Ask a Psychiatrist and Get Answers to Mental Health Questions ASAP
Hello. Welcome to JA.com. Do you mind If I ask a few detailed questions to better understand your daughter's situation?
I see that you haven't had a chance to see my reply. You must be busy right now. I'm online so when you come back to this screen and post a reply, I'll be alerted and return. It may take me a few minutes.
Apologies for the delay in my reply, I am back online now
Thank you. I'd like to start by clarifying the term "child-minder." I think that's a uniquely English term. Does it mean something like "home-daycare"? What is the basic set up there and adult to child ratio?
We are based in Scotland, yes it is essentialy home-daycare by an individual that is qualified and registered with a governing body, in this case the Care Commission. The ratio with this particular childminder is 1:3. The childcare is carried out in the childminders home and the children have a fully equipped playroom and access to a garden to play outside, they also attend 'toddler' groups twice a week where children can interact in groups of around 20 children between the ages of 1 and 4.
I'm sorry, I only see the "United Kingdom" beside location here.
That is an excellent ratio.
To let you know, my orientation here would be an "Attachment-Behavioral" one. From the behavioral side of this approach, I would want to get as precise a behavioral-snapshot description of the attachment behavior in question. What are you seeing and what is the child -minder seeing more specifically, in addition to throwing up? Are there any identifiable antecedents or triggers for these behaviors?
Further, when you say there were "severe separation issues" would you mind sharing a more behavioral description here as well? What specific behaviors did you observe? What identifiable antecedents or triggers?
The childminder has noticed a big difference in Amara in general, she can go a whole day without smiling at anyone, she will play quietly on her own rather than interact with the other children and has even gotten upset when other children have tried to play with her. When her dad drops her off in the morning she is very withdrawn and serious, whereas previously, she would be taking her own jacket off as she was excited to be there. She is a very happy chatty child at home and seems to 'change back' the minute she gets home
That's a great description thank you. And thank you in advance for tolerating my detailed questions to really get a sense of what's going on here and what strategies may apply to help out....
The original seperation issues included constant crying, she would literally not stop for 2-3 hours until a family member could go and collect her, and then stop immediatly when she was in the car, she would throw up as she approached the childminders front door or at least within the first half an hour of being there, at the original nursery that we took her to she wouldn't eat or sleep, hence the reason we removed her.
Ok, so in the initial separation problem it was literally that, separation from her parent, which would trigger her crying. Then the throwing up on approach to the child-minder's. Are you and Amara's father separate,d right now? I'm just wondering if there are also 2 separate homes involved here, for Amara to adapt to in this process or just one.
No we are together and happy
Great for everyone that you are together and happy!
Have you seen any separation issues at all unrelated to the nursery or child-minder's?
It's sinking in now for me, the dist
distinction between the nursery and childminder's..
Her Aunts, her father's sisters, look after her 2 days a week, at first they did experience issues with the seperation but this was more around if they had visitors or took Amara to meet anyone she would get upset rather than it being an issue of her being with them, this is why we felt that she suited being cared for in a 'home environment' better than in a nursery
Sorry, forgot to say that they haven't experienced any issues in this recent episode
No, I see now you are very pro-active and supportive parents who do their research.
So the child minder has observed no environmental changes that would correspond to the "separation" behaviors. There is some observable "stranger anxiety". And just to be clear, do you think that your husband dropping her off vs you, may have had something to do with the change in behavior?
It is very rare for me to do the 'childcare run' due to work commitments so her dad generally does this. There has been one recent change at home in that previously Amara didn't see me in the morning as I left for work before she woke up and I didn't get home from work until around 20mins before her bedtime, this changed around 3 weeks ago and I am now at home until she leaves in the morning and when she comes home at night. We did think that this change may have been the trigger as she enjoys the time that she has with me in the morning, but it seems to be specific to the childminder and not her Aunts and this has now been the norm for almost 1 month.
Great information again thank you.
Sorry, I probably should have pointed this out sooner!
