phelps hadn’t wanted to make too much of it. “We just thought he was a difficult 2-year-old,” she says. Friends and family seemed to shrug off these behaviors too, with comments like, “He is such a boy.” But some of Phelps’s relatives quietly questioned whether Charlie might have autism, and when he went to preschool, his teacher immediately noticed how strongly he objected when he was asked to transition from one activity to another. She suggested Charlie to be observed by the county’s early-childhood-education intervention services so that she could learn ways to help him. This led to a more formalized evaluation to test for suspected language delays.

                As it turns out, Charlie was not diagnosed with autism, though he did have a language delay. An occupational therapist determined that his inability to go from one activity to the next and his penchant for ramming into walls was a result of sensory processing disorder (SPD), a condition that is common in children who have autism but also affects a surprising number or young kids who do not. Though recent studies show the condition impacts as many as 5 to 10 percent of kids, the mainstream medical community still has not officially endorsed SPD as a diagnosis – which means that insurance won’t cover therapy for it.

 

Mixed Messages

                SPD affects the way a child processes messages sent to his brain from any of the five main senses – sight, hearing, taste, smell, and touch. He might have mild sensory intolerances or he might find it extremely difficult to handle sensory stimulation (such as when he’s at a busy grocery store or a loud sports event). Normally, if a child is tapped on the shoulder, his nervous system informs his brain that he received a light touch. For a child with SPD, the message can get misinterpreted and the child may feel that he was hit hard. Or the message may get completely lost, leaving him unaware that he’s been touched at all, explains Lucy Jane Miller, Ph.D., founder of STAR Center, an SPD therapy and research facility in Greenwood Village, Colorado. Most kids with SPD are a mixture of both over- and under-sensitive, which explains why inconsistent behavior is a hallmark of the disorder, adds Lindsey Biel, an occupational therapist (OT) in New York City and coauthor of Raising a Sensory Smart Child.

                Two lesser-known senses that can be affected by SPD are the vestibular and proprioceptive systems. They detect incoming sensory information, which is then delivered to the brain. Vestibular refers to movement sensations such as swinging or going down a slide. The proprioceptive system provides information to the muscles and joints, like telling the legs to apply more pressure when walking up stairs than when walking on flat ground, for example. If messages from the proprioceptive system get confused in the brain, a child might appear to be excessively clumsy or aggressive because he’s not aware of how much force he’s applying.

                Continuously receiving jumbled messages can be frustrating for a child, and his inexplicable reactions to everyday happenings can be confusing to his parents. His behavior can become even more unpredictable when he’s asked to transition from one activity to another, as was the case with Charlie. When a child’s nervous system is working so poorly, it can take him a long time to focus and settle into what he’s doing, explains Biel. Asking him to turn his attention to something new could be just too much for him.

                Every child can have trouble shifting gears sometimes, but it’s the number of senses affected and the severity of symptoms that will determine whether a child is considered to have SPD. Much as with autism, these symptoms occur on a spectrum. If a child’s sensory needs are intense and persistent, everyday activities that are necessary for social, emotional, and educational growth might be difficult for him. This has repercussions down the line. For example, your child might not like the sensation of Play-Doh in his hands. This may not seem important, but manipulating squishy objects is one way kids develop the muscles and coordination to accomplish skills that will be necessary later, says Dr. Miller. A child who avoids using his hands in these developmental years may later have difficulty holding or maneuvering a pencil.

 

Rewiring the Brain

                More than 40 years ago, occupational therapist and neuroscientist A. Jean Ayres, Ph.D., developed therapeutic treatments to address what she called “sensory integration dysfunction.” Though the term for the disorder has changed to SPD, the basic principles or Dr. Ayres’s therapy are still being used as the foundation for the methods many OTs use to treat SPD. Treatment consists of carefully designed, multisensory activities that challenge one or more sensory systems simultaneously – such as swinging while throwing beanbags at a target, which present both a vestibular and a visual challenge. The goal: to help build neural pathways that can lead to appropriate responses to information that comes into a child’s brain through the senses. This is time-consuming and requires frequent repetition, but it’s necessary. “Nerves that fire together wire together,” explains Biel. “So each time you practice something, you strengthen the neural connections so that it eventually becomes automatic.”

