Monthly Archives: April 2017

Is Your Hypermobile Child JointSmart?

Sometimes it must seem that OTs and PTs are the ultimate buzz killers. “Don’t do gymnastics; it could damage your knees” and “I don’t recommend those shoes. Not enough support”. Just like the financial planner that tells you to sell the boat and save more for a rainy day, we therapists can sound like we are trying to crush dreams and scare families.

Nothing could be further from the truth! Our greatest wish is to see all children live their lives with joy, not pain and restriction. Hypermobile children that grow up understanding their body’s unique issues and know how to live with hypermobility are “joint smart” kids. The kids who force their bodies to do things that cause injury or insist on doing things they simply cannot accomplish face two kinds of pain; physical pain, and a feeling that they are failing for reasons they cannot fathom.

Pain at a Young Age?
Very young children with hypermobility don’t usually see OTs and PTs for pain, unless they have JRA or MD. The thing that sends them to therapy initially is their lack of stability. Some impressively hypermobile kids won’t have pain until they are in middle age. Pain (at any age) usually results from damage to the ligaments, tendons and occasionally the joints themselves. When the supporting tissues of a joint are too loose, a joint can dislocate or sublux (partial dislocation). This is often both painful and way too frequent for hypermobile kids. Strains and sprains are very common, and they happen from seemingly innocuous events. Other tissues may bruise easily as well, creating more pain. Disorders such as Ehlers Danlos syndrome can affect skin and vessel integrity as well as joint tissue, so it is not uncommon to see bruising “for no reason” or larger bruises than you would expect from daily activity.

Becoming JointSmart Starts With Parents
So…does your child even understand that they are hypermobile? If they are under 8, almost certainly not. Do they know that they have issues with being unstable? Probably. They may have been labeled “clumsy” or “wobbly”, even weak. Labels are easy to give and hard to avoid. I suggest that parents reframe these labels and try to take the negative sting out of them. Pointing out that people come in an amazing variety of shapes and abilities is helpful, but the most important thing a parent can do is to understand the mechanics, the treatment and how to move and live with hypermobility. Then parents can frame their child’s issues as challenges that can be dealt with, not deficits that have cursed them. How a parent responds to a child’s struggles and complaints is key, absolutely key.

The first step is teaching yourself about hypermobility and believing that options exist for your child. Ask your therapists any questions you have, even the ones you are afraid to ask, and make sure that your therapist has a positive, life-affirming perspective. Most of us do, but if you are at all anxious or worried, it really helps to hear about what can be done, not just what activities and choices are off the table. If you blame yourself for your child’s hypermobility, get support for yourself so that your child doesn’t feel that they are burdening you. They don’t need that kind of baggage on this journey.

Even when we are optimistic and creative as therapists, it doesn’t mean that we won’t tell you our specific concerns about gymnastics and Crocs for children with hypermobility. We will. It would be unprofessional not to. But we want you and your child to develop the ability to understand your options, including the benefits and the drawbacks of those options, and give you the freedom to make conscious choices.

Now that is being smart!

Parents of Formerly Picky Eaters Can Feel Like The (Food) War is Still Going On

What do parents of children who have had successful treatment for oral sensory sensitivity have in common with Vietnam veterans? Parts of them do not know that the war is over.

Raising a child that can become unglued over the texture or taste of a new food is like walking through a minefield. As a pediatric OT, I have seen many children make amazing progress. The toddler who once grimaced while watching his mom eat a piece of chicken now grabs it from her hand and stuffs it into his mouth. The baby who screamed when cereal fell onto her hands is now happily swishing it around the high chair tray.

It’s the parent that is still frozen in fear. PTSD is something that people assume only happens to victims of crimes or war. Wrong. The daily emotional rollercoaster of dealing with sensory issues in young children (and older ones too, to be honest) can leave parents with all the signs of PTSD. Anticipating problems, recalling the worst mealtime blowups even when things are going well now, feeling anxious even as your child munches down a snack happily. And reacting to any minor and non-sensory complains with an internal “Oh, here we go again, I knew it would come back!”

It makes sense to me. The stress seemed to never end because the meals kept on coming. You never know if it will be a horror or an easy meal. The level of reaction your child exhibits is not always the same, so you wonder what will happen. All the time. And you feel as if no one could possibly understand how this feels. You feel alone and on edge. The next meal could be the worst, so you have to be prepared for it.

If this description fits you, please don’t think that you are alone. You are not. Good therapy can help your child learn to manage their reactions to food and mealtime. It really can. But you may need some support too. Seek it out, and reject any professional that tells you to just relax. You would have relaxed if you could have. You have been through a lot, and sometimes getting some support helps.

