RainbowVisions. A Magazine for Brain and Spinal Cord Injury Professionals, Survivors and Families Rainbow Rehabilitation Centers Inc.

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1 RainbowVisions A Magazine for Brain and Spinal Cord Injury Professionals, Survivors and Families Rainbow Rehabilitation Centers Inc. SUMMER 2014 PEDIATRIC & YOUNG ADULT RESOURCE GUIDE Volume XI No. 2 STOCK PHOTO

2 Focus Pediatric Looking back on 20 years It takes a village By: Mariann Young, Ph.D. Rainbow Rehabilitation Centers It takes a village. This line regarding raising children has been attributed to an African or Native American proverb and was popularized by a book by then First Lady Hillary Clinton. Some will say this is what it takes to raise a child, however, this is truly what it takes to raise a child who has sustained a brain injury. It takes a whole team of caring people. This year, we celebrate 20 years of treating young individuals through our Pediatric Program. And, from the moment the idea was proposed, we realized it would take a village. In the fall of 1993, a case manager shared the story of a young girl with whom I had worked. She was failing at home due to her behavioral difficulties. The case manager commented on how nice it would be if Rainbow had a residential treatment program for children. Shortly thereafter, the idea was proposed to Buzz Wilson, the owner of Rainbow at the time. The Executive Committee at Rainbow agreed that this was an idea worth pursuing, and various people were tapped to get the idea off the ground. Some individuals were assigned to find property, others to get the facility licensed and still another group to develop the program. Those of us in program development were given an opportunity that few people have and for which I will be endlessly grateful. We were allowed to envision and then bring to fruition our program. We met once or twice per week prior to the opening of the program. We interviewed, hired and trained staff before we deemed them ready to work with children. In January, 1994, we opened our doors and have since successfully treated children, adolescents and young adults. The program has grown from one home in Farmington Hills, MI to a program that now includes seven homes for pediatric or young adult clients, a semi-independent living apartment program, a young adult vocational center and a dedicated treatment center. In 2009, the pediatric program expanded into Genesee County with the acquisition of Functional Recovery, and more opportunities for children were provided by Rainbow when the Genesee Treatment Center opened in We are able to treat young people because of the help of a village of people including support staff, rehabilitation assistants, pediatric therapists, doctors, case managers, school systems, neighbors and families the families of the young people treated at Rainbow and our own families. At times this system of care can be overwhelming to the young person in the center, but the support is reassuring to them when life becomes difficult to negotiate. Upon reflection during this 20th year, it is important to acknowledge the hundreds of young people who have entered our lives. We have seen them graduate from therapy and from high school. We have seen their accomplishments in the arts, employment, higher education or starting families. We have shared their laughter and their heartache. We have watched their struggles and their victories. They have given more to us and made us better people than any of us could have imagined. A huge thank you is extended to the team at Rainbow and beyond who made this program grow from that small comment into a program in 1994 and who continue to make it possible every day. It has taken a village, and I am proud to be a citizen of this fine group. My sincerest thank you to all. Mariann Young, Ph.D., CBIS, is a licensed clinical psychologist and Director of Pediatric Services at Rainbow Rehabilitation Centers, Inc. She has more than 30 years experience in individual and group psychotherapy, family therapy, staff training and supervision. In addition, she has significant experience in assessments, intervention and care of behaviorally challenged youths. In more than 20 years with Rainbow, Dr. Young has administered the development and coordination of outpatient, day treatment and residential programming for children, adolescents and young adults with TBI. She presents locally, nationally and internationally on topics related to the treatment of young survivors and is a regular contributor to RainbowVisions Magazine and has been featured on brainline.org as one of their experts. 2 RainbowVisions

3 SUMMER 2014 Features 2 Pediatric Focus Notes from Mariann Young, Ph.D. 4 How Brain Injury Affects the Family 6 TBI Child Focus: What Happens When a Child is Injured? 14 Conferences and Events 16 Recreational Helmets for Children 19 Surviving Summer 21 Is Your Child Ready to Stay Home Alone? Cover On the Think you know how to wear a bike helmet? Page After Graduation: Negotiating Young Adulthood 26 Young Adult Program: Success in the Workplace 30 Help for Students with Traumatic Brain Injury 32 Intervention Strategies for Unwanted Behaviors 34 Understanding the Pediatric Glasgow Coma Scale News at Rainbow 25 Rainbow s 2014 High School Graduates 28 Rainbow U at the Farmington Hills Treatment Center 29 Spring Bike Fairs Editors note: This year marks the 20th anniversary of the Pediatric program at Rainbow. We are celebrating that milestone in many ways throughout the year. Dr. Mariann Young, who helped develop the program and currently serves as the director of pediatric services, has shared her vast knowledge of children and young adults by authoring many stories for Rainbow Visions. She has written on various topics to help industry professionals and the community understand what life can be like for a child and, in particular, a child with a brain injury. In this issue we have collected some of those stories and created this Pediatric & Young Adult Resource Guide for you to enjoy. 36 Employees of the Season 37 New Professionals Our mission is to inspire the people we serve to realize their greatest potential SM Editor Barry Marshall Associate Editor & Designer Celine DeMeyer Contributor Nick Galluch questions or comments to: rainbowvisions@rainbowrehab.com Copyright May 2014 Rainbow Rehabilitation Centers, Inc. All rights reserved. Published in the United States of America. No part of this publication may be reproduced in any manner whatsoever without written permission from Rainbow Rehabilitation Centers, Inc. Contact the editor: rainbowvisions@rainbowrehab.com. RainbowVisions 3