                Since Charlie began working with an OT, Phelps and her husband have learned to recognize when Charlie needs extra stimulations, often by using the mini trampoline their therapist recommended. “We’ll say, ‘Okay, it’s time to jump!’ He holds on to the handle and jumps, and it really calms him.” A treatment like “brushing” is another technique used with children who react too strongly to stimuli. A specially trained therapist uses a soft plastic-bristled surgical brush to apply deep pressure to a child’s skin and make her feel more relaxed. It’s a widely used method but also controversial. There’s no scientific evidence to prove its effectiveness.

 

A Disputed Diagnosis

                In the past year, SPD has taken some big hits from the medical community. Last June, the American Academy of Pediatrics (AAP) released an updated policy statement on SPD, saying it should generally not be diagnosed because studies have yet to prove that it’s completely separate from other developmental disabilities, such as autism and ADHD. “We can see kids have problems, but are they related to another disorder or are they from their own disorder?” asks pediatrician Larry Dresch, M.D., a lead author or the statement and member of the autism subcommittee of the AAP’s Council on Children with Disabilities.

                Equally problematic for the SPD community was the fact that the disorder was excluded from the new edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5, being released this month), which is what doctors and therapists use for diagnosis and treatment guidelines. Clinical psychologist Matthew M. Cruger, Ph.D., is among those who believe SPD is not a separate condition. “Parents describe sensory symptoms, which are clearly distressing for the child and the parents. I don’t minimize that what they see looks like sensory struggles. But the children I work with often end up being described as having autism or ADHD,” says Dr. Cruger, senior director of the Learning and Development Center at the Child Mind Institute, in New York City.

                “It’s not an obvious diagnosis,” says Dr. Miller, who adds that the behavior of a child with SPD can be confused with that of a kid who may have overlapping behaviors and a different diagnosis, such as ADHD. A child who doesn’t get enough proprioception will seek ways to stimulate his muscles and joints – continuously moving, or chewing constantly on non-food items such as straws and pen caps, she says. What’s more, roughly 40 percent of the time kids have both SPD and ADHD, found a study by Dr. Miller and her colleagues.

                The American Psychiatric Association has not ruled out making note of SPD in a possible online version of the DSM-5, where it along with other proposed disorders, will be mentioned, says David Schaffer, M.D., former chair of the division of child psychiatry at Columbia University, in New York City. This can encourage further research on the disorder, which will help determine whether to include SPD in the future, says Dr. Shaffer, who was on the committee that determined what was included in the manual.

                Occupational therapists say that SPD treatment should complement therapy for other issues, potentially making it easier to improve a child’s overall behavior and development. “When a child is more sensitive to touch, he may avoid close contact with other kids during free play,” explains Rachel Rudman, an occupational therapist in Lawrence, New York, with a specialty in pediatrics. “If that issue is addressed and he begins to participate in group play, he’ll also have more opportunities to practice and improve his language skills.”

                Pediatrician and Parents advisor Ari Brown, M.D., has seen sensory therapy work in her own patients. “There’s value in it for kids who are struggling socially and in school,” she says. Although she believes “a child doesn’t need to have a diagnosis to need help,” she also recognizes that this presents a real challenge for families who can’t afford to pay out of pocket for occupational therapy sessions that can cost $130 an hour or more. For them, she has this advice: “Your child might qualify for services under a different diagnosis code. For example, kids often have motor problems and OT will be covered for that,” explains Dr. Brown. Children can also be treated through the school system; many children receive therapy because they qualify for special-ed services.

 

Seeing is Believing

                As the medical world sorts it out, parents like Lori Kennedy say they don’t need a manual to tell them whether SPD is real or whether it can be treated with occupational therapy. Without OT, her 7-year-old son, Davis, might still have problems with his coordination, and a diet consisting of nothing more than Cream of Wheat, Malt-O-Meal, and vanilla ice cream.

                When Davis was 6 months old, Kennedy offered him a spoonful of baby food. “He had the most violent reaction,” she recalls. She got lots of “picky eater” advice from doctors and therapists, but it wasn’t until Kennedy took her then 2-year-old to a pediatric clinic specializing in occupational, speech, and physical therapy that she finally heard something different: Her son’s eating issues stemmed from SPD. The diagnosis made sense to Kennedy. “He also wouldn’t wear any kind of enclosed shoes so he wore flip-flops everywhere,” says Kennedy, of Austin, Texas. “We took him to the beach in Florida and as soon as we put him on the said he’d cry hysterically.” An OT explained to her that for Davis, the sensation of walking on the sand felt more like walking on broken glass.

