Working Through Frustration
I first met “Nina” in September when she was 15 months old, the age by which we would typically expect little ones to be “toddling” about as they start to explore their environment as new walkers. But Nina had not yet taken her first steps. At this point, she had not yet even rolled over on her own. The primary position she maintained independently was supine, resting flat on her back with her arms at her side as she did not yet have the strength to even lift her hands to bring them together.
Immediately I noticed a lot of developmental concerns, but it was clear early on that building a therapeutic relationship with Nina would be essential to guiding her through motor milestones, many of which would be challenging for her given her size and limited perspective. That is to say that she had mainly experienced the world lying on her back or held in someone’s arms. Her body and visual system had not adapted to the sensations of rolling or to the skewed view of holding her head level while she moved from her side to sitting. At this point, to introduce her to positions that babies typically explore at 5-6 months when she was already the size of 15 month-old meant that her weak muscles would have to work even harder to move her relatively bigger body. For her, the milestones that babies typically flow through felt like boulders to overcome. So it was no surprise to me that the initial physical therapy sessions were filled with expressions of her frustration despite singing, cuddles, and lots of encouragement from me.
It can be a delicate balance of knowing when to push forward and when to slow down. Especially, when a child has a complicated medical history. Nina had been diagnosed with tuberous sclerosis, a condition that affected her neurological system and resulted in low muscle tone. The unique challenges of each child must be met with compassionate attentiveness. At the same time, the objective of therapy is to empower the child to maximize their potential and I was dedicated to helping Nina unlock her potential to explore and play.
The first month was focused on building a foundation of strength by assisting her in activating her neck muscles and getting comfortable in tummy time. Usually, babies naturally explore these activities and build strength in these positions as their vision develops. In Nina’s case, she was not interested in looking at toys or people, so determining the best way to encourage her to work on these activities was a puzzle.
The goal was ultimately to fast-track her through milestones while giving her the opportunity to experience each part of the developmental sequence. Movement patterns build on each other, so while the end goal was for her to walk on her own, it was essential to capitalize on the ways that rolling, sitting, crawling, and kneeling would benefit her strength, coordination, and visual system.
For months, Nina and I worked as a team at her daycare. I provided her mother with regular updates on her gradual progress and guidance for home exercises. Her mother in turn shared with me her hope that Nina would no longer cry when she tried to work with her at home as well as her fear of never seeing her baby girl walk. She was not alone in those concerns - this is a frequent occurrence I see because it’s understandably hard for any parent to see their child struggle. But I was confident in encouraging her to keep pushing through the initial challenge because based on my clinical experience, I knew Nina had the potential to achieve her mom’s goals. We just had to help her get there.
By December, Nina was making noticeable improvements in gross motor skills. Her mother happily exclaimed to me on the phone after the holiday break, "She's starting to sit up on her own! That was our Christmas gift."
Her relief was palpable as she began to see the gap in motor skills start to close. This new milestone of sitting brought a new perspective for Nina as well. She began to reach for and play with toys, still expressing frustration when her favorites were just beyond her reach but her introduction to meaningful movement allowed us to work on moving out of sitting with less protesting from her.
Crawling on hands and knees took another three months to master. Her achievement of that milestone brought excitement and celebration to the daycare staff who had, until that point, watched her work on the same tasks over and over with hopeful uncertainty.
The transition from crawling to cruising was far smoother as by this time Nina had developed confidence with movement and was motivated to explore on her own. She trusted me to guide her to the next level.
From March to December of the following year, Nina and I consistently worked on walking. This was the most protracted and most anticipated phase of working toward her parents’ goal for her. By giving Nina just as much support as was needed to calm her fear while also giving her just as long as she needed to practice, we were able to celebrate her first steps! (Just in time for another Christmas!)
Once Nina was able to walk confidently and independently, I monitored her progress with regular check-ups. Her mom and I had a good laugh at her new obligation to baby-proof the house now that she had a toddler. We started to focus more on safety awareness and standing transitions, but the hurdle had been crossed.
The time approached when my journey with this little one and her family was coming to an end. On one of those last days, I opened my eyes wide to say good-bye for the day and watched this child lock eyes with me and take steps toward me to collapse into my arms for a hug. I felt incredibly proud of her for the effort that she had put into working through these difficult milestones and for the resilience that she undoubtedly developed through this process. And I was grateful for our therapeutic relationship that remained untouched despite this challenging journey. She experienced many tears and a lot of uncertainty, but by the end when I looked at her I saw a joyful little girl “toddling” about.
