Play

The other day I noticed both Bears playing together in a way I hadn’t observed before. Little Bear had built a new Lego set, an air ambulance, and had somehow managed to convince his brother to play with him. Not only that but he had convinced him to include his new Lego set, a superhero ship with Ant Man in it, and the two of them were caught up in some sort of imaginary world that involved Lego men living in an Egyptian sarcophagus, daring rescues and the occasional mention of a ninja. The game moved around the house, obviously, because helicopters and spaceships do fly and baddies will insist upon moving their lairs.

It felt noteworthy for a couple of reasons. Big Bear has hitherto been very cautious about his possessions around Little Bear, generally keeping new or precious things safely stowed in his bedroom with its securely lockable door. There are now days when he leaves the door open (a MUCH bigger deal than you would imagine and one we are pretending not to have noticed for fear he will shut it again) and days when he is more relaxed about his stuff. The fact that he had just built something new and was willing to play with it in the same game as Little Bear really showed how far the Bears have come in terms of trust and respect for one another.

I wondered why they hadn’t played similar games before with Little Bear’s toys (he’s only too happy to share with his brother) but realised it was because until very recently, this year anyway, Little Bear couldn’t have played those games. He wouldn’t have been able to follow the storyline or formulate appropriate dialogue to be able to join in, however much he might have wanted to. The leaps he has made (and continues to make) with his language development have unlocked a whole new world for him in terms of imaginary play. Not only that, but his ability to concentrate and to engage in more complex games has really developed too.

It has got me reflecting about play in general and the changes we have seen over the nearly three years Little Bear has been with us. I’m going to talk about play in developmental stages. There are various ways play development can be categorised but I’m thinking mainly about symbolic play/ imaginative play rather than social play. There are several different terms for each of the stages that can be found in literature on the subject but this is the version I personally find the most useful.

Exploratory play

This is the first stage of play to develop (in typical development) when infants pick things up, drop them, chew on them, throw them, bang them together. Children are exploring tastes, textures, weights, sounds, wetness/dryness etc. They tend to be fascinated by anything and everything, not necessarily things you traditionally consider to be toys. It’s their first attempts at engaging with the world around them and they want to experience everything.

I suspect that many children who have adverse starts in life don’t have enough experience at this stage. If you spend too long in a cot or pushchair or highchair without any stimuli, you won’t be able to explore the world around you in the way you should. Being neglected at this stage robs a child of the experience they need to assimilate their senses. It is hard to learn to differentiate between hard/soft, wet/dry, hot/cold, rough/gentle if you don’t have any experience of feeling/touching things. I suspect that many sensory integration needs have their root in neglect at this stage.

When we met Little Bear, aged 3 and a half, much of his free play happened at this level. We spent a lot of time splashing in water and digging in sand. I also spent a lot of time telling him not to throw things or touch things that I would have expected him to know not to touch. There is the time he tried to lick a snake, the time he played in the toilet water and the time he smashed all the hens’ newly laid eggs. I genuinely believe Little Bear was still trying to assimilate all the sensory information he was getting from his environment and can only assume he hadn’t had enough time exploring (safely) when he was younger.

I had to make conscious efforts to offer him plenty of opportunities to engage in tactile sensory activities whilst teaching him some boundaries to keep him safe.

Water, the sand pit, kinetic sand, play doh, baking, not concerning ourselves with cutlery and turning a blind eye to him laying down prostrate and ‘swimming’ in gravel were the key, alongside exposing Little Bear to a wide range of ‘normal’ play experiences.

Pretend play with real objects/ oneself

The next stage of play is when children begin to show an understanding of what everyday objects are used for e.g. they might pretend to drink from an empty cup or babble into a pretend phone.

The thing about children who have been neglected is that their development is pretty patchy and though Little Bear had gaps at the exploratory stage, he did know what everyday objects were for and could pretend in this way already. He was certainly partial to a phone, even though his language skills wouldn’t allow him to have much of a conversation.