                During weekly sessions at the clinic and at home, Davis would chew on a rubber straw to help him strengthen the muscles in his jar and get used to sensations in the back of his mouth. Davis had quick success in most areas; his coordination improved immensely and he mastered the playground obstacle course he’d had no success with before. But progress with food was slow to come. Finally, when Davis was 3, the therapist was able to feed him oatmeal and peanut butter.

                He received help because his SPD involved a developmental issue (feeding) that was covered by insurance. His second-grade teacher helped him get services in school, citing Section 504 of the Rehabilitation Act of 1973, which protects kids with disabilities from being discriminated against at school. Davis is excused from class on Friday mornings to attend therapy provided by the school, his desk is near the teacher’s desk, he’s given extra time to complete tasks, he’s allowed to sit on an exercise ball rather than a hard chair, and Velcro is attached to the underside of his desk so he can access it when he feels the need for sensory input. “He’s getting everything he needs,” says Kennedy.

                Charlie, on the other hand, only gets therapy nine months out of the year because his school system stops services in the summer. Last year, Charlie’s parents borrowed close to $4,000 so their son could continue his therapy. “He’s been working so hard,” says Phelps. “I didn’t want him to lose everything over the summer and have to start all over again when the school year started.” Charlie is on target to meet early learning and cognitive goals for his age, but this is the result of a lot of hard work. “If he could rock in his dad’s recliner and drink chocolate milk out of a straw all day, he would,” Phelps adds. “But he needs to do other things, a little bit at a time. So we’re doing everything we can to get him ready before he goes to kindergarten.”

 

Spotting the Symptoms

A child with SPD regularly exhibits many of these behaviors:

  • Finds any of the following intolerable: loud noises; dirt on her hands; having hair, fingernails or toenails cut; receiving an unexpected hug; walking barefoot on grass or sand.
  • Doesn’t notice when touched; almost always prefers sedentary activities to active ones; seems unaware of bodily sensations such as heat, cold, or hunger.
  • Uses either too much or too little force when, say, holding a pencil, or tapping someone’s arm.
  • Is passive, quiet, slow to respond to directions.
  • Is excessively cautious and afraid to try new things; upset by transitions or unexpected changes; avoids group activities.
  • Wants to spin or swing excessively; takes many risks during play and is constantly moving.
  • Is accident-prone and has difficulty with physical skills such as riding a bicycle or catching a ball.
   

If you’re worried about your child, it’s best to have a comprehensive evaluation by a multidisciplinary team that includes your child’s pediatrician, as well as a psychologist and an occupational therapist who specializes in sensory issues. To find a therapist, go to spdfoundation.net, click on “Find Services,” check the box for occupational therapist, and add your state. Those with the “SPDF” icon next to their listing have advanced training in SPD.

 

Speak Up for Kids’ Mental Health in May!

Parents is partnering with the Child Mind Institute to recognize National Children’s Mental Health Awareness Month. To learn how you can watch online talks being given this month by leading experts in the field of mental health, go to childmind.org/speakup.

Fighting Back Against Asthma

Fighting Back Against Asthma

Having a kid with the disease can be scary – but this advice on managing it, from a pediatrician and mom who’s been there, will help you and your child breathe easier.

                Watching a child with asthma struggle to breathe is terrifying and heartbreaking. I’ve seen it as a doctor more times than I can count, and it never gets easier. I’ve experienced it as a mother too; my older son had asthma and would cough and have trouble breathing when he exercised. I worried about him every time he went to swim practice in elementary and middle school, and so wished there was something I could do to make the problem go away.

                About one in ten kids has asthma, according to the Centers for Disease Control and Prevention, and those numbers are higher in urban areas and among some ethnic groups. But a diagnosis doesn’t have to be a daily challenge for your child. In the 20 years I’ve been a pediatrician, we’ve come a long way in understanding and treating asthma. Working with their doctor, parents can do a lot to help their children.

