A Matter of Policy

     The little blue Mazda stopped at the corner of Rosewood and Vine. As Susan stared at the traffic light ahead, she felt the engine shuddering. She had just had it worked on last week and it was acting up again already. "Damn!" she said out loud giving the steering wheel a whack with the heel of her hand. A woman pushing a baby stroller passed in front of the waiting car. Susan pretended to adjust the sun visor to avoid eye contact with her. Once the woman and baby had passed, Susan resumed her watch on the interminable light.

     She felt her chest tighten and her throat swell. The inside of her nose began to burn. It was difficult to see the light as her eyes started to flood with tears. Even so, she maintained her watch, knowing that if she looked down the precariously perched tear would fall. This was the third incident in less than a month and a half. They must really think she was losing it now, she thought. She could just imagine them writing off this latest outburst as some deep-seated psychological disturbance. She was certain that they couldn't see how wrong they had been this time; but she could. Another wave of anger flowed over her. "Damn!" she said, giving the steering wheel another whack. "Damn, damn, damn!"

     It was the movement of the blanket that caught her eye then. Susan turned toward the passenger seat where two familiar blue eyes were laughing at her. "So, you think this whole thing is a big joke do you?" teased Susan. Since she'd succeeded in gaining her mother's attention, 10-month-old Jennifer gave out a little squeal of delight, pulled the clutched blanket up to her chin, and kicked her feet against the edge of the baby car seat. "Oh, so you're real proud of causing all this mess are you?" continued Susan. "Well, little Miss Smarty Pants, what are we supposed to do now? I suppose you think we should go to the park and just play all day?" Jennifer shot her mother a crooked little grin, causing Susan to smile back at her. As she did, the tears lost their balance and tumbled down her cheeks. Just then the light turned green. Quickly, Susan wiped away the tears with the back of one hand and headed off toward the downtown area.

     Susan turned the car into the parking lot of Anthem Publishers on Broad Street. She looked up at the clock on the bank tower across the street. "Well, Jennifer, Mommy's late for work again. If we end up on welfare, I suppose we will be able to spend all day at the park."

     The baby just stared back at her. Susan checked her face in the rear view mirror and ran a brush through her hair. She started to pull out her cosmetic bag but, on second thought, put it back in her purse and opened the car door. She pulled the stroller out of the trunk and loaded it up with her briefcase, a few of the baby's things, and Jennifer. Within minutes they were in Susan's office. Susan placed Jennifer on a blanket with a few toys in the corner of her office and started working on a manuscript that was due the following day.

     Debbie, a colleague, poked her head into Susan's office. "Hey! What's this? . I thought the exterminators came by here yesterday!"

     "Huh? What do you mean?" said Susan.

     "Would you just look at that big ol' linoleum lizard over there in the corner!" said Debbie, smiling and pointing to Jennifer.

     "You're going to have to stand up to this woman's insults by yourself, Jenn," said Susan to the baby. "I've fought enough of your battles for one day."

     "Is she playing hookey from school today?" Debbie kidded.
 

The Policy Stated

     Susan described the morning's events to Debbie. Jennifer had gotten sick in the classroom the previous day. She was running a fever of 102 degrees. They called Susan at work, and she took the baby straight to the doctor. Not surprisingly, it was another ear infection. Susan had specifically asked the doctor whether it was alright for Jennifer to go back to school and her child care the next day. He said that Jennifer was not contagious and returning to their routine would be fine as long as she was feeling up to it. After two doses of antibiotics, Jennifer's fever was completely gone, and she was back to being her old self by bedtime. So, Susan took her into the classroom this morning. Her classroom, a half-day early intervention program sponsored by the county, was held in the annex of the Mental Health Center. There were two other babies in Jennifer's classroom, Jason, who was 16 months old, and Lisa, age 6 months.

