Behavioral Concerns

Hi, I am an occupational therapist. I have a question regarding a child with DS, 4 years old. She has behavioral concerns such as defiant behavior, cannot finish a given task, and throws toys or objects presented to her when she gets frustrated. I’m having a hard time giving a structured activity as she inconsistently complies. Another concern of the parents is that she does not like to eat solid food since last week and would prefer milk but she usually eats solid food.

Thank you for your response.

Hi! And welcome to our community!

One part of the Down Syndrome diagnosis is stubbornness and self directedness, so it’s not unusual for that type of behavior to appear during sessions.

Not sure what the child’s cognitive level is, but a picture schedule might be a good option- you and she alternate picking activities, but it’s all drawn out so it’s known what’s expected.

I have also found that in therapy sessions, sometimes we have to ignore or work with the behaviors rather than trying to change them. For example if the child drops to the floor and won’t stand up, sit down with her and start doing a floor activity or rolling a ball. It sometimes works, sometimes doesn’t, but it’s about focusing on what the goals of the session are- Behavior modification or therapy goals.

I don’t have any recommendations regarding the food. I know many children like milk because it’s very pacifying. Maybe if the parents offer the milk in a different cup than her usual so it’s less of an emotional support? It’s just an idea, I’m not really sure.

It’s probably also worth a conversation with her pediatrician to see what suggestions they have or how much milk is appropriate for her. If the picture schedule works during sessions, maybe a meal/milk schedule could be an option

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Anyone have any suggestions?

Thank you so much for this!

I have a follow up question. If the child tries to manipulate you i.e. she immediately cries when a non-preferred activity is given but immediately stops when the activity is removed or when she is able to escape, what if would you do? Redirection seems to be very hard since children with DS would love to do self-directed activities. Also, at home, her parents would always give in to her demands immediately (if she cries, parents try to pacify her with milk).

Would a firm TUS be possible in this situation or would you rather not use kind firmness?

Thank you so much for your response.

I’m not an expert in behavior, just lots of experience as a PT. I would probably play independently in front of her through the crying for a short time, or attempt to include her then switch to a preferred activity so she sees that the non preferred does have an end-then show her on the picture schedule that her activity comes next. Then I would extend the duration of the non preferred activity by a few minutes over the course of a few sessions.

I always try to start with love, but some children do respond better to firmness and showing that you have expectations that you expect her to meet, so it’s really trial and error of what works with this specific child.

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What I have done in these situations is I start small. I have a task that if I would normally want 10 reps I do 1 or 2. If it goes well we will repeat those. But if it doesn’t I often have them finish the task even if it’s hand over hand and then we get to put it away and move on to the next task. But we don’t move on until it’s complete. I just meet them where they are at and work to expand reps and time from there. I often find with kids with DS keeping the routine the same each session can help. If you want to add something novel in add it at the end in case it ends the session. It can take a few sessions but it can help with getting more compliance. Hope that helps!

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Visuals! Find out what the child enjoys and make an easy visual reinforcement chart. I’ve had even the most stubborn child with DS work for stickers or baby shark pictures! Music can also be helpful. I try to avoid videos because then once you start with that it’s hard to break away.

I’d also continue to have parents monitor the feeding and maybe even keeping a written log. I’d want to tease out if this is behavioral or if it may be stemming from oral motor or sensory issues which would warrant additional referral.

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The child goes to OT 2x a week and though I have seen progress especially in transitions as she can already start another activity regardless if it’s preferred or non-preferred. My problem for this child would be task completion. We can’t seem to finish a non-preferred activity with 10 reps. I tried adjusting the reps but she just can’t do it, even if I have given activity modifications.

When we tried a hand/finger painting activity, she would not participate and would try to escape. I tried to consider sensory issues, but when I tried to give a feedback to her mother regarding this concern, she stated that the child likes to play with paint and she even tries to paint the whole playroom. Same goes with playdoh, when we try to play with playdoh, she would refuse to play with it whenever I tell her to do so, but she can also play with playdoh when she is alone.

I tried to be firm with her and with my demands and asked her to finish the activity, but she would refuse to participate and would throw task objects presented to her instead of putting it on her worksheet in front of her. Also, she would try to escape.

I also tried to consider sensory issues and I found out that she also has tactile sensitivity issues (slime, glue). But then, the parents stated that she refuses to take in food that she previously eats. She would only ask for milk. I tried to incorporate feeding in pretend play. We tried to feed her stuffed animals then we would take turns to feed each other. Out of 10 attempts to feed her, she was able to take in finger food for 4 times.

Also, would it be correct if I asked the parents to not give her milk or to tell the child that milk is not available and see if she would ask for a different food?

Start small and make it 1 touch. Whatever amount you choose, make it so there is success so you can build on that. Even if it’s hand over hand and they get a little upset and then the next activity is a preferred activity.

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How we use language is so important in how we understand the problems we are trying to solve so I’ll just add some food for thought here. Defiant behavior and compliance draw our attention to the behaviour as a problem, rather than the activity that the child is struggling with. Why can she not finish a task? What is it about the task, the environment, the context that makes finishing the task difficult? What can you change about those things that you CAN change that can lead her towards being able to attend and push through challenges in the future? You can’t change the child but you can change the task and context. All behavior is communication, so what is she telling you?
Regarding food - a sudden change in appetite may indicate so many things. Just off the top of my head I might think her 4-year-old molars are coming through her gums making her mouth sensitive, did she have a tummy bug, constipation, a sore throat etc. These can quickly escalate into behavior issues with parents if feeding is forced and a week or so of her preferring milk is not a train smash. So the bottom line is rule out any medical issues and then just back-off and monitor. If it persists as an issue past a few weeks then definitely think about psych and dietician support as refusal to eat can quickly escalate and be tricky to manage.

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