Large doll play

It isn’t usually long before children begin to relate everyday objects to each other and to their other toys. This is when they start to ‘feed’ their teddies or get them dressed.

We are pretty partial to a teddies tea party in our house and I can remember Little Bear being a bit bewildered the first time we got plates and food out for his cuddly animals. He soon picked up the idea though, often dolling out real biscuits for the animals and taking the opportunity to have some himself.

I found this stage useful for modelling behaviours and exploring some of Little Bear’s behaviours in a less direct way. Sometimes I would make the animals do things he had done or that we were finding tricky and it was interesting to observe how he dealt with them (he often took the role of parent). We also did it in a way that took the heat off Little Bear. Sometimes it was his rabbit who had been shouting or throwing things or saying rude words and we would ask Little Bear to have a word with them and teach them how to be sensible. He loved this responsibility and getting the rabbit to behave often mysteriously led to improvements in Little Bear’s own behaviour.

I’m not sure whether the last paragraph is more about developing play or exploiting the stages of play but still. Occasionally it worked the other way and Little Bear would express a fear or a worry through the voice of his animals, which was useful too.

Sequences of pretend play

Over time children begin to put several bits of play together so they might play with their toy kitchen and act out making dinner, feeding it to their doll then washing up.

I would say we were working at this stage alongside the previous one and exploratory play when we first met Little Bear and for the first months afterwards. That is the thing with child development; it is often not neat and linear, but skills overlap and appear at different rates. I think that children who have had difficult starts are more likely to have a muddled developmental profile and I can honestly say we could go from working at a 6-12 month level in the morning to approx. a 3 year level in the afternoon then back to an 18 month level again. It was hard to keep up with but imperative to match Little Bear’s level as best we could. There is no point trying to work to chronological levels when your child needs something much different. Little Bear would not have been able to reach the places he has reached had we not filled in the gaps.

The main sequences of play we engaged in a lot involved Little Bear pretending to be a superhero. We did a lot of dressing up, building dens and pretending we were in peril. He seemed to love it and it was great for extending his world knowledge and vocabulary.

Small World Play

At this stage children transfer their play skills into miniature representatives of the types of games they have already been playing. They might start playing with a farm or Duplo or Playmobil and doing some basic pretending.

I know we weren’t ready to play at this level when Little Bear first arrived. I distinctly remember trying to introduce him to Duplo but he lost his temper within the first nanosecond because he couldn’t get the man to sit in the bus as he wanted. You would certainly expect a typically developing three year old to be able to play at this level but it would take months of exploratory play, building resilience and bigger, more physical play for us to be ready to try again.

I think it has been the development of Little Bear’s attention span and his resilience to persevere through knockbacks and failed attempts that has allowed him to engage in small world play and crucially, enjoy it. I find it uniquely pleasing to observe.

Little Bear has always had a good imagination, that was clear from day 1, but it is only at some point in this past year (he’s 6 now) that everything has come together to allow him to explore it in his play. Play stages and language development are very much aligned so it shouldn’t really be a surprise that it is the point at which he has gained linguistic competence that he has also developed complex play abilities.

Play develops from here on in, becoming more complex, with longer, more detailed scenarios panning out. The Lego game that I observed the boys playing at the start of this post epitomised the progress Little Bear has made – playing a small world game, with tiny fiddly pieces that require a heap of resilience, making up an imagined scenario, adding appropriate dialogue and crucially negotiating and listening to his brother so that they could both be in the same imagined place, at the same time, contributing to the same scenario. It is standard kid stuff on face value but it is so complex and requires so many pre-requisite skills that it really is a feat of development.

I should really give Lego its own special mention before I finish because we love Lego in our house and also because it alone is a good indicator of how Little Bear is doing.

Big Bear had a premature love for Lego, getting into it from age 2.5 and loving it ever since. Given Little Bear’s disordered/ delayed development he wasn’t going to get into it anywhere near as young. I think he was about 5 when he could first start to tolerate building a simple model with a high level of adult support. I remember worrying because he really struggled to scan the tray to find pieces he needed let alone being able to follow the instructions. As with everything, we have practised and persevered and Little Bear has developed his skills quickly (once he overcame the initially difficulty). This week he chose to spend his holiday money on a sizeable Lego model of a dragon. It has an 8-14 age recommendation and he has done brilliantly, followed the instructions well and built the majority of it himself with just a little adult support.