     When Susan walked in this morning she met Yolanda, the social worker for the early intervention program, at the front desk. They were talking together and playing with Jennifer when Kathy walked by them. Kathy was Jennifer's teacher, so it seemed odd to Susan that she didn't stop to talk or at least say "hello." Susan assumed that Kathy must have had some work to finish before class started and was in a hurry.

     A few minutes later, Susan carried Jennifer down the hall and into the classroom. Kathy was straightening some toys on the shelf. "Good morning!" Susan said. "Where are our buddies, Jason and Lisa?"

     "They're both absent today," answered Kathy. She continued to sort through the toys.

     Susan sensed that something was wrong. Kathy was usually chipper in the morning and always talked to Jennifer the minute they arrived. Not knowing what to say next, Susan stalled for time by laying Jennifer on the mat and fiddling in the diaper bag.

     "You really shouldn't have brought Jennifer today," said Kathy. "She was sick yesterday."

     Susan turned around to face her, surprised at the cool tone of Kathy's voice. Then she remembered, "Oh, I forgot to tell you. The doctor said it was just another ear infection. She's on antibiotics. She doesn't have a fever now and she's not contagious." She turned back to the baby. "You're back to your old rotten self again. Aren't you, Jenn?"

     "Susan, you know our policy," said Kathy. "Children can't come to the Center if they've had a fever in the last 24 hours."

     "But, she's not contagious," replied Susan, now using a rather cool tone of voice herself. "The doctor said it was alright for her to come back to school."

     "I'm sorry, Susan. I really am. It's just our policy."

     At this point, the conversation had become a real standoff. There were a few more exchanges between the two women. Susan argued that since Jennifer wasn't contagious, she wasn't violating the intent of the policy by bringing Jennifer to school. Kathy kept saying that she had to follow the program policy and eventually said something about Susan being unfair by putting her in this situation. Although Susan maintained her composure in front of Kathy, inside she was seething with anger. She couldn't believe this was happening. Susan finally picked up Jennifer and left, saying that she really didn't need this and was already late for work.

Concerned Colleagues

     Debbie listened attentively to Susan's account of the morning's events and agreed that Kathy had been a real jerk about the whole thing. Debbie was a good listener. Susan always felt better after they talked. Even so, she felt guilty about laying her problems on Debbie. She didn't want to become a whining and complaining friend that Debbie would learn to avoid. So, for the most part, she tried to keep her problems to herself.

     "I suppose I've bent your ear for long enough," she told Debbie. "Besides, I'm a full day behind on this editing already. The time I lost yesterday really hurt. With any luck, I'll be able to take Jennifer over to Lucy's house early. I know she had to go somewhere this morning, but maybe she'll be back before lunch." Susan turned back to her desk and picked up the phone. Debbie walked back down the hall toward her office.

     Carmen, another colleague, walked past Susan's open door. She saw Jennifer lying in the corner and stuck her head in. "Hi, Susan," she said. "Is the baby still sick?"

     "No, she's just playing hookey," Susan answered, barely taking her eyes off the manuscript spread out in front of her.

     "Listen," continued Carmen, "I hate to bug you, but I was just in Bill's office. He was asking about your progress on the manuscript. He really wants to get it out by the end of the week. I just thought I'd let you know."

     "Thanks. I'll get it to him on time," said Susan.

     "Great. I'll see you later then. Let me know if I can help." Carmen left and headed down the hall toward Debbie's office.

     Susan picked up the telephone again. Lucy, her day care provider, was home and she could take Jennifer early. Susan packed up Jennifer's things and picked up the baby. She hurried down the hall and stuck her head in Debbie's office. She was surprised to see Carmen sitting across the desk from Debbie, but ignored her presence. "Debbie, I'm going to run across town to take Jennifer to Lucy's house. I'll be back in about 45 minutes." Susan left without waiting for a reply.

     Carmen looked around the corner of the door to see if Susan had left, then she turned back around to face Debbie. "Is she alright?" Carmen asked, referring to Susan.

     "I think so," said Debbie. "She just had a rough morning."