 

When Airways Act Up

                To understand the condition, you need to know what lungs look like inside. They aren’t big bags that fill with air when we breathe, as I used to think when I was a kid. They are more like sponges, solid structures made up of lots of tubes, called airways. The airways start out big with the trachea, commonly known as the windpipe, and then branch out into smaller airways, called bronchioles. As we breathe, the air goes down into the tiniest airways, where it gets really close to the blood – and the oxygen from the air gets transferred into the blood.

                When a child has asthma, those airways get irritate and swollen, usually as a reaction to something, and the air can’t get in. The more irritate and swollen they are, the harder it is for him to breathe, leading to an asthma attack. There are drugs called fast-acting or “rescue” medications that relax the muscles that constrict the airways, and others known as controller medications that try to reduce the inflammation. Sometimes the symptoms go away easily, with medication or rest or avoiding whatever is triggering them. But in other cases they persist, and kids need additional treatment or even to go to the hospital.

 

Stopping Attacks

                It’s a relief to learn there are things that you can do to help control this seemingly out-of-control condition. Know the triggers. For some children, it’s the pollen in spring. For others, it’s the neighbor’s cat, cold air, or cigarette smoke. For many, catching a cold does it – and exercise can be a problem too. If cats make your child wheeze, ask about pets when arranging playdates, and avoid houses with them.

                It’s not always easy to know what your child is allergic to – which is why, when I have a patient whose asthma acts up frequently, I send him to an allergy specialist for testing. The info we get from blood tests or skin-prick testing is invaluable; in many cases, a child is allergic to something nobody expected – or not allergic at all (which means the family doesn’t have to go crazy cleaning or get rid of their cat). Have an Asthma Action Plan. This written plan details exactly which medications your child should take, and when. The specific plan will depend on your child, but the ones I use have three zones: Green (she’s breathing normally), Yellow (she has a cough or other mild symptoms), and Red (she’s having trouble breathing or speaking, her rib cage sucks in when she breathes, she has a cough that won’t stop). Green-zone drugs are meds that your child takes every day even if she’s well, and they may include controller medications. In the Yellow zone, we may increase (or add) controller meds and use albuterol or some other rescue medication. A child in the Red zone will usually take more rescue medication while you’re getting her medical attention. But in my experience, when parents are alert to signs that their child is in the Yellow zone and follow the instructions in that part of the plan, it helps stop things from getting worse.

                Use controller medications faithfully. These prevent of minimize the body’s response to triggers, and they can make a big difference. They’re usually inhaled corticosteroids taken through an inhaler or a nebulizer. (A nebulizer is a machine that works sort of like a humidifier, putting medication into a mist that your young child inhales.) Some parents worry when I say the word “steroid,” but the doses we use are generally too low to cause problems. If a child has a severe asthma attack, we often have to treat it with higher doses of oral steroids to stop the wheezing. These are far more likely to cause side effects and we can avoid them by consistently using lower-dose controller meds. In kids with allergies, taking daily antihistamines or using a nasal corticosteroid spray helps.

                It’s the daily part that’s key with these kinds of medications, and yet taking something every day can be hard. Parents may start thinking the medicine’s no longer necessary – which is easy to do when your child seems totally healthy. I often have to remind them that it’s exactly because of the controller medications that their child is doing so well!

                Learn to give medicine correctly. If your child uses an inhaler, you should have an aerochamber or “spacer.” This is a wide tube that attaches to the inhaler and funnels the medicine so that it gets into your child’s lungs instead of her mouth or the air around her. For a younger child, it’s best to use one that has a mask that fits over her mouth and nose. Then all she has to do is take some deep breaths, and voila: The medicine is where it needs to be.

                A mask is also important when using a nebulizer with a little kid. Learn how to clean the tubing and how often to change it, as well as how to know if the machine isn’t working right (usual first clue: It takes longer than normal for a treatment to finish). Ask your pediatrician to demonstrate how to use an inhale or a nebulizer. See the doctor regularly. Go at least every six months, or more often if your child’s asthma acts up frequently. That way your doctor can monitor symptoms and see whether more, less, or different medication is needed – and work with you to find ways to figure out and manage triggers. You can also be sure that your child is getting treatments or tests (such as spirometry, to measure exactly how and how well she breathes) that will help her live a normal life.