4 How brain injury affects the family By: Mariann Young, Ph.D. Rainbow Rehabilitation Centers T he person who sustains a traumatic brain injury (TBI) is not the only person affected after an accident. All members of the family are forever changed, and the family system has to alter the way that it operates. The literature on the effects of TBI on the family repeatedly shows this to be true. Typically, the most extensive burden is felt by the family member who assumes the role of primary caregiver. They may have to give up their career or other interests and have been known to suffer from serious depression during the first year of injury. This is a difficult process for the family to navigate one that takes time and resources, as the process is continually changing. In the hospital Upon first hearing of an accident and hospitalization, the family is overwhelmed by emotions. There is the initial fear, depression, anxiety and guilt to name just a few. The immediate concern is: Will they survive? Because brain injury is complex, most people may not understand the diagnosis and how far-reaching the effects may be. Medical terminology is used by health care professionals at the hospital and may not be understood. There are procedures, medications and instruments being used that have likely never been seen by the family before. Often, family members listen to the doctor or nurse without comprehending and nod, accepting what is being said, but not fully understanding. When a child sustains a brain injury, however, the effects are different than when an adult is injured. The child always has to be considered as a member of the family. In these cases, parents are not only the support for their child, but they may become the primary health care provider. This responsibility of caring for a child who is injured coincides with their own grieving. Because children have not completed all of the stages of development, predictions on how well they will do in the rehabilitation process are not recommended. Cognitive, behavioral and academic progress are all influenced by the location in the brain where the injury exists, family support systems in place, age at injury and social supports. Returning home When an injured child returns home, the immediate family will play an important role in the recovery process. Challenges may arise in the areas of financial resources and the relationships between parents, the other children, other family members and friends. The family roles will likely change, i.e., older siblings may take care of younger ones. They will find that time is at a premium, and there is probably not enough of it. Caregivers may experience social isolation as their personal world shrinks and a large part of the day is spent caring for the injured child. In research completed by Montgomery et al. (2002), when a child experienced a traumatic brain injury, it had a negative impact on family dynamics and/or sibling behavior in more than one third of families studied. Despite this, most families also stated that they would not limit or withdraw care if they had an opportunity to reconsider the choices that they made. There are situations in which the family becomes so involved in providing care that they do not recognize the effects of the injury on all members of the family. Even the strongest families will have challenges. 4 RainbowVisions

5 SUMMER 2014 Family Change Questionnaire Use this tool to aid discussion with your family or a counselor. How did you feel when you first learned that your family member was injured? Using the family change questionnaire Nancy Hsu, Jeffrey Kreutzer and Jennifer Menzel of the National Resource Center for Traumatic Brain Injury, Virginia Commonwealth Model Systems of Care, developed the Family Change Questionnaire (FCQ) at right. This is an easy tool that families can use to recognize how they have changed and to begin to think about the changes. It may be used in a family discussion or with the aid of a counselor. Family members can think about changes in their responsibilities and roles in order to plan for the future. Discussing the answers to the questions will help improve understanding and communication. Regular discussion about feelings and ideas can strengthen the family support system and help overcome challenges that may be faced in the future. Recognizing how the lives of other family members have changed because of the injury is an important step in emotional recovery. Family members are integrated into the recovery process as much as possible at Rainbow. Literature and education are available as are trainings in the best ways in which to assist a family member who is injured. It is important that families have resources available to them. These can be in the form of educational materials, support groups, counseling, membership in the state or local Brain Injury Associations, or all of the above. Rehabilitation is most effective when there is a team effort functioning on behalf of the injured person. Families require care for their psychological well-being throughout this process. v References: Hsu, N., Kreutzer, J., & Menzel, J. (2012). Family change after brain injury. The National Resource Center for Traumatic Brain Injury, Virginia Commonwealth Model Systems of Care. org/content/2009/06/family-change-after-brain-injury.html Montgomery, V., Ronald, O., Reisner, A., & Fallat, M. E. (2002). The effect of severe traumatic brain injury on the family. J Trauma, 52, How did you feel when you realized that your injured family member was going to live? How did you feel when you began to recognize that the brain injury might have long term effects? How have other family members reacted to your injured family member s injury? Have you made yourself available to provide more emotional support to your injured family member and other family members? If yes, how so? Before the brain injury, what were the most important plans you had for your future and your family s future? How has the brain injury affected your plans for the future? What responsibilities do you now have to care for your injured family member? In what ways do you help your injured family member get back and forth to appointments? Do you attend therapy and doctor visits with your injured family member? Please explain. Do you help your injured family member with filling out insurance, registration, medical and disability forms? Please explain. Do you help your injured family member get authorizations for medical and rehabilitative care? Please explain. Have you taken over responsibilities from your injured family member or uninjured family members? If yes, what new responsibilities do you have related to caring for the house, maintaining the car(s), working, paying bills and caring for children? Have you changed your work responsibilities or hours since the injury so you could help your injured family member or the family? Please explain. How has your family s income been affected by the injury? What new expenses are you facing because of the injury? How have your sports, social and recreational activities changed because of the injury? RainbowVisions 5

6 By: Mariann Young, Ph.D. Rainbow Rehabilitation Centers TBI Child Focus STOCK PHOTO What happens when a child is injured? Infancy (birth to 12 months) An infant s brain is not a smaller version of an adult s brain. Although the brain has many functions at birth, the main focus is survival, that is, to regulate blood pressure, breathing and body temperature. Transformation of the brain takes place rapidly as the baby moves from reflexive or involuntary actions such as sucking or grasping to being able to demonstrate purposeful activities such as tracking, controlled movement, memory and language. After a child is born, you can see the intense emotion in their face as they try to make sense of the world around them. Babies need to be fed, comforted and rested as they do the work of growing and developing. Making an infant feel loved and cared for is the best thing a parent can do to get their child off to a good start. During the first weeks of life, babies expect to be fed in regular intervals and cry when this does not happen. They become interested in the faces of their caregivers particularly around the eyes. By week five or six they discover their own hands and gaze at their fingers as they move them in front of their eyes. As infants vision matures, they begin to show a preference for faces. About this time they also begin to smile. Many babies begin to roll over by five months of age. They take pleasure in this activity, and some babies even use this as a means of going from one place to another. They can grasp a toy and drop it to pick up another. Things really start coming together at the mid-year point when a baby reaches one of the benchmarks of motor development sitting up. The world looks different as a baby can sit for about a half-hour and use both hands to turn, manipulate and examine a toy. Strings of sounds are vocalized and babies express pleasure with these sounds and laughter. At this time, children recognize their own name and will turn when called. First words are a milestone of child development as children learn to say words such as dada, mama or hi. Babbling occurs, and babies appear to enjoy their own sound production as well as that of others. Facial expressions are varied, and babies express humor and joy. They laugh at older brothers and sisters and bob their heads to music as they cling to a table, dancing. By the seventh month, a baby knows that an object exists even if it is hidden. This is the important concept of object permanence. Babies will actively search for toys if you remove them from a room or cover them with a cloth. This coincides with another important part of a child s cognitive development, stranger anxiety. This is the fear of people with whom a child is not familiar. The baby shows that there is an attachment to a caregiver and may cry when a parent leaves the room. Stranger anxiety begins around the eighth or ninth month and usually lasts until the child s second year. It does not indicate emotional difficulties, rather mental development. The distress shown by a baby is an indicator of how the stranger approaches and the baby s temperament. As infants acquire more experience and exposure to new people whether through outings or daycare, their anxiety regarding strangers decreases. Still, the response of a child suddenly shrieking or crying to known friends and relatives may be upsetting or frustrating to the adults in their lives (Stranger anxiety, 2014). Almost nothing is safe from eightmonth-olds as they are determined to move, crawl, reach, pull up, grab and lunge. They eagerly explore the world of small objects a prerequisite for higher forms of thought. They respond to noises, lights and other stimuli and are quick to act as mini-detectives investigating the 6 RainbowVisions