Want A Stronger Pencil Grasp? Use a Tablet Stylus

The trick? They need to use a short stylus and play apps that require primarily drag-and-drop play. Stop them from only tapping that screen today, because tapping alone will not make much of a difference in strength and grading of force.

Why will drag-and-drop play work? The resistance of the stylus tip on the screen builds strength and control at the same time. They gain control as they get the immediate feedback from game play. Too much force? They get stuck and can’t move the styluses the target. Too little force? Again, the target doesn’t move. Could they revert to a fisted grasp and accomplish this? Sure, but that is exhausting, and you are within view of them anyway….right?

For this to work, young children need supervision, but not helicopter supervision. And they need to know that how they hold any utensil matters to you. My best approach to build grasp awareness is to appeal to their desire to be older. Tell your child that you have been watching them, and you believe they are ready to hold a stylus like an older kid. Oh, and you can explain to them how to hold the stylus the easy way. They just have to watch your example and play some games for practice. Yup, you ASK them to play on a tablet!

Best drag-and-drop games for young children? I like the apps from Duck Duck Moose, especially the Trucks and Park Math. Every app has some tapping, but you can select and “sell” the games that require drag-and-drop. There are apps that little girls can play to dress up princesses, mermaids, etc. Pick the ones where they have to drag the items over to the characters. Same with wheels on trucks, shapes into a box, etc. The Tiny Hands series of educational apps have a lot of drag-and-drop play.

Finally, mazes are wonderful, and so are dot-to-dots that require drag-and-drop play.

Have a really young child, or a child who struggles to keep their fingers in a mature grasp pattern without any force? Then apps that require just a tap are fine. I set the angle of my tablet at various heights (my case allows this) to prompt more wrist extension (where the back of the hand is angled a bit toward the shoulder, not down to the floor). When a child’s wrist is slightly extended, the mechanics of the hand encourage a fingertip grasp without an adult prompting them.

Try drag-and drop play with a stylus on your tablet today, and see if your child’s grasp strength starts improving right away!

Wait Out Your Whiner (or Whinger) And Everybody Wins!

Whining/whinging can drive a calm parent to the edge. Like nails on a chalkboard, the effect of a small person squealing their demand may unhinge you. Add refusal to comply with a reasonable request, and you have a recipe for disaster. OK, maybe not disaster, but how your react can inflict damage on the warm and happy relationship that you really want with your child.

So what do you do with a small child who whines/whinges? You could come down on them, all threats and authority. Good luck. Your child already knows that you have the power to deny them. They are choosing whining as an alternative to outright defiance, probably as a way to avoid a showdown. Insist on taking it there, and you may get immediate compliance but risk later explosions, or risk teaching your child that threats are the way to get what he wants. Oops.

Giving in to whining/whinging isn’t much better. You may have stopped the noise for now, but you have taught them a powerful lesson: this works! If you think that your child won’t try it again, or won’t try even harder the next time he wants something, you are experiencing wishful thinking.

This is how giving in will doom your plan. Every psychologist knows that the way to get a behavior solidly stuck in a child’s mind is to reward it intermittently. If it works some of the time, it will be tried again and again. Don’t believe me? Visit your local casino to see intermittent reward theory in it’s adult form. Every time that slot machine pays out, the customer is “taught” that it could do so again, if only they will keep playing. And playing. Folks, adults know the house always wins. Your child does not. They will keep trying their strategy on you.

Looking for advice from teachers or other “experts”? You will come away with some plausible strategies that often ultimately fail to bring the whine/whinge to and end. They sound so supportive, so understandable. “I can’t understand you when you speak to Mommy that way” is a common recommendation. An alternate strategy is “Use your big-boy/girl voice please.” I am going to tell you that neither of these strategies work very well with the chronic and committed whiner, especially if the perpetrator is under 5.

Why? Because you are using words to negotiate with children that respond better to actions. I am not referring to very young children or special needs kids with language skills under 18 months of age. But wait: those children generally do not whine/whinge. They don’t have the social and language skills to do so. They can be dealt with differently. This is why peak whine/whinge time is 2-5 years old. At this age, children can create strategies and observe their success or failure. But they are still little. They don’t infer from discussion, and they watch your reactions and the tone of your voice to support their limited language and social skills. Ask Dr. Harvey Karp. Happiest Toddler on the Block transformed my understanding of toddlers, and gave me happier days as well.

