Monthly Archives: May 2017

The Difference Between Special Needs and Typical Potty Training Approaches: Address Sensory/Behavioral Issues and Use Consistent Routines

tai-jyun-chang-270109.jpgAfter writing The Practical Guide to Toilet Training Your Child With Low Muscle Tone, I have been asked what was different about my book. There must be 100 books on potty training special needs kids. What did I do differently? Simple. I am an occupational therapist, so I have no choice but to use my 360 degree viewpoint to target all the skills needed to do the job. Seeing the path to independence in this way was second nature to me, but not to parents of kids with special needs. Time to offer some support!

The books I reviewed before I started writing were great, but every one lacked at least one important feature. If the authors were psychologists and teachers, they weren’t fully comprehending or directly addressing the sensory and motor aspects of a very physical skill. Oops.

OTs are always aware of the cognitive and social/behavioral components of activities of daily living, but we also have a solid background in physiology and neurology as well. That makes us your go-to folks for skills like toilet training. And that is a major reason why The Practical Guide is so helpful to the frustrated parents of children with SPD,autism, Down Syndrome, Ehlers-Danlos Syndrome, and a host of other diagnoses that result in delays or difficulties with muscle tone and potty training independence. It explains in detail how low tone creates sensory, motor, and social/behavioral problems, and how to address them. Knowledge is power, and knowledge leads to independence.

The other huge difference is that developing consistent sensory-motor-behavioral routines matter more for these kids. Tone isn’t a constant, as anyone with a child that has low tone knows all too well. Fatigue, illness, even a very warm day; these all make kids less stable and can even reduce their safety. Having a really solid routine makes movements easier to execute and more controlled when situations aren’t perfect. Kids with normal muscle tone can shift their behavior on the fly. They can quickly adjust and adapt movement in ways that children with low tone simply cannot. It isn’t a matter of being stubborn or lazy. Kids with low tone aren’t going to get the sensory feedback fast enough to adjust their motor output.

Good motor planning on a “bad day” occurs for these kids when they have well-practiced routines that support safe and smoothly executed movements. What makes the difference isn’t intelligence or attention. It is recalling a super-safe routine effortlessly. This is completely attainable for kids who have speech or cognitive issues as well as issue with low tone and instability. It may take them longer to learn the routine, but it pays them back with fewer accidents and fewer tears.

To learn more about my book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, visit my website, tranquil babies.com, or view it on Amazon.com!ferris-wheeltai-jyun-chang-270109

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Teach Kids With EDS and Low Tone: Don’t Hold It In!

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People who have read my blog are aware that I wrote a book on toilet training, The Practical Guide to Toilet Training Your Child With Low Muscle Tone. The issue of kids who “hold it in” didn’t make it into the book, but perhaps it should have. Children that have problems with muscle tone or connective tissue integrity (or both) risk current and future issues with incontinence and UITs if they overstretch their bladder or bowel too far. We teach little girls to wipe front-to-back to prevent UTIs. We need to teach all children to avoid “holding it in” in the same manner that we discourage them from w-sitting.

I am specifically speaking here about kids with Ehlers Danlos Syndrome, Down Syndrome and all the other conditions that create pelvic weakness and muscle control issues. But even if your child has idiopathic low tone, meaning that there is no identified cause, this can still become a problem.

The effects of low tone and poor tissue integrity on toilet training are legion. Many of them are sensory-based, a situation that gets very little acknowledgment from pediatricians. These children simply don’t feel the pressure of their full bladder or even a full rectum with the same intensity or discomfort that other children experience. This is known as poor interoception, a sensory-based issue that is rarely discussed, even by parents and occupational therapists that are well versed in other sensory processing issues.  For more on how sensory problems affect toilet training, see Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!).   Kids that don’t accurately perceive fullness can be “camels” sometimes, holding it in with no urge to go, and have to be reminded to void. It can be more convenient for the busy child to keep playing rather than go to the bathroom, or it can save a shy child from the embarrassment of public bathrooms; she prefers to wait until she returns home to “go”.