7 SUMMER 2014 scene. Babies can imitate an action such as putting on a hat, even though they have not been directly shown how to do this behavior. The first signs of problem solving begin as a child learns how to use a pull toy and understands one-step commands such as up. The child may attempt his or her first steps at this time, too. As a child approaches the one year mark, the growth and development that have occurred over this first year is remarkable. One-year-olds know that when the family gets their coats on, someone is going outside. If they hear the sound ruff they can point to a picture of a dog. Responses to several word commands and questions are evident. Babies will nod when asked if they want a drink or give a kiss when asked to do so. They will happily point out the different parts of their bodies and imitate behaviors that they see the adults at home doing. The three basic interests of one-year-olds are curiosity, motor-skill challenges and their primary caregiver. A reasonable approach to providing a stimulating and nurturing environment for a one year old is to avoid extremes. Parents are not only data managers and information providers. They build the first significant relationships that a child will have and take with them into the future (Gurian, Ph.D. & Goodman, Ph.D., 2014). When children receive a traumatic brain injury (TBI) during the first year of life, it is usually due to a fall, car accident, some form of abuse or a near drowning episode. Because a child who is injured early on is in a rapid spurt of growth and development, an injury may affect the growth that has already occurred and any future development. Unlike older adolescents or adults who are injured, babies don t have the luxury of years of practice or learned skills to fall back on. The process of rehabilitation is difficult and ongoing. The brain injury will likely be with them for the rest of their lives (Sellers and Vegter, 1997) months A great deal of growth and development takes place in the toddler years. Although children grow at their own pace, during the toddler stage most children learn to walk, talk, solve toddler-sized problems and relate to others. A major task of this phase is learning to be independent. This is why toddlers want to do things for themselves, have their own ideas about how things should happen and say NO! many times throughout the day. After their first birthday, children become focused on comprehension, moving, pretending and expressing themselves. They understand simple sentences such as, Time for sleep or Get your blankie. As speech develops, they can name people and things, imitate animal sounds and point to objects that they want. One-year-olds begin to use the pronouns me and mine and put two words together to make a basic sentence. They try to hold a pencil using their fist to grasp it and imitate drawing or coloring with a scribbling motion. Toddlers may eat less, but tend to eat frequently throughout the day. They get better at feeding themselves, but spills are common. Most children walk without support by 14 months and are able to stack blocks at this age, too. Most toddlers can walk backward and walk up steps by the time that they are 22 months old. By the end of the first year, skills in physical development and intellectual development combine as toddlers solve problems. No counter is too high, bookcase too tall or chair too heavy for an independent toddler. Anyone who has watched a toddler knows that when it s too quiet, the child is typically doing something they shouldn t. Toddlers may ask for their parents and become possessive of them. They may also readily show affection and have favorite responses to words, songs or snuggles associated with a particular parent. Underneath this loving response and ability to show affection lies the dreaded temper tantrum. Somewhere between the age of 1 and 2, tantrums appear as a response to not getting their way. Toddlers soon begin to learn and accept simple rules. Usually between 2 and 2 1 /2 children become interested in being toilet trained as they feel the discomfort of a wet or soiled diaper. STOCK PHOTO From 12 to 24 months, children practice important skills for future growth. A child s memory allows them to remember past events and think about things that are not in their view. They can carry on conversations and answer questions. As the two-year-olds move into their third year, they are ready for action as they are preschoolers (Ages & Stages Toddlers, 2014)! 3 Years of Age Three-year-olds impress everyone around them with all that they know. At this age, children begin to add words to their sentences, including action words and descriptors such as big, fast or hot. They can respond to what, where and why questions. No! transforms into Continued on page 8 RainbowVisions 7

8 What happens when a child is injured? Continued from page 7 won t, don t or can t. They can describe objects that are the same or different. Children at 3 can memorize rhymes and repeat them or open a book and pretend to read a passage. They memorize songs or parts of songs and like to entertain the family. Three-year-olds can express simple feelings and wishes. Although they have trouble making choices, they still want to make them. They may try to bargain with their parents instead of having a tantrum, and this may be even more challenging. They try very hard to figure out the world around them and ask many why or what if questions. Physically, 3-year-olds have improved running and climbing abilities. They can ride a tricycle or pump a swing. They can catch a ball using both hands and their body. They can undress without assistance. Three-year-olds may play near other children, but most of their play is active not interactive. Their play is more imaginative, and you can see this when they play with action figures, cars or dolls, and when listening to their stories. They can put together simple puzzles and understand that a whole object can be separated into its parts. Sharing is still difficult, and children of this age still need security and reassurances from their parents (Child Development Tracker, 2014). As children grow into their third year, their vocabularies contain from 1,000 to 1,500 words. Although they have a great deal of words at their command, they are still confused by the way in which adults speak. Meanings get mixed up and they don t have a clue about sarcasm. It is important to be clear when you are explaining things to a three year old. Children at this age begin to initiate conversations. Be supportive and gently prompt as their language skills improve. At this age, children may begin to misbehave intentionally to test limits. This may be dangerous and disruptive. Try to STOCK PHOTO provide a safe environment and distract the three-year-old from the action that he or she wants to do. Speak calmly and set firm limits (no means no). Avoid yelling, hitting or getting worked up when your child misbehaves, and walk away if you feel like you will lose control. Try to reward and praise good behavior. Pay lots of positive attention to a young child and give them hugs and kisses. Rewards don t have to involve money paying attention, reading a story, playing a game, a bright smile and hug mean more to a 3-year-old than anything that money can buy. 4 Years of Age Knock, Knock Who s there? Anita. Anita who? Anita new bike. And so goes the humor of a 4-year-old Four-year-olds discover humor and spend a great deal of time telling adults in their world jokes. They enjoy rhyming and will laugh at words that they have made up. For example, four-yearold conversations may go like this, You re a boo-boo. You re a poo-poo followed by peals of laughter. This is the time when children may try a bad word, too. Try not to overreact if your child does this. Remember that they are trying to make sense of the world around them, and it is very hard to understand why adults can say some words but they cannot. Give them a different word if they are using words that you do not like. At this age, children are often great conversationalists and love to talk about scientific details and how things work. They ask a lot of questions, and some may be difficult to answer. Try to respond as simply and honestly as you can. 4-year-olds can tell long stories, some of the details are true and some are devised. They understand the concept of past, present and future. They also begin to recognize cause and effect relationships. Four-year-olds have a lot of energy. They are able to control their bodies better so that running, stopping, starting, and turning are skills that they can manage. They can turn somersaults, hop on one foot and gallop away. They can play catch, throw and bounce a ball, climb, ride tricycles or bicycles. 4-year-olds are 8 RainbowVisions