No problem, there is so much need information to get these things right. So back to the childminder, what's being reported now (the observable behaviors of concern) is the throwing up and the task/social interaction avoidance. Is Amara not interacting or playing with the childminder as well as the other children? Is there some preferred (high-probability behaviors) activities that she will engage in compared to others, both with children and the CG?
Is it general or activity-specific avoidance?
Are there desired activities she does but with low social interaction as a constant?
The only thing that she seems happy to do is to sit and look at books and will allow the childminder to read to her, actually, I believe tha this is specifically what she was doing today when she was sick!
What does Amara's physician say is going on here? Have you consulted any other professionals on this issue? What is the childminder's view?
At first we all (myself, her dad and the childminder) put it down to the change in her routine with now having to 'leave' me in the morning, but this doesn't seem to have affected her behaviour at her aunts. We haven't consulted any other professionals yet. The childminder is very determined to try and get through this, but seems to be at a complete loss as to how to achieve this. The original seperation issues were a massive challenge and strain on all of us but it almost seemed logical, whereas this almost feels as though she is somehow regressing
Have you talked to your family doctor about the throwing up? My concern is that there may be some underling medical issue, perhaps related to diet or food intolerance that may be a contributing factor?
I agree that the next thing that we have to do is speak to the doctor. There isn't an issue with the food intolerance as we provide all of her meals and snacks, which is the same food that she eats at home
Ok, thank you for that. I have the sense that you may have already considered my next question, but I am really interested in a detailed account of what worked last time; - what specific strategies or interventions were instrumental in helping Amara adapt and adjust to the change from the nursery to the childminder's?
I'm just writing out a flow chart I wish I could share with you mapping the changes through the different environments...
It was a long process, 2 months! The immediate differences were that she ate and slept at the childminders from day 1 which she had never done at nursery, so that was incentive enough for us to persevere! The childminder dedicated alot of her time to Amara one to one, comforting her for the length of time that she cried (although crying doesn't seem to be an issue this time) if I am being honest the biggest breakthrough actually happened when we went on holiday, Amara was getting more relaxed with the childminder when the 3 of us had a family holiday, she had quality time with her father and I and seemed to come back a different baby! She was immediatley happier and more relaxed. The biggest difference between now and then though is in Amara's development, she can now walk (she only started walking at 20months) and can communicate very well so we do have the luxury now of being able to try and talk to her about it which we couldn't before.
Yes, Amara sounds like an incredibly bright and sensitive child. So she really responded and recalibrate emotionally through the joint relaxation and quality time of the family vacation. Your saying she came back from this time away with you and your husband and was far more emotionally resilient, she didn't cry or throw-up at the childminders there after until your change of schedule at work. Is that fair to say?
I almost spontaneously want to ask if you can go on such a vacation again for 3 days together!
Not until June!
Ok, but I just had to mention that.
Well that has been some very practical information. My plan now is to go and produce a formal "answer" to your question. Do you have any other points of of information or observation that you think will be helpful here before I start?
Thank you for that. Nothing that I can think of other than the thing that I find most odd is that when Amara does come home from the childminder at night she is happy to talk about her day (including that she through up!) exactly in the same way as she did before, it isn't as if she had such a terrible time she doesn't want to talk about it, don't know if that helps any!
Thank you for trying to help!
No that makes sense. Avoiding a recollection of an uncomfortable experience for a child or adult for that matter, is like avoiding the uncomfortable experience in the first place physically if you can, by simply walking away from it. One very good thing here is that her memory is clear for her so there's likely nothing "traumatic" just uncomfortable. Regrettably even with an extremely bright and expressive child like Amara we can't get the high quality of behavioral observation and description that would be really helpful here. But remember, most adults don't know how to look for subtle behavior changes (including mood), as manageable antecedents to behavior, not even the childminder herself.
There's a certain level of detail in my answer. I also have to work with some oth
My answer should be posted here for your review by 8:30PM your time. You'll get an e-mail alert once I post it. Does that make sense?
Yes it does, thank you for your time.