This is not a good idea at all! The bladder is a muscle that can be overstretched in the same way the hip muscles loosen in children who “W-sit”. Don’t overstretch muscles and then expect them to work well. The ligaments that support the bladder are subject to the same sensory-based issues that affect other ligaments in the body: once stretched, they don’t bounce back. Holding it in just stretches vulnerable ligaments out.  A weak pelvic floor is nothing to ignore. Ask older women who have had a few pregnancies how that is working out for them.

The stretch receptors in both the abdominal wall and in the bladder wall that should be telling a child with low tone that it is time to tinkle just don’t get enough stretch stimulation to do so when they have been extended too far.

When should you teach a child not to hold it in?  Right from the start.  The time to prevent problems is when a child is developing toileting habits, not when problems have developed.

So….an essential part of toileting education for children is when to head to the bathroom. If your child has low muscle tone or a connective tissue disorder that creates less sensory-based information for them, the easiest solution is a routine or a schedule. They use the bathroom whether they feel they need to or not. The older ones can notice how much they are voiding, and that tells them that they really did need to “go”.   The little ones can be rewarded for good listening.

Understanding that the kidneys will fill up a child’s bladder after a large drink in about 35-45 minutes is helpful. But it can always be time to hit the bathroom after a meal, before leaving the house, or when returning home. As long as it is routine and relatively frequent, it may not matter how a toileting schedule is created. Just make sure that as they grow up, they are told why this is important. A continent child may not believe that this is preventing accidents, but a child who has a history of embarrassing accidents in public may be your best student.

For little girls who are at a higher risk of UTIs, I tell parents to teach wiping after urination as a “pat-pat” rather than the standard recommendation of front-to-back wiping.  Why?  Because children aren’t really good at remember that awkward movement, and even if you are standing right their reminding her, she may just wipe back-to-front because that is easier and more natural.  “Pat-pat” is an easy movement and reduces her risk of fecal contamination.  I cannot tell you I have done hard research on this, but then, I have common sense.  This is the smarter way for her to wipe.  Want more info on wiping?  Check out How To Teach Your Toddler To Wipe “Back There”

The good news in all of this? Perceiving sensory feedback can be improved. There are higher-tech solutions like biofeedback, but children can also become more aware without tech. There are physical therapists that work on pelvic and core control, but some children will do well with junior Kegel practice and some education and building awareness of the internal sensations of fullness and urgency.

Good luck, and please share your best strategies here for other parents!!

If you are interested in purchasing The Practical Guide to Toilet Training Your Child With Low Muscle Tone, please visit my website, tranquil babies and click on “e-book” at the top ribbon. You can also buy it on Amazon and your therapy source. My e-book is designed to truly help parents make progress, not just offer statements like “Don’t push your child” and “Look for signs of readiness”. That doesn’t help anyone! The book has useful readiness checklists and detailed strategies for every stage of training.  I want children to become independent in toileting without all those tears, and for parents to feel good about guiding their kids in this important skill.

Prevent the Summer Slide in Handwriting By Making It Fun To Write

“The Summer Slide” is the phenomenon of losing academic skills during summer vacation. With the exception of the children who insist on you buying them workbooks and those that read a book a day by choice, all summer long, summer slide will happen to most children.

Here are some strategies to limit it’s effect on your child’s handwriting skills by using fun activities, not rigid homework:

* If you must use a book, use Handwriting Without Tears workbooks and limit practice to one page a day. Five minutes of work is better than 30 minutes of stalling and avoiding a page filled with poorly designed assignments. HTW’s pages are so targeted and organized that they get the job done fast.

* Think beyond workbooks. Write a book with your child on a topic they love. Use drawings and photos to illustrate it. Pretend play may need restaurant menus or store signs. Pretend garages or hair salons need price lists or bills-of-sale filled out. Be imaginative and have fun.