9 SUMMER 2014 developing confidence in their physical ability, and at the same time, their imagination develops. They may be too bold or timid and need to be supervised in physical play. They are creative and enjoy doing new things (Important Milestones: Your Child at Four Years, 2014). During this stage of life, children are learning to understand the feelings and needs of others. Their behavior shows that they can feel sympathy, take turns, share and cooperate at least part of the time. They can use words to express anger rather than act on this emotion. Four-year-olds can sometimes feel jealous. Parents can help children by reassuring them how important they are. Four-year-olds will occasionally tantrum when they don t get what they want. They can be bossy, and sometimes their behavior is over the top. Four-years-olds love adult interaction, so it is important to provide a great deal of positive attention. Parents can play word games or sorting, matching, and counting games. Talk to your child, listen to their stories and tell them stories about what it was like when you were growing up. Provide play space, play time and opportunities for your four-year-old to play with other children. Supervise their activities and show them that you can set limits so the world is not a scary place for them. Smile and hold them and tell them that you love them. They will respond similarly. 5 Years of Age A 5-year-old is typically more energetic, cheerful and responsible than a 4-yearold. This is a big year, as they will likely start kindergarten. School may be an extension of childcare for your child, or it may be a first separation. You can help ease them into kindergarten by going to the school before they start, buying a new book bag, and listening to all the stories about the wonderful new world When young children have a brain injury, impairment in function may occur in one or more of the following areas: Arousal ability to awaken/show action Information processing the ability to understand the meaning of written, verbal, or visual communication Orientation knowing your place in time (day, hour, month & year) and space Paying attention Short-term and long-term memory Reasoning logic and planning Emotional growth child may be stuck emotionally at the age of injury Motor Abilities Social behavior lack of certainty about how to behave in society Sensory abilities difficulty with one or more of the senses (touch, taste, smell, hearing, seeing) Mood increased sadness or irritability (Sellers and Vegter, 1997) of school. Home routines will provide comfort to a 5-year-old during this time of transition. Establishing good sleep habits may be a challenge, but it is important for children of this age to get hours of sleep per night. Five-year-olds enjoy planning and spend time discussing who will do what. They like dramatic play, enjoy mimicking adult roles and playing dress up or make believe. 5-year-olds know right from wrong and honest from dishonest. They enjoy showing off how strong they are and how well they can play games. They are not really emotionally ready for all the rules of competition and may have trouble being good sports. They may articulate their feelings but also display emotional extremes and contradictions a 5-year-old may have a melt down over spilling a glass of juice (4 to 5-Year-Olds: Developmental Milestones, 2014). By the time children are 5 years old, they typically speak fluently and correctly use plurals, pronouns and tenses. They are able to use complex language and understand about 13,000 words. Good luck to all caregivers because 5-year-olds talk frequently and like to argue and reason using words like because. They are able to memorize their address and phone numbers, know the days of the week, and can name coins and money. At this age, it is important to give your child the chance to make choices when appropriate. Establish good communication and discuss problems that may arise. Try to limit television time to one hour per day and encourage conversation, storytelling, cutting, drawing and active play. Provide lots of praise and verbal encouragement so that pro-social behaviors are reinforced. They need cuddles and comfort and enjoy being babied from time to time. Have your 5-year-old child do child-sized chores so that they feel like a part of the family and develop a sense of accomplishment at the same time. Most of all, have fun with your five-year-old. Continued on page 10 RainbowVisions 9

10 What happens when a child is injured? Continued from page 9 Young children with TBI The greatest percent of brain maturation occurs in the early years, birth through age 5. Sadly, it is also during this time that children ages 0-4 had the highest emergency department visits rate (2, per 100,000). Children disproportionately incur brain injuries (The Essential Brain Injury Guide, 2009). In an attempt to prevent injuries by making sure that your child is safe, assess your house for hidden dangers such as loose carpeting or objects that are not balanced and can fall. Do not leave your infant unattended on a changing table, bed or in the bath not even for a second! Make sure that your child is in a car seat or booster, and supervise outdoor and playground activities. Beyond infancy, children may survive brain injury in larger numbers than adults and may experience good physical recovery. However, they may have serious cognitive and behavioral difficulties. When treating children, it is short-sighted to think in terms of the present, as there is so much more growing and developing to be done. It is very important to try to project the future needs of the child and to become his or her advocate. Young children with brain injuries may have injured a part of the brain where functions are not seen until later in life. For example, the frontal lobe is the center for executive functions. This area controls judgment, decision-making, planning, organizing and attention. A young child may not show signs of serious difficulty in the executive functions until they reach the third grade when learning becomes increasingly rule-based. During adolescence, these qualities become evident as emotional and behavioral difficulties impact making and maintaining friendships. The elementary years: 6-11 years of age In the early school years (grades 1 through 3) you will notice an increase in the amount of questions a 6, 7, or 8-year-old will ask. This is the way that they learn to understand the world. Children have a longer attention span in these grades and begin to display serious and logical thinking. They try to solve more complex problems, and parents will be able to see the individual learning style that each of their children use. Conversations improve, and at the end of third grade a child converses in a manner that is similar to an adult. Reading may be a major interest, and a 6, 7, or 8-year-old will begin to understand the concept of reversibility (4+2=6 is the same as 6-2=4). Children in the early elementary grades can be helpful and cheerful, but their emotions may change quickly. Then they may be bossy, rude or selfish. They tend to be obsessed with money which can become a big motivator, especially by the time they are in third grade. Kids of this age typically make friends rather easily and like STOCK PHOTO to have close friendships with the same gender. They like to feel a part of the group, and early elementary children are usually engaged in group play on the playground, at recess and lunch. Children at this age want to be liked and accepted by their friends. Early elementary school children will begin to experience peer pressure. This may be the first time that they try on behaviors. They may imitate a behavior of a friend and use this at home. This may be a different way of laughing, responding or using a new saying. Early elementary school children have a strong need for love and understanding and want approval and attention from their parents (Middle Childhood (6-8 years of age), 2014). Upper elementary children (9 and 10-year-olds) show intellectual, emotional and physical change. Skill level and endurance improve. Children of this age have excellent fine motor control, can manipulate tools well and draw pictures with a large amount of detail. They may stay with an activity until they are exhausted and are typically active and energetic. At the end of their 11th year many children begin showing their first signs of puberty. Girls may have softening and rounding of their features as well as the first signs of breast development. They may also shoot up in height. Boys may start to have more muscle development. As children become more aware of their body changes, body image and eating problems may arise (Middle Childhood (9-11 years of age), 2014). Boys and girls in this age group are developing their conscience but may not always tell right from wrong and still rely on parental guidance. Kids are typically happy, but may act silly. 10 RainbowVisions