What are my conclusions? Well, Little Bear is something of a legend but that is often my conclusion. Play has played a crucial role in his development and is very much intertwined with language development. Play has to happen in developmental order. You can’t skip bits willy-nilly; whichever stage a child is at, that is where you need to meet them. Development doesn’t happen overnight; stages take as long as they take. Developmental delay is never hopeless. Progress can and does happen and we should be aspirational for our children, no matter their start in life.

 

 

 

 

 

 

Play

Talking is Crucial

We’ve had a flurry of activity here over the past week or so, with various people visiting us and several sleeping over at different points. Each person has come with their own story, most of which have made our day to day challenges pale into insignificance. Their stories are not mine to share of course, so I won’t, but reflecting on it all has left a few thoughts whirling about.

Firstly, talking is crucial. It is crucial in a very basic form: the form where it allows you to have your needs met. We know this as a family, having adopted Little Bear at a point when he couldn’t communicate well and there was more he couldn’t tell us than he could. We know it but sometimes a situation arises that reminds you. One of our guests was a family friend who happens to have learning difficulties. Her speech and language skills are very limited and even in the short time she stayed, we could see a snapshot of the challenges she faces every day. She couldn’t always tell us what she wanted to eat; she couldn’t tell us what she wanted to watch on TV; she couldn’t tell us why she did or didn’t want to do certain things. It must be incredibly frustrating, especially as she can understand much more than she can express (you can’t help but notice these things as a speech and language therapist and incidentally, be a little desperate to solve them).

I certainly feel as though life would be different for her were she able to say everything she is capable of, whether that was verbally or in another way. I also felt it must have been really scary for her, to come and stay somewhere she hadn’t stayed before, knowing she might not be able to get all her needs/ wants met. Imagine how vulnerable that would make you feel. I suppose some people might think that due to her learning difficulties she doesn’t think about these things but I know she knows her communication is different. I think she’s embarrassed about it and is certainly more reticent if there are a lot of people around or people she doesn’t know well. More words began to sneak out as she settled but there was still a huge disparity between the ones she comprehended and those she was able to verbalise at the point she wanted to say them.

I can’t help but think of the what-ifs. What if she’d had more/better speech and language therapy when she was younger? What if she did now? Is it too late? Is it ever too late? Should something alternative have been put in place? What should it be? Why wasn’t more offered? Did people think it was ok because of her learning needs? What if a young child presenting as she did when she was young was under speech and language therapy now? What potential would be seen in them? Would outcomes be different? I like to think so but given what we know of speech and language therapy services since Bercow10 (see Ensuring Children’s Speech and Language Needs Are Met: A Call to Action) I wonder…

Surely we should be striving for the most a person can do, whoever they are, instead of settling for the least we can get away with.

On another note, it was interesting to observe Little Bear with this person. Firstly it really highlighted the progress he has made with his communication. He is a competent communicator now; he can say everything he wants to say and mostly with clarity. It’s not to say that his speech and language skills are perfect, because they are not, but in general, if you popped him into a group of people he didn’t know well, he’d be ok communication-wise. I don’t mean to draw a comparison, because that’s wholly inappropriate, but the realisation that Little Bear has reached that point was a bit of a surprise. I worried for so long that he wouldn’t reach it that this little revelation is very welcome.

Along with this revelation came an uncomfortable truth. Little Bear is now able to use his communication skills for both positive and negative purposes and though he was mostly great with the lady I’m talking about, there was one point when he was tired and cottoned on to the fact that he was verbally wilier and could use his words to wind her up. It was weird to observe because I have seen it so many times directed towards Little Bear, from wilier peers. I tried to intervene to stop him as I could tell he was upsetting her but as he was on that trajectory where he couldn’t stop himself he carried on regardless and I decided to take him out of the situation and up to bed.

