Let me share an article 'The role of parenting in developing communication skills in infants and toddlers- an experience from a Child Development Centre', which I sent to the Developmental Paediatrics Unit at CMC Vellore, for a conference, which was arranged in April, 2023 at Vellore.
I have updated the article, giving some more information on the child development initiatives that ASHIRVAD, Developmental Paediatrics Department at MOSC and the department of Physical Medicine and Rehabilitation of the Bangalore Baptist Hospital, jointly sponsored during the last four years.
In fact, at the fortieth year of ASHIRVARD, an initiative for Child Development, started in 1983, fostering development of its services in Chennai, Nagpur, Vellore, Pondicherry, Bangalore and Kolenchery, the following narration of the events and experiences of the last four years highlight some of the aspirations we pursued.
During my morning walk recently, I noticed tender cashew nuts covered with red ants in the cashew tree inner garden. I felt awful. The red ants suck the sap from the pulp of a tender nut, which would have become a full cashew nut in few months. If not sprayed with insecticides, these nuts would have considerably reduced the pulp inside, sometimes leaving them as a shell without any pulp!
The cashew nuts have to survive this vulnerability!
1 The changed infant nurturing practice
It was while walking back to our cottage after sighting the cashew nuts covered with ants, some thoughts about the vulnerability of an infant in the changing circumstances, in which they grow up now, dawned on me. For most part of my childhood and later years, till the technology revolution invaded the homes from the nineteen eighties, with the use of the colour TV, computer, internet, later the Mobile phone, iPads, etc, parenting was an interactive process between infants and parents. The parenting process of a new born was at the centre of a family’s daily rhythm. Now infants and toddlers have to adapt to the priorities parents choose for themselves. Now in the words of Dr Susan George, while referring to the technology invasion in our home capturing the pre-school children, wrote: 'Their bodies are with us but their mids are sold'!
I remember how parents used to sing to their children, tell stories, read stories from picture books, play with them with balls made of paper or coconut palm leaves, go to a nearby stream to play in the water, play in the sand, make clay models, etc,. Even when I was training to be a paediatrician in the seventies, it was common for parents to give reasonable attention to promote communicative habits in infants and toddlers by engaging them in play.
Just as the red ants invade and harm the tender cashew nuts, the overuse of mobile phones, TV, internet and iPads distract and impair the normal development of language, communication and social skills of pre-school children! The machine interface has replaced the normal physiological human interface between infants or toddlers and their parents.
2. A challenge to Infant’s processing skills
The auditory system of an infant is conditioned to recognise human voice from few weeks after birth. The visual cortical system enables an infant to recognise the mother's face by about three months and develop a reciprocal smile with a familiar person by four to six months. The human voice, facial appearance, the feel of the person who often carries the infant, his or her odour, the touch and strokes on the face and hands or rituals during bath time, feeding time or while or changing the napkins create a sense of familiarity and curiosity in an infant.
An infant, who babbles or makes jargons sounds in the latter half of the first year, as early imitations of regular sounds heard at home, goes on to express variety of sounds, syllables and words before the first birthday. An infant wants to communicate and reciprocate as he or she grows up in an environment of words, gestures, actions, pictures, singing, etc. Being in such an environment increases the communication instinct of an infant.
Now about seventy percent of pre-school children, who come to the Child Development Centre, where I work now, are brought by their parents, for not having shown the proficiency of language development expected at two or three years. The history of many infants is that, from the time of starting the weaning food at six months, they were introduced to the visual screen of TV or Mobile phone, where they watched advertisements, cartoons or other entertainments for four to six hours during the day. Some of them slept late and developed fragmented sleep due to the over-activation of their visual and auditory systems. Since most mothers, if they work outside home, return to work after six months of the maternity leave, the breast feeding got discontinued and a third person would have taken charge of the infant care. This further hampers the development of attachment behaviour between the infant and parents, required as a foundation for developing normal language and communication process.
The eco-system of the human interface is replaced by the machine interface, which might be a factor for the current explosive numbers of toddlers brought to Child Development Centres for delay in their language, social skills and behaviour. Is this a consequence of making the TV or Mobile phone as the 'Third parent' !