11 SUMMER 2014 Friendships are very important, and by the end of the 11th year they may start to show an interest in the opposite sex. Kids of this age are still respectful and affectionate toward their parents. A great deal of a child s time is spent playing, walking, or riding bikes. These areas are often the most fun, but can also be the most dangerous for children. Inadequate use of bicycle helmets is associated with many motor vehicle-related injuries or deaths. For information on proper use of bicycle helmets, see Recreational Helmets for Children on page 16. In- line skating, skate boarding and scooter use without helmets pose substantial injury risk. Hospitalization data indicates that skateboarders are more likely to sustain head injuries than rollerbladers or scooter riders. However, since the lightweight, foot-propelled scooters were popularized in the United States in 2000, 42,500 people sought emergency room care for injuries; most of these were not brain injuries (School Health Guidelines to Prevent Unintentional Injuries and Violence, 2014). Pedestrian versus motor vehicle injuries are the most common cause of serious head trauma in the lower elementary age group. This is typically due to the mid-block dash/dart into the street or the attempt to beat traffic at an intersection. These account for 60-70% of the injuries to children under the age of 10. Children are more frequently injured in heavily populated urban areas due to the large volume of traffic. It is important to teach your child to never cross between parked cars. When crossing at the light, remind them to look both ways before stepping into the street and watch for turning cars (Child Pedestrians, 2014). TBI and the early elementary child When an early elementary school-aged child sustains a brain injury, there may be personality or behavioral changes. Their emotions may increase in intensity to the point that they become out of control. Dramatic or rapid shifts in behaviors may also occur. These are usually not related to or in agreement with the event that triggered them. A child who has had a brain injury may become whinier, irritable, or upset with the smallest issue. If the child has a frontal lobe injury, then inhibition of the behavior may become difficult. Once a child engages in a behavior, they may be unable to stop or curtail it without intervention. Other changes that may be observed include: Inability to get along with siblings Changes in play habits Changes in coloring and handwriting Changes in understanding and following parental direction Changes in developmental milestones, e.g., bed-wetting may reappear Change in sleeping and eating habits Little ability to soothe themselves or be comforted Upset if corrected about mistakes at school or at home Pediatric brain injury also affects a family in the following ways: The child with the brain injury becomes the center of attention Needs of other siblings may not be met due to the care and energy put into treating the injured child Parental needs may not be met because of the overwhelming amount of time spent on the needs of all of the children Time becomes a commodity Parents may feel guilty or that they are failures There may be a feeling of overall unhappiness There may be a diminished quality of life for the entire family (Ylvisaker, M., 1998) The teenage years Adolescence may be defined as the time in a person s life when characteristics move from what is typically considered childlike to what is considered to be adult like. For adolescents, this period requires adjusting to changes in their body, ways of thinking, emotions, and changes in their family and peer group. These changes are challenging for them and for those around them. Teenagers struggle with the desire to be independent while being dependent on their parents. They are pressured to fit in and do well in school and other activities. Continued on page 12 RainbowVisions 11

12 What happens when a child is injured? STOCK PHOTO Continued from page 11 As young teens (13-15) move toward independence, they may become moody trying to figure out who they are and in which groups they fit. Their peers become important and influence clothing styles and other tastes. As their body changes, they may become uncomfortable with the changes. One day they may be on top of the world, and the next they struggle with poor self-esteem. Relationships with parents also change as teens realize that their mom and dad are not perfect. With the improved ability to express themselves, they are often willing to say this. They may not show affection to their parents like they used to and complain that their parents are interfering with them or more dramatically ruining their life. As grown up as they like to believe they are, they often revert back to much younger behaviors when they are stressed. This is the age in which serious rule and limit testing begin. Experimentation with sex, cigarettes, alcohol and drugs may also start. However, there is increased and consistent evidence of a conscience. There is concern about appearing attractive to others, and relationships may change quickly. There are a lot of concerns about being normal. As the youth enters the older teenage years (16-19), parents will begin to see a young adult emerging on a regular basis as the question Who am I? is answered satisfactorily and happily. But remember, even the best and most well-adjusted adolescents will experience times of confusion. The older teen is more able to think things through and compromise on solutions. There is decreased conflict with parents, and although friends remain important, they take an appropriate place among other interests. There is an increased concern for others and increased selfreliance. As the young person s depth of character develops they become able to have serious relationships. They set goals, are insightful and place an emphasis on personal dignity and self-esteem. In a study of teens that left high school for careers or further education, it was found that positive factors influencing teens included a supportive family and friends, making money, satisfying leisure activities, realizing personal achievements and educational success. The adolescents reported that negative factors included relationship problems, career confusion, financial difficulties and a difficult adjustment to post-secondary educational demands. As a teen navigates this time of life, there are things that parents can do to make the journey easier. Although it is very easy to notice the irritating behaviors and comment on these, try to refrain and remember to reinforce the positive ones, too. This will likely keep the teen coming back. Work with your teenager to keep the lines of communication open. Don t ignore the first signs of a problem and hope it will go away. It is easier to fix something small. Ask for help if you need it (Understanding Your Teen s Emotional Health, 2014). Teens with Traumatic Brain Injury By far, the most common cause of traumatic brain injury in teens is due to motor vehicle accidents. Teens are four times more likely to be involved in a motor vehicle accident and three times more likely to die from it than older adults. Teens make up seven percent of the population but are involved in 14% of the crashes (Teenagers, 2014) Teens with peers as passengers take more driving risks. There is typically an interaction between the driver s behavior, the car and the weather or highway conditions. Gender is also an important factor, as the incidence of severe injury among males is much higher than females. Overall, the most important factor associated with an increased risk of a car crash involving teenage drivers is the Teens are four times more likely to be involved in a motor vehicle accident and three times more likely to die from it than older adults. Teens make up seven percent of the population but are involved in 14 percent of the crashes. 12 RainbowVisions