Your very welcome.
Hi again. Thank you so much for all of the detailed information you provided during our chat earlier. I’d like to commend you and your husband for being such wonderful, proactive and loving parents.
It’s very difficult to provide a detailed solution-focused answer to your presenting question, because with such a vibrant, intelligent, communicative and sensitive child like your Amara it is very important to have very detailed behavioral observation and to test ongoing strategies for helping her adapt her way out the current conundrum.
First, I’d like to reinforce the importance of talking with your family dr. about the throwing up and behaviors of concern. Although what we’ve been talking about may be primarily behavioral and psychological, there could also be a subtle medical issue contributing to her current pattern of responding at the child-minder’s. It’s in Amara’s best interest to really rule any and all potential medical contributors out.
From the behavioral angel, you can also systematically rule out medical factors or non-behavioral interventions by really learning and helping the child-minder to observe “behaviorally”. There are 2 important areas to pay attention to. The first thing to watch for are “contingent antecedents” to her behaviors of concern. The second are called “distal antecedents”. Proximal antecedents are the ones that happen within a second or 2 of the behavior change.
An antecedent is any person, place, thing or subtle stimulus change (social or environmental) that comes right before the behavior of concern. Often and especially with mood and emotion in children, the child’s own behaviors can be the antecedent to their own behavior of concern.
One example of a very subtle antecedent that a sensitive intelligent child can easily pick up on would be care-giver behavior’s associated with compassion fatigue. A subtle but normal change in eye contact or a sense of frustration on the child-minder’s part could be associatively reminiscent of the kind of role overload that is commonly seen in nursery staff, from the previous care-environment. I’m not saying this is the case here; I’m just giving one of many possible examples, that can only be gleaned through more refined behavioral observation and even simple data collection or charting in some cases.
Distal antecedents are environmental events and changes that precede the behavior of concern by more than a few seconds like in proximal antecedents. “Distals” can sometimes take place hours or days before the behavior. For example, from our chat, your brief change of work schedule can very likely be viewed as a distal antecedent to the current your daughter’s current behaviors.
Proximal and distal antecedents can often work together in a behavioral effect. For example, your change of schedule may have set the emotional tone for a 2 way response. If your daughter was missing you that day, her subtle emotional communications and increased need for proximity and soothing could have elicited the subtlest compassion fatigue response in the child-minder, (as I’m sure you know good research shows that meeting the emotional, social and developmental needs of single child Amara’s age is considered a full time job) that would not have influenced your daughter if there wasn’t a schedule change. This is an effect I have observed in children in real time, but again it serves only as a theoretical example here.
You also touched on the recuperative effect that the 3 day family vacation had on Amara. When a child’s attachment behavioral system is stimulated by a sense of separation anxiety, there can be subtle changes in their little nervous systems that can take some time to recover or recalibrate. Beyond rephrasing what you already knew an expressed, you may consider a similar vacation as an adjunct behavioral parenting strategy if the following recommendations fail independently.
Here are some suggestions to help Amara readjust:
Refine your already excellent parenting strategy to look for what works. I think really starting to learn more about ABC’s behavioral observation (this is a pun because ABC stands for Antecedent, Behavior, and Consequence) will really make a difference in helping Amara get back on track when the normal schedule changes or other potential attachment triggers come up.
The difference here would be to really start to experiment and observe. One of the most powerful tools for managing the social withdrawal and task avoidance behaviors and even to counter the mood changes that can go with attachment-responding is to find and work with high probability behaviors towards increased activity and on-task time. Questions to ask here are what are some novel and enjoyable new tasks apart from looking at and reading books that can be introduced?
Front end interventions or supports are one important strategy. That’s where you look for and reduce identifiable antecedents to the problem behaviors and intervene immediately or do your best to get rid of or to replace the problem antecedent.