The incident had a weird, double-edged irony: I was sad to observe it and sad for the lady’s communicative limitations whilst being simultaneously disappointed that Little Bear would do it yet also noting it was indicative of his developmental progression. We talked afterwards about it and Little Bear could remember times when he wasn’t able to say what he wanted and times when he had to resort to other methods of getting his messages across, such as hitting out and I think he understood why he shouldn’t have exploited her communication difficulties as he had. He was sorry afterwards.

Although it feels like an important moment to reflect on, I don’t want to make it more significant than it was. Overall both boys were fabulous and just took all the issues of the past week in their stride. They are both very empathetic and I’m extremely proud of the kind, understanding, non-judgemental young men they are becoming.

At one point the lady I keep talking about gave Little Bear a bear hug that was a little squeezier than he might have liked. Initially he got a bit upset and took himself out of the room. When I went to him he started with the usual “I hate said person/ she hurt me/ she did it on purpose/ I hate her now” rhetoric but we had a little chat and I left him to calm down. The next thing I knew he was coming over to her, offering another hug but asking her to be more gentle. Again, I could see the progress he had made. Previously he wouldn’t have been able to put his communication skills to such good effect, would not have calmed so quickly and would have given said person a wide birth/cold shoulder for a lengthy period. I think the approach he took showed real maturity and I felt a glow of pride.

Our week also taught me that it is not just talking at the fundamental level of getting our most basic needs met that is crucial. Talking is also crucial to keeping us mentally well. Other guests we had were carrying other issues and when I say carrying them, I mean lugging about a massive sack of stress, hurt and grief wherever they go. The difference, I think, between that massive sack dragging you further down or you being able to get on with your life despite it, seems to be your ability to talk about it. The person who internalises or who does not have an available/ safe outlet for their worries and feelings is in danger. I know that sounds a little dramatic but I genuinely believe it’s true. There is a lot on social media at the moment about suicide prevention and all the statistics around the issue. It’s worrying.

Talking helps people take things out of their massive sack. Issues can become less, opinions can be sought, advice given, soothing words or hugs dispensed. Talking doesn’t make things go away but sometimes it can give perspective, space or a fresh view point. Things tend to multiply or expand or metastasise when left in the sack. Talking can curb things, keep them in check, prevent them taking on a life of their own.

On face value, one of our guests maybe seemed to have a lot of issues. They told me a lot of things. They seem to have a lot to worry about. However, I know that another of our guests, who said nothing, also has a huge sack of issues. It’s the one who said nothing that worries me. The one who talks spills the contents of their sack at regular opportunities and I’m glad they do. They have hard things to cope with but they’ll be ok. The other one, the one who doesn’t talk, I worry about them. I don’t know if they have that safe outlet, that trusted person, that someone who will just listen. I don’t know and I think their lack of being able to talk, even though they have the communication skills they need, is a red flag. I suspect it is not being viewed as such by people around them – they do not appear upset, they aren’t saying upset things ergo they must be fine.

Whilst talking is crucial, so is listening and both are required for mental wellness. I know many people who think they are good at listening but few who genuinely are. The best kind of listening is not just done with the ears; it is about observation, reading between the lines, hearing the unsaid. It is the ability, or maybe the willingness, to see beyond what is presented. I suppose it is about connection. I suspect not everyone thinks they have the time.

I also suspect that people don’t always think the same level of observation and alertness to emotional wellbeing is required for children; that somehow children are just fine. They aren’t and the ways they manage, or don’t manage, their feelings and worries and grief will follow them into adulthood and shape their future selves. This whole talking thing needs to start as soon as possible.

Sometimes I wonder if I’ve got too wrapped up in adoption and the issues it brings. None of the people who have been here this week are care-experienced. They are not adopted yet they have experienced trauma. I guess I’ve been reminded that we don’t know what sacks people might be lugging with them; these cumbersome burdens are often invisible. The emphasis is on us, as fellow human beings, to be alert, to look beyond appearances, to actively observe and skip the snap- judgements. Talking is crucial but so is hearing the unspoken.