     "I don't know how she thinks she's going to have that manuscript ready for Bill by tomorrow," said Carmen. "He's really itching for it, you know. I've offered to help her, but she won't accept any help."

     "She'll get it done," assured Debbie. "She's pretty amazing. I roomed with her my first year in graduate school and she'd stay up all night long to finish assignments. Her school papers were always top-notch. If I did that, my writing would be reduced to a mere dribble by about 1 A.M."

     "Well, she looks as though she's stayed up all night for the last three nights, if you ask me," said Carmen. "She looks awful! She couldn't weigh much more than 100 pounds and she looks absolutely grey. As a matter of fact, I tried to talk to her one day about eating right. She said she didn't have time for breakfast in the morning, but I told her it didn't take much time to eat something with a little protein in it. You know...an egg, some yogurt, a little bowl of instant oatmeal, or just a glass of milk. She just seemed to keep making excuses."

     "It hasn't been easy for her, Carmen," said Debbie. "What with all the doctor visits, missing work when Jennifer is sick or in the hospital, and the divorce. Even when Jennifer is well, she has to get up every two or three hours to feed her. You know, she still has to be fed through that tube in her stomach."

     "Divorce?" asked Carmen. Obviously, she hadn't heard about Susan's separation.

     "He moved out about three or four months ago," explained Debbie. "I never trusted him anyway. If you ask me, she'll be better off without him in the long run. What a jerk! He hasn't even been paying child support."

     "Maybe I should talk to her," suggested Carmen.

     "Ummm . well, she really doesn't like to talk about it much. Maybe you should hold off until she comes to you about it," said Debbie. She realized now that Susan had probably been quite purposeful in not telling Carmen about the separation. She wondered if Susan had told anyone else in the office.

     "Does Susan have anybody at all to help her?" asked Carmen, sounding quite concerned.

     "Not that I know of," said Debbie. "After she got married and moved out of the apartment, I didn't see much of her outside of class. Then she had Jennifer and dropped out of graduate school. I hardly saw her at all after that, that is, until she took the position here. To tell you the truth, I couldn't stand being around her husband. And when the baby was born, I didn't know what to do. I saw her at the hospital, but that was about all."

      "I didn't realize that you knew Susan that long," said Carmen.

     "Yeah, we used to have great fun together in grad school," replied Debbie. "Susan was a real card. She could even make washing the kitchen floor seem like fun. We used to go out to the Beach Club every Friday night to go dancing. I really miss those times now."

     "It's hard to imagine Susan ever being like that," said Carmen. "She always seems so serious to me."

     "I guess she's changed a lot since then," said Debbie. "I don't think she's been away from Jennifer for one night since she was born. I've thought about offering to babysit for her but that kid is just too damn scary. I wouldn't know what to do."

     "What about her family? Don't they help?" asked Carmen.

     "They live in Virginia, a good 500 miles away. I met them once a long time ago. They were real nice people . not a lot of money though. Susan seemed to have a good relationship with them." Just then, the phone rang. Debbie stopped talking and reached over for it. Carmen signalled that she was leaving and walked out the door.

Dealing With An Irate Parent

     It didn't take Susan long to leave the building after her standoff with Kathy. Kathy didn't try to stop her either. Instead, Kathy went straight to Ron Thompson's office. Ron was the Director of Infant and Preschool Services at the center and Kathy's supervisor.

     "Ron, do you have a few minutes?" asked Kathy. Ron motioned for her to sit down and Kathy continued: "It's Susan Berkowitz again. I'm afraid I've upset her."

     "Is she here?" asked Ron.

     "No, she just left with Jennifer," answered Kathy.

     "Okay then, let's hear what happened." Ron settled back in his chair and folded his arms across his chest in a relaxed pose.

     Kathy told Ron about everything that had taken place, from Jennifer's getting sick yesterday right through to Susan walking out the door. Then she added: "I'm not sure what Susan might do about this. She said something about not needing to deal with all of this and that she felt like pulling Jennifer out of the program." She paused for a moment, to think and concluded: "She might just do it, Ron. I don't think she realizes just how handicapped Jennifer is aside from her medical problems. Susan talks to that child as though she were perfectly normal."