If your child clearly understands your request and your response to their request, and you consistently react in the same manner, you can wait out a whiner and teach them how to approach you. If you sometimes give them cookies right before dinner so that you can concentrate, or if you inconsistently administer natural consequences (taking toys that are thrown away from them, for example), then again, waiting them out isn’t going to work. But if you are reasonably consistent, this is the one strategy that will save your sanity and improve your child’s behavior in a lasting way.

By wait-it-out, I mean ignore the whine. Don’t react. You have ALREADY given them a response. Whether you are using Patience Stretching, my favorite move from Happiest Toddler on the Block, or simply a statement that if they want a snack, they need to sit on their chair, your response was already understood and rejected. Now you do nothing. You do not even make eye contact. Busy yourself, if possible, with some task in the room. This could be putting dishes away, folding clothes, etc. You want to be observed by your child to be non-reactive. You need to be able to observe them so that if they improve their behavior, you can respond right away.

The best way to respond to a formerly whining/whinging child who has come around is with warmth and humor. Nothing, absolutely nothing, sends home the message of success to them like an adult that welcomes them warmly. Don’t spend your time reviewing what went right. “You listened to Mommy so well. Nice sitting on your bottom in the chair” only works well with the youngest of the whiners. Most of them already understand that your warm response is in reaction to their compliance. Save the sing-song review for your infant; give your toddler or preschooler a hug, a kiss or some physical response instead.

Good luck, and see if waiting works for you!

Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children

rockybeach.jpeg

When most parents think of sensory processing issues, they think of the children who hate clothing tags and gag on textured foods.   Joint hypermobility, regardless of the reason (prematurity, Ehlers-Danlos syndrome, head injury, etc) can result in kids who stumble when they move and wobble when they rest.  They are seen by orthopedists and physical therapists, and told to build up those weak muscles.  Well, those kids have sensory processing issues too!   And they deserve more effective treatment than they typically receive.

Lack of joint integrity, especially decreased joint stability, results in a decrease in proprioception and kinesthesia.  These two under-appreciated senses tell a child about her body’s positions and movements without the use of vision. The literature out there is sparse. If you are hoping that a lot of research on this topic exists, and doctors understand why your child curls his fingers around a pencil but can squeeze the @@#$% out of clay, good luck. Most of the hard science has been done by PTs on proprioception in the leg, and there isn’t a lot of it. But OTs know a lot about the connections between sensory processing and motor performance.

Consider the process for touch-typing to better understand these senses.  Your awareness of your hand’s position while at rest on the home row is proprioception.  You know where your movement starting and end points are via proprioception.  Your awareness of the degree of movement in a joint while typing is kinesthesia.  Kinesthesia tells you that you just typed a “w” instead of an “e” without having to look at the screen or at your fingers.Your brain “knows”, through learned feedback loops, that your finger movement was too far to the left to type the letter “e”, but far enough to have been a “w”.

You are able to grade the amount of force on each key because your skin, joint and muscle sensors transmit information about the resistance you meet while pressing down each key.   Your brain compares it previous typing success and the results on the screen, and makes adjustments in fractions of a second. This is sensory processing at work.

Why do children with hypermobility have proprioceptive and kinesthetic processing problems?  Because information from your body is transmitted is through receptors embedded in the tissue within and surrounding the joints.   These receptors respond to muscle and tendon stretch, muscle contraction, and pressure within the joint.   Joint hypermobility creates less stimulation (and less accurate information) to these sensory receptors.  The information coming into the brain is insufficient or delayed, and therefore the output of postural stability or dynamic movement is correspondingly poor.  This shows up as a collapsed posture, difficulty quickly changing positions to catch a ball or leap over an obstacle, a heavy-footed gait, and a whole lot of other difficulties.  It can even make speech and feeding more challenging.  Read Can Hypermobility Cause Speech Problems? to learn more about the signs that your child may benefit from speech therapy as well as OT and PT.

Can children with hypermobility improve their sensory processing and thereby improve the quality of their movements in daily life?  Absolutely.  Because sensory processing is a complex skill, addressing each component of functional performance will give the hypermobile child more skills.  Building muscular strength within a safe range of joint movement is only one aspect of treatment.  Positioning a child to give them more sensory feedback while in action is essential.  Increasing overall sensory processing by using other sensory input modalities is often ignored but very helpful.  To learn more about how to handle hypermobility, check out Joint Protection for Hypermobile Toddlers: It’s What Not To Do That Matters Most , Hypermobile Child? Simple Dental Strategies That Make a Difference in Your Child’s Health and Teach Kids With EDS and Low Tone: Don’t Hold It In!