It has been a funny old week.

 

 

 

Talking is Crucial

Interoception

When I went on Sensory Integration training (admittedly about ten years ago) we were taught that there are seven senses: all the ones you usually think of (taste, touch, sight, smell, hearing) plus proprioception and the vestibular system.

Proprioception is the sense of knowing where your body is in space and is stimulated by things like deep pressure, heavy work and vibration.

The vestibular system is in your inner ear and is the sense that helps you battle gravity. It is stimulated by movement, especially spinning or being upside down, and is the sense that causes travel sickness. If anybody has experienced Labyrinthitis they will have experienced their vestibular system on overdrive! Grizzly had it so badly that he literally didn’t know whether he was the right way up or not and couldn’t get out bed for several weeks or even move his head.

I think about Sensory Integration (SI) quite a lot when it comes to Little Bear and I’ve previously written about it a little in Too fast, too hard, too loud. The basic premise of SI is that everybody has a sensory system and we are integrating sensory stimulation all of the time. Everybody’s system is different and what we can cope with/ what we need in terms of sensory stimulation in order to be comfortable in our bodies will differ too. Little Bear certainly seeks proprioceptive and vestibular input which has led to us having a free standing pull up bar in the playroom so he can climb and hang as he needs, instead of seeking similar input in a more dangerous fashion (like clipping his belt loop to the bed and hanging from there. Full marks for ingenuity but a little too dangerous for my liking).

However, a couple of articles have caught my eye recently which have suggested my SI knowledge is a bit out of date. Current thinking is that there are in fact 8 senses: all the ones I mentioned plus something called Interoception. I have done some digging to figure out what it is and why it might be important for our children and thought it may be useful to share.

Interoception is a bit like proprioception but from the inside. It is the sense of knowing how things are within our bodies. It includes things like being aware of our heart beat and whether it has sped up or slowed down; being aware of our digestive system – are we hungry/are we full/do we feel sick; is our temperature ok – are we too cold or too hot; awareness of blood sugar – are we getting shaky and a bit low on fuel; awareness of our bowel and bladder – are they full/ do they need emptying; do we have pain anywhere.

I’m imagining it like there is a telephone system between our internal organs and our brain. The lines of communication need to be kept open so that if our heart is beating faster, it can “ring” the brain which can then take measures either to ignore that or suggest for you to sit down and rest for a bit. Or you might have a full bladder. The bladder would call and tell the brain to make you aware you needed a wee and you would go to the toilet. It’s all good and very effective when working properly but there are lots of things that can get in the way.

IMG_1077

Studies of infants have suggested that interoception develops very early, perhaps in the first few months of life and might be stimulated by things such as their parent stroking their cheek or rubbing their back – which are pleasant sensations that might ease internal states. One study showed that being stroked on the face led to a decrease in heart rate in 9 month olds. I read something else which stated that infants “associate interoceptive signals of warmth and satiety with their caregiver’s face, which in turn drives attachment behaviour”.

From the limited evidence, you can see that a child who has been neglected (hasn’t received physical comfort) or who has had multiple caregivers (seen many carers faces), might not develop typical interoceptive skills. There is already evidence to say that children who have suffered physical abuse grow up to have altered pain sensations. One article I read suggested that investigating the impact of adverse childhood experiences on interoception is a big area which requires loads more research.

Even if we don’t fully understand all the reasons why a child may end up with a faulty interoception system, we do know that they can and that they may be under-responsive, over-responsive or seeking of interoceptive input. Being over-reactive to bodily signals such as heart rate, butterflies and muscle tension has been associated with anxiety and depression. I suppose that is the equivalent in my analogy of the brain being phoned constantly for every internal twinge or tickle instead of just for the big ones.

Being seeking or under-responsive to feelings of a full tummy has been linked to eating disorders. In this example the brain isn’t getting the call when the tummy is full or the brain starts to panic when there aren’t calls so stimulates the body to continue eating. Something about the feeling of fullness is desirable. I think the converse could also happen – being empty being the more desirable feeling.