     Kathy and Ron talked for a while about what to do next. In the end, they agreed that Kathy should call Susan Berkowitz at home that evening and see if they could work things out. Kathy wasn't exactly thrilled about the prospect of calling Susan, but she knew it was probably the best thing to do.

     Kathy walked back to the staff lounge for a much needed cup of coffee. Julie, the physical therapist, was sitting at the table with a cup of coffee working on some files. "Mind if I join you?" Kathy asked Julie.

     "Be my guest," answered Julie, pulling out a chair for Kathy. "Are you taking the morning off or something?"

     "No, but I should have," said Kathy.

     "Something wrong?"

     "It's Susan Berkowitz ."

     "Say no more!" interrupted Julie. "I've had it up to here with that woman. Tell me, is that kid still scooting on the back of her head?"

     "Yeah, I suppose so ." said Kathy, hesitantly.

     Kathy didn't want to say too much about that issue. She hadn't entirely agreed with Julie's position in the rather heated disagreement between Julie and Susan concerning Jennifer's physical therapy needs. It happened just about a month and a half ago. Jennifer hated being on her stomach. The gastrostomy tube she was fed through may have been part of the problem, but she also seemed to have some structural abnormality in her shoulders. Her shoulders felt at least partially dislocated and she seemed to have very little strength in them. Whatever the reason, Jennifer cried whenever she was forced to lie on her stomach. She made no attempt to get up in a crawling position, but had created her own way of getting around while lying on her back. She arched her back until the top of her head was touching the floor. Then she pushed with both feet which propelled her across the floor. She did this over and over again and could travel quite a distance in a fairly short amount of time. She had actually worn a bald spot on the back of her head from the friction on the carpet. But the real friction was between Susan and Julie.

     Julie had insisted that scooting on her back was bad for Jennifer because she would develop abnormal motor patterns. Initially, Susan had agreed to Julie's recommendations and Susan had tried to get Jennifer to spend time on her stomach, but Jennifer just cried. Then one day Susan came to pick up Jennifer early. Julie had just caught Jennifer scooting on her back, so she told her "No," in a firm voice and turned her over on her stomach. Jennifer started to cry. Unfortunately, Susan had witnessed the event and became upset. There was a showdown and it ended up with Susan saying that she felt it was more important for Jennifer to be able to get around on her own than it was for her to tolerate being on her stomach. In the end, Susan decided that she didn't want physical therapy services for Jennifer anymore.

A Telephone Call to Susan Berkowitz

     The encounter with Susan Berkowitz bothered Kathy the rest of the morning and on into the afternoon. Even so, Kathy couldn't bring herself to call Susan. Just the thought, made her stomach tighten. Kathy thought if she waited until the evening, Susan would have a chance to cool off and think about it.

     After dinner Kathy gave her three-year-old a bath, read him a story, and tucked him into his bed. Then she returned to the kitchen where her husband was washing dishes. While Kathy loaded up the dishwasher, she told her husband about what happened with Susan Berkowitz. He suggested that Kathy go ahead and make the call so she could enjoy the rest of the evening. "After all," he said, "what's the worst thing that could happen?" He always made things seem so simple, but Kathy knew he was probably right. She decided to make the call.

     "Hello," said Susan, picking up the phone on the fourth ring.

     "Hi, Susan. This is Kathy, Jennifer's teacher."

     "Oh . Hi," said Susan.

     "I hope I'm not interrupting anything," said Kathy.

     "No. I just finished giving Jennifer a bath. She's playing on the floor."

     "How's she feeling?" Kathy knew it was the wrong thing to say the minute it came out of her mouth.

      "Just fine," came the expected icy reply.

      "Listen Susan," said Kathy. "I'm really sorry about what happened this morning."

     "That's OK," said Susan. Her voice was still cool.