                After all, that’s the goal. We don’t want children to have to worry about something as simple and fundamental as breathing. We – doctors and parents alike – want all kids to be able to be, well, just kids.

 

Can You Prevent Asthma?

Although there’s no proven way to steer clear of asthma, there are steps you can take to reduce your child’s risk of developing it. They are particularly important if there is a history of the disease in your immediate family.

  • Avoid smoking – during pregnancy and after – and don’t expose your child to smoke.
  • Breastfeed for at least four to six months, and longer if possible, to strengthen your baby’s immune system.
  • Know that pets are not necessarily a problem. Children born into a home with a dog – especially more than one – or a cat, to a lesser extent, appear to be at a lower risk of developing asthma. (But if your child develops asthma later, you’ll need to find another home for your animals.)
  • Wait until at least 4 months before you start solids, and begin with just a tablespoon of pureed food or cereal once a day.
  • Reduce your child’s exposure to allergens in the air, particularly dust mites. Use dust-mite covers for pillows and mattresses; try to limit the use of rugs and curtains because they trap dust; and wash bedding well weekly in hot water.
  • Try not to spend time outdoors on days when the air quality is poor (check airnow.gov). Children who are exposed to high levels of air pollution are more likely to have asthma.
  • Keep your home free of mold and cockroaches.
  • Minimize the use of antibacterial products and antibiotics. Many experts theorize that our reliance on these has caused our immune system to develop in ways that make allergies and asthma more likely. It’s for similar reasons that kids who grow up on farms are less likely to have asthma and allergies. We don’t understand this fully, but certain germs seem to be good for us. I’m not sure that having a dirty kid or making regular trips to the petting zoo will help, but at least you don’t have to go nuts about sanitizing everything.
   

 

When It’s Time for a Specialist

Your child should meet with a pulmonologist or a specialist in allergy and immunology, preferably one with pediatric training, if:

  • He has a known lung problem – such as one related to having been born prematurely.
  • Allergies are suspected and not easily controlled with antihistamines.
  • He often has sinusitis, ear infections, or pneumonia.
  • He needs to use his rescue inhaler more than twice a week, has either frequent symptoms (a few days a week or more) or severe attacks, even with treatment.
  • You want more help learning about and managing your child’s asthma than your pediatrician is able to give you.

Go Wild!

Go Wild

 

Spend the day at one of these animal centers, and let the kids hang out with their favorite creatures.

 

Farm Fun

Old MacDonald, look out! While many farms let kids pet or feed animals, these locations offer more barnyard activities and family events. E-I-E-I-go!

Slide Ranch

Muir Beach, California

Lake Metroparks Farmpark

Kirtland, Ohio

Green Meadows Farm

Eight locations in the U.S.

 

  • This former dairy ranch turned nonprofit teaching farm in Golden Gate National Recreation Area near San Francisco puts together many super-cool, half-day family programs on weekends year-round. Activities often include milking a goat, cooking from the organic garden, collecting eggs from chickens, and spinning wool from sheep. On May 25, there’s even a special program for families with toddlers that emphasizes using your senses to explore the farm. In addition, several times a year the ranch offers overnight family campouts focused on farm activities and nature exploration. Programs typically cost $25 and up per person, with discounts for families and free admission for babies; slideranch.org.
   
  • About a half hour from downtown Cleveland, this 235-acre farm has more than 100 animals, including llamas, baby goats, horses, lambs, and pigs. Kids can help milk a cow, watch a cheese-making demonstration, and, on certain weekends, help make ice cream by hand. After you finish at the barn, you can take a wagon ride to the Plant Science Center (with gardens and interactive exhibits) and the Woodland Center (to learn about maple sugaring, which requires 40 gallons of sap to make one gallon of syrup). Time your visit with one of the farm’s many special events – such as HorseFest, on May 18 and 19, when kids can groom miniature horses and make a lasso. Admission is $6 for adults; $4 for kids ages 2 to 11, free for younger kids; lakemetroparks.com.