If children struggle with interoception, they can find it difficult to know whether it is something inside or outside of them that is causing discomfort, leading to dysregulation or an unusual response. I think hunger is a really good example as Little Bear definitely struggles to identify when he’s hungry (hangry!) and will tend to get irritable and aggressive with anything and everything rather than identifying his tummy is empty and that he needs to eat.

Some researchers think that interoception could underpin many psychopathologies and could be a lot more crucial than we yet realise. One thing they do agree on is that being able to recognise and respond to your internal states (interoceptive feedback) is a crucial skill for recognising your own emotions, learning and good decision-making. Poor interoception tends to be linked to risk-taking behaviours such as drug-taking, promiscuity and alcohol abuse in later life. Could this be because these things tend to heighten sensation, giving the brain the feedback it needs but doesn’t usually get?

As emotions such as anger, nervousness, and excitement have a physical impact on the body, as well a neurological one, we can see how interoception also has an involvement with our emotional development. In fact interoception is crucial in helping us to identify which emotions we are feeling from the signals our bodies are giving us.

It turns out that interoception is a much more complex and wide-ranging sense than you would initially think.

So what about Little Bear? What I have learned that is of use to him?

Well, according to SPD Star “it’s only when all of the other senses are regulated and in check that our body is quiet enough to listen to what those internal signals are telling our brain”. In other words, most children who experience SI challenges are likely to experience some interoceptive differences and they won’t be resolved until their other sensory needs are being met. Let’s hope that hanging bar is doing its job then.

I have identified that when it comes to the interoceptive sense, Little Bear is under-reactive. I have already mentioned that he would neglect to eat without adult support but perhaps the biggest thing I’ve learned is that he is probably under-reactive in the bowel/bladder department too. I have talked about his Continence Issues previously but this information shines a new light on them. It seems very likely that the phone line between Little Bear’s bowel/ bladder and brain is a bit faulty. When the bowel/bladder start to fill up, the message does not immediately get passed to his brain. It is only when they are full to capacity and the red warning light should be going off that Little Bear’s brain gets the signal to tell him to go to the loo. By that stage he often needs to run and sometimes he inevitably doesn’t make it. The theory certainly fits with the behaviour we observe.

I like this as a way of explaining why he’s not consistently dry, it makes sense. As with most aspects of SI it also means there is hope and that with the right approach he should be able to make progress.

I have found it more difficult to find specific advice about how exactly to work on interoception, other than to speak to an OT or get a sensory diet written. However, what I have gleaned is that you basically want to get the brain more tuned into the signals from the organs/ muscles and Mindfulness is mentioned quite a bit in the literature. I guess that makes sense – quietening everything down so that you can hear the internal whispers that you would otherwise miss. Once you are more tuned into those signals, your brain should get better at listening out for them.

Some of the things we already do at home seem to be appropriate for improving this sense. Things like when Little Bear is hungry, I will draw his attention to the rumbling sounds from his tummy and explain what they mean. Sometimes he will say he has tummy ache and I’ll know from the coincident hyperactivity that he needs the toilet. Since reading about interoception I am getting more conscious of not just herding him to the loo but trying to encourage him to feel that tummy ache and identifying it as the feeling of needing the toilet and explaining that when you feel that sensation, you know you need the loo. This sort of cause and effect doesn’t always come naturally to our children anyway and sometimes they do need us to state things that seem obvious to us (it isn’t obvious to them otherwise they would be able to act on the sensations).

Apparently regularly prompting a child to go to the loo helps them to get used to the sensation of an empty bladder and to experience the contrast with a full bladder which should help to develop their interoception over time. Using technology such as vibrating watches is a helpful way of keeping on top of their interoceptive challenges a bit more independently, as well as teaching them strategies such as going to the toilet during every break whether they think they need it or not.

As with most things adoption related, this isn’t a quick fix. It takes time and getting other sensory needs under control first.

