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Terrible Twos, Tranquil Threes and Fearsome Fours
(email a question)
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Question:
I am an occupational therapist with a high number of children recovering from brachial plexus injuries on my caseload. Recently an early 3 year old with a mild ROBPI returned to me with parental complaints of increased scapular winging. There was scapular winging, a 15 degree loss of elbow extension and supination to about neutral. I recommended the BPI TheraTogs kit as one of the treatment options. Parents obtained the garment and came for a fitting. By the time the pelvic segment was placed (2 to 3 minutes) it was obvious that as a team we had failed to ask this child for her input. She became more distressed and agitated with each minute. Do you have any recommendations for this child/situation?
Answer:
This sounds like a very intelligent 3 year old. The old saying is “terrible twos, tranquil threes and fearsome fours”. She seems to have skipped through to the fearsome fours, so she is bright. The problem is that she has a serious problem that needs treatment and some of it, she will not like. As professionals, we have the responsibility to help the parents understand. I use the analogy of the 3 year old with juvenile diabetes. That child does not agree to or like the daily blood tests and insulin shots, but they get them and they adjust. Parents and professionals understand that the treatment and testing is necessary for the child’s life. And the 3 year old does not have the option to opt out.
Somehow, in pediatric neuro-rehabilitation, a lot of people approach the issue as if the tests and treatment are optional. In my view they are not. Winging scapula in a 3 year old is progressive. If she has an elevated scapula, surgery may be needed. She may respond to taping a bit better as you work towards introducing the TheraTogs...there are options. (Many of them will be covered in our Albany course, May 19-20. If there is enough interest, we may do a DVD of it.) But this child’s first priority is some behavior management and the family has to understand the consequences of letting a 3 year old make life altering decisions. The shoulder joint is precious. If it is damaged, she will have pain and increased disability as she grows. Dr. Waters did a terrific review article on BPI. He said that progressive deformity was the rule in children as they grow and he is right.....If you do not treat the problems early, they get worse. TASC Network is committed to the concept of active treatment of the problems in the hopes improving the outcome. The parents have the responsibility of working for the best possible outcome for their child. It will be tough for them to do what she needs. But a distorted, painful shoulder is not a good outcome. So talk to the family first. Speak to the Pediatrician and enlist help. Consult with all the Child’s team to see what the options are for managing this problem. Then just do it.
Parents are welcome to write in their questions as well. Working together is the best way to change outcomes. And when the going gets tough, remember that lots of 3 year olds want to play with matches. Saying “no” to unwanted behavior is easy when you clearly understand the result of giving in and giving up.
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