     "I mean it, Susan. I really am sorry. I didn't handle the situation well and I hope you accept my apology."

     "Sure," said Susan. "I just didn't understand ."

     "Susan," interrupted Kathy, "It seems to me as though there's a lot more going on than just what happened this morning. You don't seem very happy about a lot of the things we are doing with Jennifer. You do know that I really care about her, don't you?"

     "I think so," said Susan, softening up a little. "I suppose that's what hurt my feelings this morning. I've always thought that you liked her, but it seemed as though you were trying to get rid of her this morning. You didn't even say hello to her . like she wasn't there, or wasn't a real person."

     "I could never stop liking Jennifer," said Kathy. "But I think we need to talk about the other things that seem to be bothering you so you don't stop liking us. Do you think that you could stay for about an hour when you bring Jennifer in tomorrow morning?"

     "No. I really can't," answered Susan. "I have a deadline at work that I need to meet and I'm behind on it." She hesitated for a moment before continuing: "Kathy, I don't think I'll be bringing Jennifer to the classroom anymore. I've thought about it a lot today and it seems like the best thing to do. Lucy said she'd keep her full time."

     "Is it just because of this morning? Because if it is I . "

     Susan interrupted her: "No, Kathy. It's not just because of this morning. I suppose this morning was just the straw that broke the camel's back. I'm tired of trying to hold my life together with string and Elmer's glue. As much as I'd like to think I can, I can't do everything. Something has got to give for a while. Besides, I feel as though I've caused nothing but trouble at the Center lately. I've become the witch of a mother that everyone avoids."

     "That's not true, Susan."

     "That's how it feels to me," said Susan. "I've got to work full-time. I don't have a choice. I provide the roof over Jennifer's head and the medical insurance. Believe me, I'd much rather be providing the love and the therapy. But this is how it is and I might as well accept it. So, to do a good job at work, Jennifer is going to have to do without. I'll do whatever extra it takes with her at home in the evenings and on the weekends."

     "Susan, I know it's been hard on you," said Kathy. "I guess I didn't realize just how hard it has been. But, I hate to see Jennifer leave the program. I'll miss her."

     "I'm sorry, but it's just the . "

     "There's no need for you to say you're sorry," said Kathy. "There must be something else we can do. I don't know what, but there must be something. Would you be willing to look into some other possibilities?"

     "Well, I suppose so...."

     "Good," said Kathy, snapping up the opportunity. "Maybe we could get together and talk about it in the next day or two."

     "Kathy, I really need to meet this deadline at work. You don't seem to understand.... "

     "Of course I understand," said Kathy. "I just keep forgetting! Could you meet me downtown for a late lunch one day? We could go somewhere near your office. How about this Friday?"

     "That should be alright with me," answered Susan. "I'll meet you in the parking lot behind Anthem Publishers. Would one o'clock be late enough?"

     "That should give me enough time to get there. I'll see you on Friday then. Goodbye . and, again, I'm really sorry about this morning."

     "There's no need for you to say you're sorry," replied Susan with a faint chuckle. "See you Friday. 'Bye."

A Brief History

     Jennifer Berkowitz was born after a full-term pregnancy, which was complicated by polyhydramnios. No history of infection, illness, or drug ingestion during pregnancy. Delivery was to be by Cesarean section because of cephalopelvic disproportion (CPD). At delivery, the baby was noted to have right facial palsy, and malformed, low-set ears. Birth weight was 7 pounds 8 ounces. Apgar scores were 3 at 1 minute, 6 at 5 minutes, and 8 at 10 minutes. In attempting to suction via nasogastric (NG) tube, the catheter did not pass to the esophagus. A small amount of barium revealed a type III tracheoesophageal (TE) fistula. This was surgically repaired within the first 24 hours of life with the only complication being a pneumothorax that required insertion of a chest tube. Jennifer required a respirator for 4 days following the initial surgery. The chest tube was removed in 6 days. A renal workup revealed normal kidney functioning and a computer tomography (CT) scan was also normal. Chromosome studies were normal. While Jennifer was still in the neonatal intensive care unit (NICU), follow-up barium swallows showed no obstruction; however, the baby was still unable to handle secretions. In addition, the baby was unable to obtain nourishment from a nipple. At two weeks of age, surgery was performed to insert a gastrostomy tube for feeding.