3. A change in co-parenting
The machine interface is an invader that displaces infants and toddlers from being attentive to human voices, their faces and interactive communication. Adding to this, if the infant is left without the usual rituals of being sung to (not listening to music from the phone), played with, taken for social contacts with adults and children, or engaged in play at home with toys and household articles, then the delay in the interactive and communication process would get compounded.
The mind set of some parents currently from what I come across, is that the Internet, Mobile phones, cartoons, etc are good for pre-school children as they would help to develop proficiency in language early. What toddlers do is repeat the machine language in the way they heard in the cartoons, without knowing the meaning or context. They parrot a language which is too early for the brain to process for its semantics, pragmatics and prosody. The colourful screen, animations, movements, stereotypical body movements of the cartoon figures with no semblance to normal human body or appearance or behaviour, freeze an infant or a toddler to a fixation of sight and sound which occupy their mind, displacing the human interactive process they needed to develop for normal communicative intent and content.
The American Paediatric Association suggested that children below four years watch mobile phones or the TV only when one adult accompanies a child, in order to explain to the toddler what is going on in the screen, that too less than half an hour in a day. It is not ideal to let children below six months to watch TV programmes on a regular basis. Often infants and toddlers jointly watch the adult TV programmes with their parents, which add to the complicity of the causal pathways for the delay in acquiring the language and social skills.
4. Adverse influences on child development
We seem to have created an iatrogenic developmental delay of language, communication and social behaviour in infants and toddlers by overexposing them to the visual screen!
Another dis-service professionals do to the parents is to announce this, as an Autistic Spectrum Disorder, without carefully studying the causal pathway for this developmental delay. Only a few pre-school children might have an unknown cause for the developmental delay. Most of the toddlers were already vulnerable due to hereditary factors, antenatal events or perinatal risk factors, which initiated their developmental delay. This got compounded by lack of human interface, which if present would have naturally enhanced the neuro-plasticity for some recovery from the developmental delay.
I feel disturbed by large number of pre-school children showing low values of vitamin D, Iron, Zinc and high levels of IgE, ASO titre, and cholesterol in blood. The premature closure of the coronal sutures observed in seventy percent of pre-school children with communication dysfunction who visit us alarms me. Is it linked to low levels of vitamin D from early infancy! A few publications appeared on this topic from this department. I have some clarity now from the evidences gathering from 2002, that the Cortical Electrical Dysfunction identifiable in the EEG of about thirty five percent of pre-school children with language and communication disorder or sleep dysfunction might be factor in the causal pathway for their developmental delay.
During a pre-school health survey of 540 children in a school we noticed that less than five percent were left handed unlike the normal distribution of ten percent or more of left handedness. This raised the suspicion of enforced change of handedness at home or school. In the pool of pre-school children we welcome with language and communication disorders, about twenty five percent of children had a prominence of their left thumb and great toe, while they use the right hand as the dominant hand or are ambidextrous. In such children a high percentage used the left leg to kick a ball.
We are now developing a criteria to distinguish between natural left handedness and acquired left handedness due to cerebral insult. The interference with the lateralisation of dominance and its impact on evolution of language and communication dysfunction that arises out of it is now in an advanced stage of a study in our department. We are shocked how there is consistently low pulse oximetry readings at night in children, who have obstructed nostrils with or without snoring, which have gone unnoticed for a while in many pre-school children.
Most families do not follow a sound sleep hygiene practices leading to fragmented sleep caused by sleep latency disorder, sleep interruptions and disturbed sleep-wake rhythm. From the time I was involved in setting up a sleep monitoring room with EEG tracing in 2004 for children in the Hall of Residence, at the Developmental Paediatrics Unit at CMC Vellore, I have pursued the role of sleep dysfunction in behaviour and communication dysfunction since then. The three studies published from this department on sleep and the benefit of using Melatonin to overcome the sleep related disorders, carry the message of the value of monitoring the sleep behaviour of children at home. We rely on the videos parents take to help us understand the sleep ignition process, sleep duration and sleep related disorders
Let me quote one of the articles to indicate the thought process that evolved in responding to the sleep related challenges in pre-school children.