13 SUMMER 2014 use of alcohol. Lack of driving experience with challenging weather conditions, nighttime driving or high-volume traffic combined with alcohol can be deadly. Concussions are a fairly common form of brain injury that can occur with teenagers. A concussion results in a temporary loss of normal brain function. One of the most common reasons teens get concussions is through sports injuries. High contact sports such as football, boxing and hockey pose a higher risk of injury, even with the use of protective headgear. For girls, cheerleading and basketball account for the highest number of concussions. Teens can also get concussions from falls, bicycle and rollerblading accidents, as well as physical assaults (Concussions, 2014). When a teenager suffers a brain injury there may be personality or behavioral changes. Similar to what is seen in younger children, their emotions may increase in intensity to the point that they become out of control. Dramatic or rapid shifts in behaviors may also occur. Many teens remember their former selves and have difficulty adjusting to the changes caused by their injury. Some may use substances, such as marijuana or alcohol, in an attempt to increase their ability to cope. Some teens may look the same as they did pre-injury and deny the fact that they have an injury. They may also have limited or no insight into their injury. In addition, parents may be in denial, believing that their child has fully recovered and everything will be the way it used to be. Other changes in behavior that may be observed include the following: Social awkwardness Difficulty learning new information Difficulty planning and organizing Decreased self-control Inability to recognize problems Dangerous risk-taking Psychiatric problems Academic difficulty or academic failure Difficulty succeeding in work or after school placement For the child with a TBI, needs are constantly changing. No matter the age of injury, both the family and the child will face new challenges throughout the family cycle. As a child goes through different developmental stages, their needs will change. Interventions will shift from the home to the school, however, parents will need to set appropriate expectations and boundaries. Families will need to understand the new person who emerges after an injury and mourn the loss of their former child. (Fremont Smith-Coskie, 2011). This is a difficult task for families, and assistance and guidance will help the healing process. v References: 4- to 5-Year-Olds: Developmental Milestones. (2014, March). Retrieved from Web MD: com/parenting/guide/4-to-5-year-old-milestones Ages & Stages Toddlers. (2014, March). Retrieved from Urban Programs Resource Network: Child Development Tracker. (2014, March). Retrieved from PBS Parents: Child Pedestrians. (2014). Retrieved from University of Washington: depts.washington.edu/hiprc/practices/topic/pedestrians/index.html Concussions. (2014, March). Retrieved from Teens Health: kidshealth.org/teen/safety/first_aid/concussions.html# Fremont Smith-Coskie, Dixie, (2011), Unthinkable: Tips for Surviving a Child s Traumatic Brain Injury A caregiver s Companion. Oregon,Wyatt- MacKenzie Publishing, Inc. Gurian, Ph.D., A., & Goodman, Ph.D., R. F. (2014, March). How important are the first three years of a baby s life? Retrieved from The Child Study Center: how_important_are_first_three_years_baby039s_life Important Milestones: Your Child at Four Years. (2014, March). Retrieved from Centers for Disease Control and Prevention: Middle Childhood (6-8 years of age). (2014, March). Retrieved from Centers for Disease Control and Prevention: gov/ncbddd/childdevelopment/positiveparenting/middle.html Middle Childhood (9-11 years of age). (2014, March). Retrieved from Centers for Disease Control and Prevention: gov/ncbddd/childdevelopment/positiveparenting/middle2.html School Health Guidelines to Prevent Unintentional Injuries and Violence. (2014). Retrieved from Morbidity and Mortality Weekly Report: Sellers, C.W., & Vegter C.H., (1997) Pediatric Brain Injury The Special Case of the Very Young Child. Houston, HDI Publishers Stranger anxiety. (2014, March). Retrieved from Encyclopedia of Children s Health: Teenagers. (2014, March). Retrieved from Insurance Institute for Highway Safety: The Essential Brain Injury Guide. (2009). Vienna: Brain Injury Association of America. Understanding Your Teen s Emotional Health. (2014, March). Retrieved from Family Doctor.org: emotional-well-being/understanding-your-teenagers-emotional-health.html Ylvisaker, Mark, (1998), Traumatic Brain Injury Rehabilitation Children and Adolescents. Second Edition, Newton, MA. Butterworth-Heinemann RainbowVisions 13

14 June/July/August 2014 Conference & Event Schedule Summer/Fall June 5 BIAMI Legal Conference Crowne Plaza Lansing West - Lansing, MI June 13 CPAN Golf Outing Eagle Eye Golf Club - Bath, MI June CMSA National Conference Cleveland Convention Center - Cleveland, OH July 15 BIAMI East Grand Invitational Golf Outing The Inn at St. John's - Plymouth, MI August 7 BIAMI Western Golf Outing Belmont, MI August 12 CMSA Detroit Dinner Conference Farmington Hills Manor, Farmington Hills, MI September September 10 BIAMI Veteran s Conference Lansing Center - Lansing, MI September BIAMI Annual Conference Lansing Center - Lansing, MI September Contemporary Forums Case Management Conf. The Venetian Casino & Resort - Las Vegas, NV September 16 CMSA Grand Rapids/Kalamazoo Dinner Conference The Bluffton Conference Ctr. - Grand Rapids, MI September Contemporary Forums Brain Injuries Conference Grand Hyatt - San Francisco, CA September International Symposium on Life Care Planners Marriott City Center - Minneapolis, MN October October 14 CMSA Detroit Breakfast Conference Farmington Hills Manor - Farmington Hills, MI October 18 CPAN Gala Dinner Eagle Eye Banquet Center - Bath, MI October American Assoc. of Nurse Life Care Planners Atlanta, GA October NASHIA Annual State of the State Meeting Courtyard Marriott Downtown - Philadelphia, PA October 28 MSU Case Management Conference Kellogg Center - East Lansing, MI Rosalva.Aguilar@hc.msu.edu Oct. 29-Nov. 1 ARN Educational Conference Disneyland Exhibit Hall - Anaheim, CA NOTICE: The conferences and events information listed on these pages is dated information. For the most up-todate information on industry-related conferences and events, please visit: 14 RainbowVisions