     A heart murmur was noted on the first day of life. This was a grade 3 of 6 systolic murmur. An electrocardiogram (EKG) obtained on the fifteenth day of life, appeared to be normal and chest X rays during the first month of life were read as normal. On the tenth day of life, Jennifer began to have seizures that were tonic-clonic, lasting 4 minutes, and generalized in nature. Phenobarbitol was given; however, seizures continued despite therapy. Blood levels later revealed lowered calcium levels. Calcium was then administered directly (IV push) and added to the hyper-alimentation. Calcium rose steadily and no further seizures were noted. Phenobarbital was discontinued.

     Jennifer was discharged from the NICU to the care of her parents one month and three days after her birth. Her mother was taught how to suction the child and instructed in feeding the child via the gastrostomy tube. The baby was to be fed a small amount of breast milk every two hours.

     In the nine months since her discharge from the NICU, Jennifer has had numerous upper respiratory infections. She has been treated for seven instances of ear infections. About half of these illnesses were in conjunction with throat infections or acute bronchitis. Jennifer has been hospitalized once for pneumonia and once for a high fever (106 degrees) and pneumonia that was discovered to result from a blood infection (i.e., Haemophilus influenza). She was hospitalized a third time for dilitation of the gastrostomy. Jennifer is scheduled for outpatient surgery in two weeks for insertion of ventilation tubes in her ears (myringotomy).

     Jennifer was seen by a cardiologist at six months of age. A chest X-ray at that time was read as mild cardiomegaly, with prominent vasculature. This has been diagnosed as patent ductus arteriosus (PDA) and will require surgery at some time-probably between the ages of 2 and 3 years. Jennifer becomes slightly cyanotic around the head and extremities and diaphoretic with crying.

     Two months ago, when Jennifer was 8 months old, her mother took her to an audiologist upon the advice of her pediatrician. Testing at that time indicated a bilateral hearing loss, with a stapedius reflex present at 70 decibels in the right ear and absent at 90 decibels in the left ear. Further testing will be done after the myringotomy.

     A relative weakness of her upper extremities has become apparent. Although she has been seen by specialists for this problem, no diagnosis has been made. At this point, a partial dislocation of the shoulders is suspected. Jennifer has remarkably well preserved fine motor movements of the hands (inferior pincer grasp).

     Last month, at 9 months of age, Jennifer was admitted to the large regional hospital for a full diagnostic workup. The pediatrician suggested this to the mother and made the referral primarily to obtain information on the persistence of Jennifer's difficulties in handling secretions and not swallowing.

A Diagnostic Workup

Growth
     Head circumference - Approximately 10th percentile
     Height - Approximately 5th percentile
     Weight - Below 5th percentile

Persistent Dysphagia
     The results of the cine-esophagogram and the presence of a good gag reflex suggest that this is primarily a problem of esophageal motility and not a result of central nervous system dysfunction. Barium swallow revealed propulsion of barium into proximal esophagus with minimal, but present, aspiration. There was a delay of barium movement in the distal esophagus. Considerable aerophagia was seen with regurgitant movement of air in the esophagus. The neurologist felt that there might be a right hypoglossal palsy in addition to facial palsy (causing tongue to deviate to the right).

Right Facial Paralysis
     Much improved since birth; however, recovery appears to have plateaued. Permanent damage to 5th cranial nerve is suspected.

Patent Ductus Arteriosus
     Aortic shadow is now prominent, suggesting increased shunting since last examination at 6 months of age.