International Journal of Contemporary Pediatrics
Thampy M et al. Int J Contemp Pediatr. 2023 Apr;10(4):546-553
http://www.ijpediatrics.com
pISSN 2349-3283 | eISSN 2349-3291
DOI: https://dx.doi.org/10.18203/2349-3291.ijcp20230735
Original Research Article
Megha Thampy1, M. C. Mathew2, Anna Mathew3*, Liya Grace Kurian4, John Michael Raj5
The role of melatonin in regulating sleep wake disorders in children attending the developmental pediatrics outpatient service of a tertiary care hospital in South India
2Department of Developmental Pediatrics and Child Neurology, 3Department of Pharmacology, 4Department of Developmental Pediatrics, 5Department of Biostatistics, 1MOSC Medical College, Kolenchery, Kerala, India
Received: 20 February 2023 Revised: 15 March 2023 Accepted: 16 March 2023
*Correspondence:
Dr. Anna Mathew,
E-mail: mosc.research@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: We have observed that 75% of children with neurodevelopmental challenges visiting the Developmental Pediatrics department of this institution have sleep wake disorders. Disturbed sleep has a negative effect on learning and behavior. In this study we assessed the effectiveness of melatonin in improving sleep wake disorders in children with developmental compromise from this south Indian state.
Methods: Children with developmental challenges having sleep wake disorders confirmed by the pediatric insomnia severity index PISI, who were prescribed a daily dose of 3mg of melatonin participated in this prospective, observational, longitudinal study if the parents gave written informed consent. Parents were educated in the practice of sleep hygiene. The sleep disturbance scale for children (SDSC) was used to assess the overall pattern of sleep and six common disorders before and three weeks after starting melatonin.
Results: Based on the PISI scores, 13, 58 and 20 children had mild, moderate and severe insomnia respectively. Melatonin improved sleep latency, increased duration of sleep, decreased night awakenings, crying spells, dreams and daytime drowsiness. There was a significant improvement in the sleep pattern as indicated by better scores in the total SDSC score as well the scores for the six sleep disorders (p<0.001).
Conclusions: Melatonin has a significant role to play in regulating duration and quality of sleep and improving sleep pattern in developmentally challenged children with sleep-wake disorders.
Keywords: Melatonin, Sleep disorders, Neuro-developmental challenge, Sleep-wake rhythm disorders
5. A fall out of the COVID time restrictions
It is the COVID season which brought this to its current serious situation. All were advised to keep 'social distancing'. But what was needed was to practice ‘physical distancing’ and engage in creative ways of sustaining social communication. The on-line schooling legitimised the prolonged use of the visual screen at home. The inadequate social vigilance by the professionals, added to the woes of parents struggling to find a way forward to engage their pre-school children, when social restrictions prevailed for over two years.
The post-COVID season calls for urgent corrective measures and emergency action plan to help toddlers and preschool children, who are currently struggling to catch up in their language, communication and social skills! The therapy centres, offer occupational therapy, speech therapy and behaviour therapy to pre-school children. But more action is needed to offer parenting education to restore communicative and interactive practices at home.
6. Towards restoring healthy parenting practices
Let me share six exercises of the last two years in the Child Development Centre where I work, which arose out the need to engage parents and professionals to promote a communicative and interactive environment at home and at the pre-schools.
The first exercise was to invite parents of pre-school children to have a weekly online interaction on co-parenting and define the content of the nurturing behaviour to promote play based engagement with children at home. This involved each parent taking turns to be with their child during a meal time, bath time, play time, bed time, outing time, etc. It was one way of restoring the routines and rituals associated with infant and toddler care, which got dislocated during the COVID season. Some parents who brought feedback gave indications of how they were able to find an alternative way to media over exposure, by introducing new experiences through play.