I believe that vestibular input is one of the most powerful but rarely used modalities that can improve the sensory-motor performance of hypermobile children.  They don’t have to demonstrate vestibular processing deficits to benefit from a vestibular program.  The lack of effective sensory processing due to poor proprioceptive registration and discrimination creates problems with balance, and targeted vestibular input is designed to fine-tune the brain’s balance center.  I could link you to scholarly articles on this concept, but you would fall asleep before finishing them.  Trust me, vestibular input can make a difference.  This program can be done without stressing fragile joints, which is often a limitation for the programs that focus too much on muscular strengthening and stabilization activities.

My favorite sensory processing strategy for hypermobile kids?  The use of rhythmic music during movement.  Programs that use the powerful effects of sound on the brain are effective treatments for hypermobile children.  Using sound to improve vestibular processing increases the quality and the speed of response to a loss of balance.  Muscle tone increases in children while they are listening, and this combo helps children improve their safety while moving and while sitting still.  It is difficult to explain to insurers and sometimes even neurologists ( don’t get me started on how hard it is for orthopedists to follow this) but if you understand the complex processes that support sensory processing, you will be changing the background music in your clinic or your home in order to capitalize on this effect!  I recommend the Therapeutic Listening programs for their ease of use and child-friendly music.

Children with hypermobility can benefit from occupational therapy sessions that provide more than a pencil grip and a seat cushion.  All it takes is an appreciation for the sensory effects of hypermobility on function.

Does your hypermobile child also have toileting issues?  My e-book, The Practical Guide To Toilet Training Your Child With Low Muscle Tone, could help you make progress today!  Many children with hypermobility also have low tone, and the theories and strategies that support stability and sensory processing are totally applicable for hypermobile kids!  It has readiness checklists and strategies that parents can use, not platitudes like ” read your child’s signals” and “don’t push your child to train”.  You will learn about the sensory, motor, and social/emotional issues that contribute to toileting delays, and how to select the right equipment, clothing, and more!

The Practical Guide is available on my website, tranquil babies and on Amazon , as well as at your therapy source, a great place for therapists and parents to find exercise programs and activities for children.

Teach Your Child To Fail Today. You Can Thank Me Later

Yes, I said it: fail.  We all will fail at something sometime.  Even, and most especially, the gifted kids who experiment and explore constantly, will fail at something.  Knowing what to do with your feelings when you fail is essential for a happy life.  And that is why you will thank me later.

Angel Duckworth is one of my heroes.  Her focus on building grit is so important in this new world we live in.  In the old days, say 50 years ago, families and religious institutions provided a roadmap for children to handle challenges in life.  Maybe it didn’t always provide the widest highway for people with differences, but opportunities to learn perseverance and receive support after a failure were more available.  I don’t believe we can turn back the clock, so it is time to move forward and create new structures.  And this time, everyone will fit under the tent and get more support.

When we fail, we have the choice to feel bad or feel inspired.  The child who believes that his intelligence and his abilities are fixed will feel worse, perhaps even ashamed.  That child will be less likely to want to feel those emotions again, and will look for situations that ensure success.  At any cost.  Even cheating.  The rise in anxiety disorders and suicide in the college-age population has me worried about how these kids see failure.  It doesn’t have to be a crisis, it can be a learning experience in the truest sense.  Why you failed and what to do differently (if possible) are things you can learn, but only if you aren’t crushed or horrified that you failed.

The child who knows that failure is common to all of us eventually, and is not a sign of weakness or lower ability, will give things another try.  In fact, that child will not want to engage in a “sure thing”, whether it is a class, a sport, or an interaction in which there is no challenge.  The child who isn’t afraid of failure will welcome novelty and risk. They have, as Dr. Duckworth would call it, a growth mindset.   Failure is their clue that some variable in the experiment should change; useful information for their next attempt.

Just imagine what your child could do if she wasn’t afraid to fail!  Solve the many health and environmental challenges we have, broker peace between groups and countries, raise a family that believes in the power of failure….anything!

If you have a fixed mindset about failure, if you were raised to take the sure thing, the easy road to success, use the emergency instructions you get from the airlines.  Change your mindset before helping your child to change theirs.  You can thank me later.

Your Bossy Baby or Toddler May Be Gifted. Really. Here Are The Signs You Are Missing!

Toddlers are known to be a challenge at times.  Tantrums over broken cookies, insistence on hearing “Goodnight Moon” for the 11th time in one night, etc.  They can be adorably cute and amazingly difficult in the same 15 minute period!   But lurking inside chaotic toddler behavior may be signs of genius.  Really.  Here are two important signs of giftedness that emerge before 12 months of age:

  • Makes eye contact early and frequently.  The gifted baby seems incredibly alert and appears to be constantly aware of what is going on around her.
  • Resists being left alone without anything to do; wants interaction with you and with the world.