Motor Development
     Greater than two standard deviations below the mean (Bayley Motor Scale). Psychomotor development index (PDI) = 54; 6 month age equivalent. Lifts head in prone for about 30 seconds with much encouragement. Rolls from back to front and front to back using mostly her feet to throw herself over. Cannot sit or creep. Complete head lag in pull-to-sit but can hold head steady in supported sitting. She cannot elevate herself by arms in prone. She is able to bear weight on both arms despite the fact that her shoulder stability is very poor. Nevertheless, she fusses a great deal during weight-bearing activities. Reaches for objects and uses an inferior pincer grasp. Combines objects in midline.

Mental Development
     Greater than one standard deviation below the mean (Bayley Mental Scale). Mental development index (MDI) = 74; 7 month age equivalent She did not demonstrate object permanence (e.g., did not look for fallen spoon, but did uncover toy). She reaches persistently, retained 2 out of 3 cubes, but did not attempt to secure the third. She did not attend to scribbling, nor finger holes in a pegboard. She did, however, look at pictures in a book and "turn pages." She was able to secure a small pellet with an inferior pincer grasp. Jennifer coos frequently and makes single "ma," "ga," and "ba" sounds. Her hearing seems subjectively better than hearing tests show, in that she did turn to the sound of the bell and rattle.

From the Diary of Susan Berkowitz

     Susan Berkowitz started keeping a diary for Jennifer a few days after she was born. She made entries a few times a week and wrote a summary of Jennifer's progress every month. With Susan's permission, her entry for Jennifer's 10^th month is shown below.

October 31^st

     Ten months old today! It is also your first Halloween. At 9:30 last night I began to make your Halloween costume for your class party today. I stayed up until after midnight sewing letters on a pillowcase. My goodness, Jennifer, I felt like a real mother!

     At 10 months you weigh about 15 pounds and are a little over 26 inches long. It's hard to believe that you're so close to being 1 year old. This has been the most traumatic year of my life. But, every time I look at your sweet grin, I can't imagine my life without you. You have given my life so much more meaning and direction.

     I've seen such a difference in you this month. You are so active and roll or scoot on your back all around the room getting into everything in sight. You delight in playing in front of a mirror, imitating yourself  nonstop. You are getting a much louder voice now and have learned to make a few new sounds.especially "da-da-da." You love to clap your hands, hold your own toes, pull my hair, grab my glasses, and play with books and paper. Sitting is getting much better. You can sit, holding yourself up with your arms for 3-4 minutes. Then, you get excited (or mad) and fall over sideways. Occasionally, you can even catch yourself on the way down. Your favorite sport is teddy bear wrestling. This moth you have struck up quite a relationship with a red and white bear that is bigger than you are. It's wonderful to see you wrestle with it and yell at it. You are also laughing more (out loud) and you still pat me on the shoulder when I pick you up-I love it!

     Separation anxiety has also struck! I can't stand it when I leave you at Lucy's and you cry. Mostly you cry if, when I pick you up at 5:30, I walk out of the room for a minute. Your sleeping habits (or should I say, lack of them) are absolutely atrocious. You love to take a late nap (4:00 - 5:30) and stay up until 10:30 or 11:00. That really bites into my time alone! We're feeding you 5 ounces every 2 hours.

     This month has been a particularly hard one for Mommy to get through. When you reached double-digit (10) months, I realized how far behind you were and I started to think about how close to 1 year old you are. I'm so scared that you won't catch up. Yet I see a spark inside your eyes that tells me that you'll be okay. I suppose I'm frightened in a selfish sort of way. I do so want to be able to talk to you and have you understand me.and talk back. I want to read you stories and help you explore the world. But I feel as though there is little more I could do than I'm already doing to help you. I guess we just have to give it more time but the worrying is wearing me out.

     You are such an adorable baby. And you are mine.at least for a while. We'll have a good life, Jenn, and a happy one. No matter what it takes from me.I give you my promise on that.

This case story originally appeared in McWilliam, P.J., & Bailey, D., (Eds.). Working Together with Children & Families, Case Studies in Early Intervention. (1993). Baltimore: Paul H. Brookes Publishing Co.

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