I can see improvements in Little Bear’s interoception system though. He was certainly under-responsive to pain when we first met him and though he still has a high pain threshold (a few more than average phone calls from the injured area to the brain before a response happens) he does now respond to knocks and bumps in a much more typical way. He will cry and come for a rub where previously he could have banged his head on a solid object and not even broken step or let out a yelp. The toileting and hunger issues have improved too, but in a stepwise fashion, where we still have some steps to go.

Interestingly, while being hyper-aware of your own heart rate can go hand in hand with anxiety, some children enjoy the sensation of a heavily beating heart and actively seek this – driving them to exercise – and consequently they become very fit. I’m not sure if this applies to Little Bear but I’m not sure that it doesn’t either as he certainly likes running about/ bouncing/ hanging etc. and is developing into an impressive sportsman.

As with most differences, a differently developed interoception system brings its challenges but also its unexpected silver linings.

 

 

*If you want to know more about interoception, this is a particularly comprehensive article:

https://www.sciencedirect.com/science/article/pii/S187892931630127X

 

**This blog is based on my own reading. If you think I’ve missed something or not quite explained something properly please let me know.

 

 

 

 

Interoception

Continence Issues

This week’s post has been inspired by a fairly innocuous seeming comment from a friend. He said, in reference to his newly adopted 2 year old, “he’s fully potty-trained now, day and night!”, with just the teeniest hint of competitive parenting lacing his voice. He’s rightly proud of the achievement but I have to confess that part of me thought “oh FFS!”. I think I managed a polite smile and no eye-rolling…

It is just that toileting is something of an ongoing situation here with Little Bear and, at 5 years old, we are fairly far from reaching the golden pinnacle my friend speaks of.

When Little Bear arrived, aged 3 and a half, he wasn’t toilet trained. His foster carers claimed it was because he “wasn’t ready” but in all honesty I don’t think they had really tried. Obviously tackling toileting wasn’t very high on our agenda in the first weeks of placement either, as bonding and behaviour issues were much more pressing. We also identified fairly quickly that we would need to sort out Little Bear’s digestion before attempting to get him out of nappies.

On his arrival he was taking prescribed Movicol for constipation and he created several very effortful and repulsive nappies each day. It was distressing to see the discomfort he was in and at night he seemed to be suffering from stomach cramps (he would writhe about in his bed whilst asleep and sometimes fall out). On reading the Movicol packet we established that this could be the cause of the pains.

We also observed that Little Bear barely ate any fruit or vegetables which might well be accounting for his sluggish gut. It was strange because I always assumed that during Introductions we would be given a list of food likes/ dislikes but we weren’t. When I pressed the foster carers on it they were vague, as though they didn’t really know what he liked. Either way, fruit and vegetables weren’t really mentioned or visible and whenever we gave them to Little Bear he certainly didn’t appear familiar with them.

Another observation was that when we first met Little Bear his tongue had a very unusual appearance: kind of lined and cracked looking. It looks normal now so in retrospect we have concluded he was dehydrated. We certainly didn’t really see him drink and if we tried to give him something he would only take tiny sips.

It became a fairly major priority of mine to get him to eat and drink properly, with the end goal of getting his digestion working properly without the need for Movicol. It was possible that there was a physiological reason for his constipation of course but we just weren’t convinced, given the other things we had noticed.

Tackling Little Bear’s diet wasn’t easy as we also had issues with getting him to sit at the table and actually eat. It turned out though that Little Bear would eat pretty much anything if it was mashed or pureed or hidden by gravy and if one of us would feed it to him. Looking back, it seems we might have still been at the weaning stage. The benefits were that I could get vegetable soup or pureed casserole or pasta sauce with hidden vegetables into him and he was having lots of tastes of different foods without knowing it. I also tried smoothie lollies which worked well until he got fed up of them.