Yes, the gifted baby is taking notes and making plans.  Once she can move, she is into everything.  The things that fascinate her might be objects you never suspected an infant would even notice.  She may have abandoned those rattles very early in life.  She might not be interested in chewy toys or tags on toys. In fact, one of the signs of a gifted baby can be a distinct disinterest in chewing on books and toys.  They realize that these objects have another (higher) purpose!

Here are some signs of gifted behavior in toddlers:

  • Obvious and strong interest in shapes, shape sorters, containers, letters and numbers in all forms.  This is way beyond being taught to sing the “Alphabet Song” in a cute way.  The gifted toddler is likely watching, listening and teaching herself what those symbols mean!  She may even gather three sorter toys and proceed to group all the circles, triangles, etc in a pile before 12 months old.
  • Completing puzzles and shape sorters beyond age expectations for the toy.  For example:  I expect a child to place a circle in a shape sorter by 12-14 months.  If I see a 9 month-old that can manage it easily, I assess that as significantly early motor and perceptual development.
  • Is eager to please, and feelings can get hurt easily.  Yes, this is one of those gifted characteristics that parents don’t brag about.  Sensitivity, in all it’s versions, (emotions, physical sensitivities, allergies, etc.) is very commonly seen in gifted people of all ages.
  • A long attention span, with insistence on finishing things and completing tasks independently.  This can lead to tears and frustration as a child imagines actions and creations he cannot execute to his satisfaction.  His physical development isn’t at the same level as his mental capacity. The frustration this asynchrony causes is a pervasive issue for gifted children well past early childhood.
  • Other adults describe your child as bossy, stubborn and possibly spoiled.  Yup, the gifted toddler isn’t always everyone’s fave grandchild.  They can be insistent on doing things their way, and only their way.

How can you tell the difference between typical toddler behaviors and signs of giftedness?  It isn’t always that easy.  The behavioral issues of developmental asynchrony and sensitivities can mask the underlying issue of giftedness.  I look for improvement in their behavior when they are given appealing but highly complex problems to solve. I might invite a toddler to join me in a play activity that is complex and intense, but has been selected to modulate arousal states.  The gifted toddler who is given a chance to shine in this environment is a wonderful thing to observe.  A typical child with behavioral issues often becomes more irritable and bossy when given the same situation.

When I am working with a child that is reported to have sensory processing difficulties and I ask the right questions, I start wondering if I am also seeing signs of early giftedness when I hear the following comments come out of a frustrated parent’s mouth:

  1. “From the minute we brought him home, he seemed to watch everything we did”
  2. She isn’t happy unless she has something new to play with, and then she always surprises us with how fast she figures it out”
  3. “He never stops exploring, from the minute he wakes up”
  4. “She put together her brother’s puzzles and then said “Store” so we would go get her more puzzles!”
  5. “He watched his sister drawing, and before we knew it, he drew a face, right down to the eyebrows and ears!”

The gifted infant and young toddler is almost always more work for parents than a typically developing child.  That constantly curious mind likes complexity, it is driven to explore the world and the world of ideas, and their non-stop intensity seems to begin at birth.  Some parents are also gifted individuals, and they recognize the situation right away.  They may be worried about being up to the challenge of parenting a gifted child, or they are overwhelmed by their job, their other family roles, and now the responsibility of supporting a gifted child.  Daycare and preschool staff may not recognize behavior as giftedness, even if this has been mentioned.  Take a look at  Supporting The Gifted Toddler at Preschool for my suggestions on how preschool teachers can help gifted children thrive in preschool.

Some parents aren’t gifted, even if they are professionally successful and personally content.  The perspective from their gifted child is hard for them to embrace.  They don’t see the world through the same mindset as their gifted son or daughter.  I believe that is because the mind of a gifted person is as different to a non-gifted individual as the mind of a developmentally challenged person appears to them.  Different processes, different problems.  Every parent can come to understand their child, regardless of brain differences.  Knowing what those differences are is the very first, but very important, step.

Do I rush to tell the parents my suspicions?  No.  I am not a neuropsychologist.  My license doesn’t give me the right to diagnose.  I watch, work, support, and trust that the truth about a child’s abilities and issues will come out in time.  And I go right on doing what I have been asked to do.  Addressing the sensory processing issues that some gifted children face is more than enough of a challenge for an OT, and I am happy to support these kids to have happier, calmer and more enjoyable lives because of my input!