 

Children’s Farm at the Center

Palos Park, Illinois

  • During a two-hour guided tour, families can learn about pigs, cows, horses, sheep, goats, llamas, and more. Everyone can milk a cow, touch a chicken, pet a duck, hold a rabbit, and hug a donkey – all Green Meadows locations focus on close contact with the animals. Some locations also have train and tractor rides. Farms are in Hazlet, New Jersey; Grand Prairie, Texas; Kissimmee, Florida; Floral Park, New York; Waterford and Sherwood, Wisconsin; Jessup and Fredrick, Maryland; admission varies, starting at $12 per person, kids 2 and under are free; greemeadowsfarmnj.com.

 

  • This nonprofit farm in the Chicago area hosts “family time” on weekend afternoons, when kids can brush a sheep, hold a baby chick, and become buddies with bunnies. Hayrides are one of the highlights of the Summer Farm Festival, on June 1. Admission is $4 for adults, $2 for kids ages 2 to 17, children under 2 are free; thecenterpalos.org.

Underwood Family Farms

Moorpark, California

 

  • Animal shows are the highlight for kids at this farm about 45 minutes north of L.A. Set in a hand-painted amphitheater; the shows take place three times a day on weekends and holidays from March to November. Kids in the audience can volunteer to find chickens hiding behind the doors built into the backdrop or call Bingo, a black Lab, to come out from backstage. At the end of the show, kids can pet the animals. Save time to pick your own produce – strawberries, oranges, avocados, and lettuce are in season in May. Entrance fee is $3 to $6 per person, depending on the day, free for kids 2 and under; underwoodfamilyfarms.com.

 

 

 

Wildlife Adventures

Hang out with animals your kids may have never seen before. These places deliver up-close encounters in a more natural setting than many zoos offer.

Virginia Living Museum

Newport News, Virginia

San Diego Zoo Safari Park

Escondido, California

  • Red wolves, foxes, a bobcat, and a coyote are among the animals that families can see along the museum’s ½-mile, stroller-friendly boardwalk through woods and wetlands. Visit during one of the monthly storytimes, which pair a book (like Olivia Owl) with a visit from an animal (a screech owl). The museum also offers an aviary with 16 bird species, a butterfly garden, and a walk-through “swamp” with an alligator and a turtle. Admission for museum and boardwalk is $17 for adults; $13 for kids 3 to 12, free for younger kids; thevlm.org.
 
  • Unlike the zoo downtown, this 1,800-acre park about 45 minutes north boasts more than 3,500 animals, mainly in a cageless, free-range environment. Families can take a safari tram ride to see rhinos, giraffes, and elephants roaming the fields. Plan to be there in the afternoon for the cheetah run – the park is the only one in the nation that lets the animals race at full speed. If the kids get tired, take a break by playing in the spray fountains and shaded, animal-themed rest area. Admission is $44 for adults, $34 for kids ages 3 to 12, free for younger kids; sdzsafaripark.org.

Flamingo Gardens Botanical Collection & Everglades Wildlife Sanctuary

Davie, Florida

Fossil Rim Wildlife Center

Glen Rose, Texas

  • Although feeding flamingos gets top billing at this nonprofit attraction near Fort Lauderdale, it’s home to more than 90 animal species. “Most were rescued from the wild and can’t be released because of injuries,” says Keith Clark, managing director. During wildlife-encounter shows, held three times a day, trainers bring out animals such as snakes and birds and talk about their importance to the environment. Stop by Kidz Fest on May 27, for free pony rides, games, and crafts. Admission is $18 for adults, $10 for kids ages 4 to 11, free for younger kids; flamingogardens.org.
 
  • With more than 1,100 animals roaming 1,800 acres about 90 minutes from Dallas. Fossil Rim may be the closest you’ll get to an African safari. As you drive through the 9 ½-mile trail, you can open your windows or sunroof and feed giraffes, ostrich, antelope, deer, and many others. “We breed a lot of animals here that are in danger of extinction, like cheetahs,” says Warren Lewis, director of marketing. About halfway through the drive, stretch your legs at the Children’s Animal Center, where kids can pet goats, pigs, and emus. If you’re not wild about making the trek in your own vehicle, the center also offers guided tours. Admission is $21 to $24 for adults, $15 to $18 for kids ages 3 to 11, free for younger kids; guided tours start at $27 per person; fossilrim.org.