15 SUMMER SUMMER MBIPC Michigan Brain Injury Provider Council RINC Rehabilitation & Insurance Nursing Council meetings MEMBERS ONLY Registration at 11:30 a.m. / Lunch at Noon Presentation begins at 12:45 p.m. Learn Over Lunch Meeting times are noon 2 p.m. (Registration at 11:30 a.m.) Cost: MBIPC Member $25 / Non-member $60 For information contact Mary Mitchell or mary.mitchell@rainbowrehab.com June 10, 2014 Topic: Multi-disciplinary Rehabilitation for Post-traumatic Headaches Speaker: Kara Ebrom, DPT Location: Holiday Inn West, Livonia, MI For updates on meetings, visit June 13, 2014 Topic: Neuroplasticity Location: Santorini Estiatorio, 501 Monroe St., Detroit, MI Speaker: Heidi Reyst, Ph.D., CBIST Vice President of Clinical Administration Rainbow Rehabilitation Centers Sponsored by: Rainbow Rehabilitation Centers RSVP to: Marianne Knox or RINC meetings are generally presented the third Friday of each month. There are no meetings in July or December. For more information on meetings and membership contact Adrienne Shepperd: Become a Certified Brain Injury Specialist The Academy of Certified Brain Injury Specialists (ACBIS) offers a national certification program for experienced professionals working in the field of brain injury. ACBIS provides an opportunity to learn about brain injury, to demonstrate learning with a written examination, and to earn a nationally recognized credential. As a service to our brain injury community, Rainbow offers a free 9-week training course to prepare for the CBIS exam. Nurses, case managers and other professionals who partner with Rainbow and have at least one year of experience working in the field of traumatic brain injury rehabilitation are invited to attend. NEW TIME! Sessions will be held every Thursday from 11:30 a.m. 1 p.m. July 10 September 4, 2014 NEW LOCATION! Rainbow Rehabilitation Centers Farmington Hills Treatment Center Orchard Lake Road, Farmington Hills, MI INSTRUCTORS: Lynn Brouwers, MS, CRC, CBIST and Heidi Reyst, Ph.D., CBIST To participate in CBIS training, contact: Lynn Brouwers at lynn.brouwers@rainbowrehab.com RainbowVisions 15

16 Recreational helmets for children Why should children wear protective helmets when participating in recreational activities? Each year in the U.S., about 324,000 children under the age of 19 are treated in emergency rooms for bicycle-related injuries alone (Gilchrist, MD, Thomas, MPH, Xu, MD, McGuire, PhD, & Coronado, MD, 2014). Speed activities and high-impact sports impose risk of head injury and aside from practicing good safety protocol, helmets are designed to protect the head when accidents or impact occurs. Making sure that your child is developmentally ready to participate in contact sports or high-speed recreational activities is an essential safety measure. Once you decide that they are mature enough to participate, selecting an appropriate helmet with the proper fit and making sure they have adequate supervision will go a long way in keeping them safe. Types of helmets Helmets are used for different purposes and differ greatly in their design. For example, a bicycle helmet needs to protect against falls and blunt impact forces compared to a helmet designed for rock climbing, which needs to protect against falling objects. Consequently, bicycling and rock-climbing helmets are not alike. Practical concerns also dictate design: Bicycle helmets have an aerodynamic shape and are wellventilated, while rock-climbing helmets are lightweight with minimal bulk so that the climber s technique is not inhibited. When selecting a helmet for a recreational activity, consider the following: 1. Pick a helmet designed specifically for the chosen recreational activity. The U.S. Consumer Product Safety Commission suggests that you do not rely on brand names or advertising claims. Rather, make sure the helmet meets federal safety standards or voluntary standards set by the industry. 2. Make sure the helmet fits well and is comfortable and snug. Since the best way to gauge comfort and fit is through comparison and manufacturer instructions, try on several helmets before purchasing. 3. Pay attention to the chinstrap, making sure that it fits snugly and comfortably. The helmet should not shift or easily move when worn. How long does a helmet last and when should it be replaced? Since children usually grow out of helmets before they degrade, fit should be the number one factor in when to replace decision-making. For older teens who replace their helmets less frequently or children who use a hand-me-down helmet, be aware of degradation due to: Glues, resins and other materials used in production Hair oils, body fluids and cosmetics Normal wear and tear Petroleum-based cleaners and paints Damage or accidents Degradation of helmet materials along with improved safety and product advancements suggest that helmets should be replaced every five years, or immediately if the helmet has been damaged. Bicycle helmets According to the Insurance Institute for Highway Safety, helmet use has been estimated to reduce the risk of head injury by 85 percent (Pedestrians and bicyclists, 2014). Helmets worked equally well for all age groups and that motor vehicle accidents involving cyclists were the most significant risk factor for severe injury increasing the risk by 360 percent. This makes a good argument for more bike paths, but busy intersections still remain a problem for children. What type of protection does a bicycle helmet provide? Helmets protect the head by absorbing energy created by an impact or fall. Currently, bicycle helmets are tested in 16 RainbowVisions

17 SUMMER 2014 laboratories with test procedures set by standard bodies such as Snell, the American National Standards Institute and the U.S. Consumer Product Safety Commission. The helmet s liner is made of stiff foam that limits the deceleration of a fall onto a flat, hard surface by absorbing energy. Common complaints about wearing a helmet I don t like the way they look. A survey on why children don t like wearing bicycle helmets was completed by the Consumer Product Safety Commission and the AAA in In that survey, children noted that helmets made them look like a nerd, a geek, weird or dorky. They commented that they wanted to see helmets with cooler colors and more interesting and varied designs. Over the past twelve years, manufacturers have come up with many options. If this is your child s complaint, investing in a helmet that appeals to their sense of taste could be the answer. I don t like the way the helmet feels. As children become more independent around the fourth or fifth grade, they are more likely to wear helmets if they are comfortable. Make sure that your child s helmet fits well, and replace it before it gets too tight. The helmet messes up my hair. For older children and teens, managing helmet hair can be a big issue. The combination of a snug-fitting helmet, heat and humidity can be disastrous on hairstyles. If your child has long hair, wearing a low pony tail is the most practical solution, and there are bicycle helmets designed with ponytail ports. If your child has hair braids and/or beads, this hairstyle will raise the helmet above the head. The result is that the helmet covers less of the head, leaves the sides unprotected and destabilizes, causing it to move more easily. If beads are included, they are a potential impact hazard. They can shatter, cut the scalp or concentrate the force of the blow on one spot. Helmets are designed to spread out that force to prevent the skull from fracturing. Concentrated impact force from beads can cause skull fractures. The best solution to this problem is to change the hairstyle, but another less optimal solution is to fit your child with an adult-size helmet and tighten the ring-fit headband below the beads and balls. Helmets for individuals who have had a brain injury Following a concussion or other brain injury, doctors typically recommend that children not ride until they are healed. But when they are given the go-ahead to ride, are helmets available that do a better job of protection? Unfortunately, we don t know. Helmets are designed and certifed for the average rider who can take a certain amount of g-force without permanent injury. Someone who has already Continued on page 18 RainbowVisions 17