The publication below, released in 2021 by ASHIRVAD at the time of the tenth Anniversary of the Developmental Paediatrics Unit at MOOSC Medical College, is a guide to parents to observe and record the developmental sequences of children in ten domains, and for parents to be keen observers of the developmental path, their children take. This was a step towards making parents primary developmental champions of their pre-school children. There are video links provided in this booklet, which help parents to follow the steps involved in taking, weight, height, mid arm circumference, and observe skills of hearing, and vision.
The second exercise was to popularise the idea of creating a Child’s Corner and play at home. A child’s corner is a place at home to locate the collection of toys, books, art and craft materials and other visual aids which would engage pre-school children. The Child Development Centre uploaded videos in the u-tube to propose a design for a child’s corner at home and illustrated how this can make children gravitate towards play and interaction. The traction towards the visual screen could be partially altered when children have an area at home, which reminded them of what they can do with their toys. We have had parents bringing back encouraging reports of how the child’s corner gave an interactive space for parents and children to explore new activities. The link to the videos:
https://youtub.be/kqdTnSWBvco and https://youtu.be/1eONrsUbwkA .
The third exercise that we got involved was to create videos of nursery rhymes and action songs, sung by the professionals in the Child Development Centre and upload them in the u-tube. They were sung and acted in a way, that parents watching them would get introduced to the way rhymes and action songs can be used to engage pre-school children to initiate them to sing along and follow the actions. Most young parents we were in touch, got used to screening the rhymes to the pre-school children, while they sang along and joined in the actions. The videos we created helped some parents to return to live singing without the video, which captured the attention of children and promoted better interaction. The link to the videos:
https://www.youtube.com/watch?v=1fMNug5ncyM
https://youtu.be/1Y2j_e6kZ88 https://youtu.be/0xG1jJpBi5E
The fourth exercise was to invite all parents who came to the Child Development Centre to visit the Family Life Centre, which is a room of exhibits of toys, books, papercraft for children and posters displaying the different stages of child development from infancy to adolescence. This exposure to the canvas of child development was introduced to the parents for them to pause and reflect on what changes they can bring in their parenting style of pre-school children.
Parents were drawn by what they saw and heard from the professional accompanying them to arouse interest in revising the parenting practices. The child development process is often nebulous in the minds of parents. The visual images help parents to develop a perspective to promote child development practices by proactive steps in parenting.
The fifth exercise was to create a manual for parents, Accompany your child, a plan for monitoring the developmentally challenged child (1-5 years), which in its 70 pages of parent friendly presentation, give charts describing the developmental domains.
Parents can observe and record the developmental process of their pre-school child every two months. This manual is being used by some parents for self-monitoring the development of their pre-school child. They carry this with them when they come to visit us and show their recording of the developmental process of their pre-school child in different domains.
The sixth experience was getting some professionals to meet online weekly for two years, to discuss the issues of child development and clinical pathways to support developmentally challenged children. The physical Medicine and Rehabilitation department of the Bangalore Baptist Hospital under the leadership of Dr Vinita Varghese created the Zoom platform for this during the COVID season. This provided a forum for peer reviewing some of the activities we were promoting to augment the parent-involved and home-based child development plan.
7. The way Forward
All Child Development Centres have two cardinal functions. One is to be a resource centre engaged in paving the way for the developmental journey of a child through an individualised action plan. The second is to enable parents to pursue sound parenting practices to make homes formative and educative for child development.
What pre-school children have lost in the recent years is the normal communicative environment at home. They were denied regular school experience during two academic years due to the COVID restrictions. Now is the time to restore to pre-school children, their regular communicative environment both at home and in the pre-schools.
Parents and professionals are to be partners in this journey!
M.C.Mathew (text and photo)
A note: All the percentages of different co-morbidities referred to in this article is based on the unpublished data from the department of the Developmental Paediatrics, MOSC Medical College, Kolanchery, Kerala, India. They are preliminary findings of the studies currently going on.
Acknowledgments: The professionals at the MOSC Child Development Centre, Miriam, Liya, Shalini, Femy and Femine for creating the videos. Shalini composed Accompany your child; Dr Anna Mathew edited it and ASHIRVAD published it. Dr Vinita Varghese of the Baptist Hospital co-ordinated the weekly online professional forum.
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