It was difficult because Little Bear did and still does use food as a means of control and whilst I felt it was in his best interests to improve his diet, I was also wary of putting too much pressure on him to eat. I did do things like withhold chocolate or pudding until he had at least tried his proper food or eaten a few bits of veg. I know there are a lot of opinions out there about whether this is the right/wrong way to approach things but it turns out that healthy eating and the wider impact of it on health, alertness and behaviour was a big deal for me. It wasn’t something I could overlook.

I also found Little Bear’s behaviour at mealtimes one of the most challenging things to manage in a calm way. Everybody finds certain behaviours particularly triggering and for some reason this is what really pushed my buttons. I have had to work hard at finding a happy balance between meeting Little Bear’s nutritional needs and working on his table manners. As much as it pains me that he gets up every 3 seconds and will do anything but eat at the table, I have recognised that sometimes it doesn’t matter what else goes on, as long as he has eaten something. Little Bear is perfectly capable of feeding himself and sometimes he does so without issue but there are other times where no matter how infuriated I get, he just won’t. On those days it is more important that I swallow my issues and feed him, as then he will eat and if he has a full belly the world is generally a better place. I can just thank my lucky stars that he no longer screams, throws his food about the room or head butts the table.

Anyhow, after a couple of months, we had managed to successfully wean Little Bear off the Movicol and he had developed a regular, healthy bowel habit. It was around this point that we turned our attentions to toilet training. Little Bear knew when he needed a poo and was able to say so, so it didn’t take long to get him into the habit of using the potty. It would have been good, given he was nearly 4, to go straight to the toilet but he was quite wary of it so I went with what he was comfortable with and made that transition later.

It wasn’t long into potty use that Little Bear wanted “big boy pants” so we just went for it. In the early stages everything seemed to be going well. Little Bear was sorted with his bowel movements from day 1 and if we prompted him to go for a wee regularly we didn’t have too many wetting accidents. It was only when we tried to move on to Little Bear going off to the loo as and when he needed it that it became apparent there was a problem: he didn’t ever seem to need it. However, he clearly did as he was wet all the time. Little Bear didn’t seem bothered by this and didn’t tell us. I wasn’t always sure he was aware he was wet.

It feels to me as though some sort of developmental window has been missed so Little Bear has never developed the sensations warning him he needs to go and has grown so used to sitting in a wet nappy that being wet feels normal.

We have had to manage this by going back to regular prompting to help Little Bear stay dry, even though he is not always keen to comply with the requests. We have bought him a special watch, which you can set to vibrate at certain times to remind him to go to the loo and to help him become more independent in his toileting. I do think it’s good and I would recommend it but ideally your child would want to be dry and would be more motivated to do what it tells you than Little Bear. It worked well for us for a while but then he couldn’t help pressing all the buttons (even though it does have a child lock system) or constantly taking it off and losing it. As he is a little bit oppositional the fact that it was telling him to do something just made him want to do the opposite.

However, we have persevered and worked on Little Bear telling us when he is wet. If he does tell us, we praise him for that and try not to comment too much on the actual wet pants. He has made lots of progress with this and mostly does tell us now if he’s had an accident rather than us having to detect it from the smell!

We have also figured out that the first warning sign Little Bear gets is when a dribble of wee comes out. It appears that he can then stop the rest from coming until he chooses to release it. We are working on Little Bear taking himself to the toilet after the first dribble rather than just doing it in his pants. This is definitely improving and just this week, over a year into toilet training Little Bear has said a couple of times that he needs a wee and taken himself off for one. This is a big deal for him and I’m grateful that signs have started appearing to suggest we will eventually get there.

As we are not yet secure in day time dryness, we haven’t even thought about attempting night time dryness. Little Bear’s pull up is completely sodden in the morning and occasionally overflows during the night so I know he isn’t ready.

As with many things I write about Little Bear, none of this is his fault and I can’t help feeling sorry that he hasn’t been afforded the same chances as his peers, who were probably beginning their toileting journeys 12 to 18 months before he was. So, whilst I’m glad for my friend that his little one is gifted with exceptional bladder control I do wash a lot of urine-soaked clothes and bedding and hopefully you will forgive me for also being a teensy bit irritated by his comment.

Continence Issues