It’s often best to combine front-end interventions with back-end interventions through the use of positive reinforcement. A positive reinforcer is any stimulus you deliver within 1 second of a behavior that reliably predicts and increase in that same behavior next time, under similar conditions. Reinforcers are very child specific so again, it’s good to experiment with different types and combinations. This is called a reinforcer assessment process, and you can actually get charts to help you optimize this process. Verbal praise is usually very powerful, stickers, sing-song praise, a short celebration dance/song healthy edibles, when appropriate or when other reinforcers are not as effective.
Targeting and shaping replacement behaviors can also be very helpful here, so you have something that is helpful to Amara to reinforce. So you could shape a specific behavior to get involved with an activity that she can easily access when things are difficult.
Of course she knows these social skills already implicitly and does them when naturally motivated because she’s brilliant, but the idea is to have a set behavior that she practices with you when things are fun and that is densely positively reinforced.
If you use specific parental instruction word’s like “let’s draw and earn some stickers!” The child-minder can use the same antecedent instruction and then reinforce the behavior similarly. This kind of behavioral parenting intervention would only be indicated as a “scaffolding” tool for when Amara is having difficulty, - to help distract her, manage her mood and get her moving again naturally. Then you don’t need the behavioral intervention any more. It’s much like “activation therapy” for adults across a wide spectrum of issues.
You don’t need to intervene once the natural and logical consequences of her natural behavior take over the reinforcement function again. It’s like providing a cast for a bone to heal. In another metaphor, the distraction and increased pro-social activity this would allow may provide similar conditions to taking a short vacation, allowing her emotional system to recover and recalibrate.
Here are some further learning resources to consider this perspective and evidence-based intervention and support approach:
Here is some more detailed info on positive behavior change:
Here’s a good site that explains Attachment fairly comprehensively:
The “incredible years is a great behavioral parenting program that has very positive effects on attachment. Here’s a free article on its application in a daycare center in an impoverished neighborhood. The sited research and positive behavioral effects are quite helpful:
I’m doing some online research for you to find resources on the kind of behavioral strategy I’m advocating. It’s difficult to find popularized articles on this topic because your daughter is so bright. So much of the available online resources are for kids with severe, traumatic attachment disorders and real problem behaviors.
A final suggestion I have is you may want to consider working with a Board Certified Behavior Analyst. They can provide very tailored and simple intervention tools and strategies to very precisely target positive replacement behaviors (like increased social and activity involvement at the child-minder’s. They would also be able to provide you with “simple data collection tools for the child minder to use. I know from my work as a behavior consultant for a major school board that data collection can often positively change care-giver interactions and help alert them to strategies and observations they often miss otherwise.
BCBA’s are the hidden gold mine for evidence-based behavior change interventions. They are most often associated with ABA for children with autism, where in most cases they can academically and socially normalize an otherwise highly under-functioning autistic child. However BCBA’s also work in every facet of psychology you can think of. They are even working in businesses to help increase performance and help people get along with through the same behavior change principals I’m talking about here.
You may even be able to work at no cost with a Master’s level BCBA student who is accumulating hours towards board certification. In that case you’d have the BCBA candidate and the highly experienced BCBA supervisor helping you to intervene here. You can work with BCBA by phone and online as well if there isn’t one in your area.
Here is the BCBA link to learn more:
Actually here are some Scottish BCBA’s you could talk to. They will generally provide you with free initial consult to see if you, Amara and them, are a good match. You can also ask about BCBA students who might want to work with you under supervision for free. BCBAs are specially trained to look for and rule out non-environmental sources of behavior as well, which would help any other professionals you would then work with:
Well I hope, my answer has been helpful, and our chat thought provoking. Sometimes just hearing another opinion helps you to refine your own. If you feel I’ve missed something in my answer I can opt-out and let another expert take a crack at providing you an answer. Don’t pay for an answer you don’t like. Just let me know.
If you find value in my answer, please don’t forget to press the “Accept” button at sign out. I’d also very much appreciate your positive feedback statement that JA.com provides quickly once you accept the answer.
I wish Amara, you and your husband the very best!
Thank you very much for your detailed response, we will definately carry out further research in the areas that you have suggested and involve the childminder in our approach.