Oatland Island Wildlife Center of Savannah

Savannah, Georgia

  • On the center’s 2-mile trail, families cross three types of animal habitats – maritime forest, salt marsh, and freshwater wetlands. Among the dozens of animals you’ll see: gray wolves, Southern flying squirrels, and a red fox. Pack a picnic lunch and enjoy it at the tables dockside, where you might even catch a glimpse of dolphins and diamondback terrapin turtles. Every Tuesday morning, there are special programs for toddlers, including wildlife nature walks. Get in free on May 18 from 10 A.M. to 2 P.M. to celebrate Coastal Wetlands Day and see tidal creeks up close. Admission is $5 for adults, $3 for kids ages 4 to 17, free for younger kids; savannah.chatham.k12.ga.us/schools/oat.

 

Where the Wild Things Are

Visit national parks and wildlife refuges to see animals in their natural habitat. Get more details at nps.gov and fws.gov.

ALLIGATORS:

Everglades (Homestead, Florida)

BATS:

Carlsbad Caverns (Carlsbad, New Mexico)

CONDORS:

Grand Canyon (Arizona), Pinnacles (Paicines, California)

DEER:

Grand Canyon, Grand Teton (Wyoming), Zion (Utah), Yosemite (California)

DOLPHINS:

Channel Islands (Ventura, California), Olympic (Washington), Ten Thousand Islands (Naples, Florida)

ELK:

Grand Canyon, Glacier (Montana), Rocky Mountain (Colorado), Great Smoky Mountains (Tennessee)

MOOSE:

Yellowstone (Wyoming and Montana), Grand Teton, Acadia (Bar Harbor, Maine), Silvio O. Conte (Sunderland, Massachusetts)

PELICANS:

Everglades, Channel Islands, Pelican Islands (Florida)

SEA TURTLES:

Everglades, Padre Island (Texas), Archie Carr (Florida), Canaveral (Florida)

WILD PONIES:

Assateague Island (Berlin, Maryland), Cumberland Island (Saint Mary’s, Georgia), Cape Hatteras (Manteo, North Carolina)

Independent Streak

Independent Streak

Your child is eager for more freedom, but should you give it to her? Experts help you make the call.

                At the supermarket, my 8-year-old, Stella, begs me to let her pick a box of pasta by herself. At home, she wants to flip pancakes on the stove. And, she asks, could I please leave the bathroom while she showers? Sure, Stella is growing up, but I worry about her independent nature interfering with her safety. “It’s normal for some kids this age to ask for more responsibility,” says Parents advisor Jennifer Shu, M.D., medical editor for HealthyChildren.org, the website of the American Academy of Pediatrics. “You don’t want to hold your child back, yet it’s common to have reservations about whether she’s really mature enough.” Experts says yay or nay to five common big-kid requests.

 

Showering Solo

                Yay! Your kid probably switched from a bat to a shower a while ago but still needed some help to shampoo his hair and work the faucet. If he can now handle both on his own, they’re signs that are able to shower on his own, says Dr. Shu. Just stay within earshot until you’re confident that he has the hang of it. Transferring shampoo to a pump bottle can make it easier for him to get it out – and not overpour. Also put down a nonslip mat and remove sharp object, like razors.

 

Cooking On the Stove

                Nay! Kids need to be at least in middle school to work on the stove independently, says pediatrician Andrew Adesman, M.D., chief of developmental and behavioral pediatrics at the Steven and Alexandra Cohen Children’s Medical Center of New York, in New Hyde Park. Whether your child is ready to flip pancakes or stir-fry veggies with your close supervision depends on her maturity and impulse control. But avoid cooking over high heat and boiling water because the contents can splatter and burn her. Never let her carry a hot pot, pan, or tray.

 

Using a Public Restroom Alone

                Maybe! It’s usually fine as long as you stand outside the door so your child is within earshot. An exception: “In a loud, crowded place, like an amusement park or a stadium, you should have someone else, whether it’s another child or a parent you know and trust, go in with your kid,” says Dr. Adesman. “If that’s not possible, you may have to bring him to the women’s restroom with you.”

 

Taking a Pill

                Yay! “Kids this age have been taught how to swallow pills,” says Christine Chambers, Ph.D., a clinical psychologist at Dalhousie University and the IWK Health Centre, in Halifax, Nova Scotia. Her technique: Ask your child to put a tiny round cake-decorating sprinkle on her tongue, take a drink, and swallow. Then do the same with a slightly larger candy, working up to a Tic Tac or an M&M and having her swallow it whole.