18 Recreational Helmets for Children Continued from page 17 sustained a brain injury may not be safe at that rate. Since secondary injuries can be more dangerous than the first, it s smart to be extra cautious. Here are a few things to consider when riding after injury: Look for a helmet with extended protection on the sides and back of the head. The more coverage the better. Make sure the helmet is fitted properly (see sidebar at left). An ill-fitting helmet can fall off in a crash. Ride with extra caution. As with any rider, it s important to pay close attention to traffic, speed and hazards in the road. Staying alert to the surroundings can make the difference between crashing and staying on the bike (Helmets for Head Injured Riders, 2014). v How to wear a bicycle helmet Choosing a bicycle helmet that fits and wearing it properly increases protection. A bike helmet should sit level on the head (as shown) NOT tilted back like a hat. Use the appropriate foam pads and the rear stabilizer to create a snug (but not tight) fit when you place the helmet level on your child s head. They should be able to open their mouth wide without discomfort. Pay attention to the chinstrap make sure that it fits around your child s ear and under the chin snugly and comfortably. The helmet should not shift or move. The best way to gauge comfort and fit is through comparison. Have your child try on several helmets before purchasing. If necessary, additional pads can be added to make it fit snugly. When the helmet fits well, it should be level just above the eyebrows, and easy for your child to put on (How to Fit a Bicycle Helmet, 2014). RIGHT References: Hemets for Head Injured Riders. (2014, May). Retrieved from helmets.org: How to Fit a Bicycle Helmet. (2014, May). Retrieved from Bicycle Helmet Safety Institute: Pedestrians and bicyclists. (2014, May). Retrieved from Insurance Institute for Highway Safety : iihs/topics/t/pedestrians-and-bicyclists/topicoverview 5 tips To encourage your child to wear a helmet Your kids still don t want to wear a helmet? Try these tips: 1. Wear a helmet yourself. Kids learn by observing their parents. If it isn t important for you, why should it be important for them? 2. Establish the habit early in life. Start kids out wearing helmets on tricycles or when passengers on your bike. They ll be more apt to keep up the habit for a lifetime. 3. Make it a rule: No helmet, no riding. If you occasionally allow kids to ride without helmets, they won t believe that it s really important. 4. Let kids help choose their helmet. If they like the design and fit, they ll be more likely to wear it. WRONG 5. Talk to your kids about the importance of protecting their brain. Let them know about the potential consequences of a brain injury and remind them that many professional sports require head protection. 18 RainbowVisions

19 Surviving Summer By: Mariann Young, Ph.D. Rainbow Rehabilitation Centers SUMMER is the time for picnics, vacations and outdoor fun of all kinds. And, for some of us, the question is, What am I going to do to keep my children safe, supervised and entertained? With planning and some preparation, children can have fun and stay academically enriched during the summer and parents can keep their sanity! RainbowVisions 19

20 Surviving Summer survey of readers of the Children s A Hospital of Denver Magazine were asked what they would be doing for the summer. About half of the readers (52 percent) responded that they believed their summer would be just the right amount of busy. Yet an all too familiar complaint from tweens and adolescents is that they are bored. Survey takers in their early teens were most likely to say that they would be bored (40 percent) while only 10 percent said that they would be overscheduled. These numbers were nearly equal for the older teens. This result is not too surprising, as older teens are typically more independent, have increased responsibilities, and have had several summers of planning and organizing their lives. They are closer to transitioning to young adulthood and this is reflected in their decision making. There are several strategies that parents may utilize to ensure that their children are not bored or overscheduled. Make the summer enjoyable for children by planning the following for summer break: Engage children in the planning process. Plan ahead and have supplies on hand for indoor activities. If an activity is to take place outdoors, try to have an alternative plan if the weather does not cooperate. As the summer passes, review the summer plans that you have made to date. Brainstorm ways to fill the gaps and discuss if a planned outing or event was successful. Mark all of the activities on a familysized calendar and post it in a central location. Make sure to consider the needs of each child on the calendar. Insist on summertime learning. Summer outings may present opportunities to learn about history, geography, and nature. Encourage your child to keep a journal of activities, including pictures and postcards, to reinforce what they ve learned on the outing. Revamp, but don t eliminate routine. 20 RainbowVisions You may loosen up on some chores e.g., Friday and Saturday can be don t make the bed day, but it is important to keep other chores and routines intact. Planning for events, getting adequate rest, packing and organizing for events are all good summertime strategies. Develop and review safety procedures for kids, including both outdoor and indoor activities. For example, teach kids not to give out personal information on the phone or while on the Internet, or teach sun safety. Insist on summertime reading. Let your child choose the material. Explore the local library and become familiar with the summer programs offered. Set a bedtime. Getting the proper amount of sleep every night is important. Limit TV and video games. Reinstitute bedtimes and wake-up times two weeks before the start of the school year this helps kids adjust back to the school routine. Play and exercise. Help around the house (Tips for Shifting from School Year to Summer Break, 2010). The transition to staying home alone Are you thinking about leaving your child at home alone? Many parents wait until the tween years to attempt this milestone for a few minutes, or for a few hours everyday after school. Here are suggestions on making the transition easy for you and your child. Discuss rules and expectations Sit down with your child and discuss your family rules and expectations. Is your child allowed to watch television, use the computer when home alone? Write down what your child can and can t do while he s at home alone. Since your child s demands may vary from day to day, update his daily to-do list to reflect his schedule. Be specific about whether or not family or friends are allowed to visit while you re away. Also, make it clear if you expect your child to work on his homework, practice the piano, or set the table for dinner. It s also important to discuss consequences if your child decides to ignore the rules you ve established for him. Roleplay Your child should never reveal that he is alone, so role-play potential situations with him to make sure he is prepared. Prepare your home before allowing him to stay by himself. Make sure all your smoke detectors are in working order, install a peep hole in your front door, restock your first aid kit, and make sure he checks the caller ID on the phone so he knows who is calling the house. Begin gradually Transition your child to time home alone gradually. Begin with thirty minutes, adding on time as your child s confidence grows. Before you know it, you and your child will be comfortable with him at home alone, and another milestone of growing up will be behind you (Is Your Tween Ready to Stay at Home Alone?, 2014). Provide your child with rewards for assuming this responsibility. These can be in the form of verbal praise or a tangible reward such as a new game, clothing, or other treat. Talk to your child often and review how things are going. Be flexible. Work together to build your child s confidence. Summer can be a challenging time for parents, but with some planning, it can also be rewarding and memorable for parents and their children. Have fun! v References: Is Your Tween Ready to Stay at Home Alone? (2014, May 12). Retrieved from about.com: about.com/od/afterschoolactivities/tp/ The-Home-Alone-Experience.htm Tips for Shifting from School Year to Summer Break. (2010, April 13). Retrieved from Great Schools: special-education/support/662-tips-for-shiftingfrom-school-year-to-summer-break.gs