 

Grocery Shopping

                Yay! “It’s fine to let your child separate from you at the supermarket as long as you are able to see him the entire time,” says Dr. Shu. But establish ground rules first – for example, he has to come back to you immediately and never go to another part of the store without talking to you first.

Play Nice!

Play Nice

Help your child successfully navigate the social scene.

                When my daughter invited her friend over for a playdate, I was surprised that the girls were bickering within minutes. Even if kids have had plenty of playdates before, experts say that glitches are common at this age. “Most kids have shifted from parallel play (where they play independently next to each other) to cooperative play (where they actively play with the other kid). However, they still want the other child to play what they want and on their terms,” explains Caron Farrell, M.D., Ph.D., a child psychiatrist at the Seton Mind Institute, in Austin. If your child’s last playdate was a disaster, try these tips for a happy get-together.

 

Time It Right

                Playdates are less likely to be successful when kids are tired. So if you find that hosting them right after a full day of school or camp results in two cranky kids, consider switching to weekend mornings, when everyone is well-rested. And don’t let get-togethers drag on. “An hour is actually a long time for a kindergartner to play,” says Dr. Farrell. “An hour breaks into about three to five different play scenarios with time for a healthy snack.” Even for kids who are used to playing together, cap playdates at two hours.

 

Review the Rules

                Before the other child comes over, talk with your kid about how to be a good host. Remind him to take turns picking what to play and prepare him by rehearsing common scenarios, like how to respond if he and his friend can’t agree on an activity. Explain that if his toys are out, they are fair game and the other child can play with them. Then give him the option to put away anything special he doesn’t want to share, like that Lego tower he spent hours building the night before. If your child really seems to have a hard time sharing his possessions, Dr. Farrell recommends moving playdates to neutral territory – such as the playground or the library – for a few months, until he warms up to the idea.

 

Have a Social Agenda

                While Candy Land is an excellent game for you play with your 5-year-old, it’s best to avoid games that could leave one child in tears. “Quite simply, kids this age are not good losers – even waiting patiently to take turns is a challenge,” explains Susan Diamond, a speech-language pathologist and author of Social Rules for Kids.

                “Instead, encourage noncompetitive activities like playing outside on the swingset or running around on the yard.” Five- and 6-year-olds are often fascinated with anything that involves pouring, measuring, and basic counting, so baking (with your help) is also a great option, as are crafts or playing house. Finally, electronics like Wii can be a (small) part of the playdate if both kids enjoy it. “Children today interact and relate by playing video games together,” says Diamond. “Just set a timer for 20 minutes. When time is up, the electronics go off and they need to choose a new activity.”

 

Oversee the Situation

                While your child may want some independence and privacy when she has a fried over, kids this age need to know that you are present. “It’s a good idea to check in regularly by showing up in the doorway every five to ten minutes,” says Diamond. Another option: Listen in on playdates with a strategically placed old baby monitor if your child and her friend are playing out of sight. Of course, don’t forget to offer up praise if they’re playing nicely when you check in. “Positive reinforcement goes a long way at this age,” says Diamond. “Give kids specifics like, ‘I love how you’re taking turns with that rocket ship! I’ll check back in ten minutes.’ Rewarding them with a little more space will encourage them to repeat the good behavior.”

 

Manage Meltdowns

                Resist the urge to jump in at the first sign of trouble. “Kids squabble; that’s how they learn to solve their differences. So give them a few minutes to try to work out disagreements on their own,” suggests Daniel Hilliker, Ph.D., a child psychologist at the Mayo Clinic Children’s Center in Rochester, Minnesota. However, if the situation turns to shouting, becomes physical, or the kids seem to be unable to come up with a solution, then you need to get involved. When tensions rise, first separate the children for a few minutes so they can calm down. After that, briefly talk it out and provide some suggestions for compromise. Then, have each child apologize to the other before quickly moving on to a diversion, such as a new activity or game. Should you tell the other parent when things go south during a playdate? “If there were a few harmless spats, then there’s no real need to bring it up,” says Dr. Hilliker. “However, if the other child consistently refused to follow your rules or things got physical, you should talk about it with the child’s parents. Think to yourself, ‘What would I want to know?’ and use that as your guide.”