* Find or make notecards to send mail to relatives. It is often more fun to get mail back from them, so make sure grandparents have something fun to send back, even if it is a blank coloring page. Even though we are a digital society, everybody loves receiving personal mail, and children really love seeing their name on an envelope.

* Arts and crafts projects aren’t cop-out activities; they have real value. While creative craft play teaches many pre-writing skills for the younger kids, they can also preserve or develop skills in older kids. Look for fun kits, such as building a rubber band racing car or rhinestone mosaic picture kits, if your child isn’t the kind that grabs your empty egg carton and a glue stick and emerges with a masterpiece. Buy colorful writing tools, decorative craft scissors, and definitely make something crafty yourself. Seeing parents writing and creating is probably the best motivator for children to engage in these activities that prevent the summer skills slide!

Sensitivity and Gifted Children: The Mind That Floods With Feeling

 

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Gifted children are often the most emotional and empathic toddlers in the room.  They are the kids who cry when the ASPCA runs those tearjerker commercials.   They are the teens who want to develop an NGO to provide clean water in developing countries.  Gifted children don’t do this to get a boost on a college application, but because it physically hurts them to think of another’s suffering.  Your gifted child’s mind cannot help but to feel strongly and care deeply.

How can you help your child navigate these feelings without crushing their altruism and energy? The first step in helping these children to handle their sensitive social and emotional nature starts with adults understanding that this isn’t a personality quirk; it’s a neurological bias that accompanies an impressively active and intense brain that doesn’t “turn off”.

Sensory Sensitivity, Autism, and Gifted Sensitivity
When OTs usually refer to sensitivity, we usually speak about the physical sensitivity that our clients may experience.  We know that sensory sensitivity can lead to avoidance of sensory input and poor modulation of arousal.  The poor modulator is the child who has a hard time staying in an optimal state of calm, struggling to focus attention on accomplishing their daily activities.  This can be true with gifted children, but is not always a feature of giftedness.

We also know that children with ASD find it difficult to connect with another’s emotional experience due to their neurological wiring.  It is not that they choose to misinterpret other’s emotions.  They may long to know what others are thinking and what to do and say in interpersonal relationships.  Temple Grandin and John Elder Robison have written about their difficulties and discomfort in understanding how friends and family feel.

The gifted client is swimming at the other end of this pool:  they have profound emotional connections to people (and sometimes feelings for objects as well!),  even strong connections with the imagined emotional experiences of strangers!  Again, this is not just their temperament or their personality; the emotional flood is coming from their brain wiring that generates deep connections between profound concepts and expansive comprehension of situations. Gifted kids see very clearly how the human race is all one, how affecting a part results in affecting the whole, etc. It can be overwhelming for them to know this at 4. Or 14. Gifted children are not little adults, even when testing indicates amazingly advanced mental abilities. Their asynchronous development means that they may understand concepts but still cry when they lose a game. They are still children.

There is some science behind the idea that gifted children are emotionally advanced as well as academically advanced.  Researchers on giftedness are eager to display their fMRI views of the gifted brain as it thinks, showing it humming along at warp speed, lighting up like a Christmas tree in areas that are mostly quiet for other people.  I would guess that those mirror neurons (proposed to support empathy and interpersonal skills) that seem inactive in ASD are probably switched on 24/7 in gifted individuals.

Parents get their first taste of this quality when they see how attuned their baby is to their speech and their movements.  “She would just watch our faces all day long!” is a familiar report when asked about early development.  Toddlers begin to be aware of their own emotions and the emotions of others, and the gifted toddler can be quite a handful as she sorts this out. The gifted child may want to volunteer, may become upset when reading news stories, and may insist that the family participate in activities for social causes. On the other hand, a gifted child may become sad and overwhelmed by situations that other children are unable to comprehend. It can lead to feelings of powerlessness and anger when the adults in their world don’t respond in kind or disregard their concerns.

My message to parents and teachers of gifted children, and those who work with children showing strong emotions and advanced skills without a gifted label is to consider that the strong reactions that you see may be a brain effect, not a personality defect. Your next step: supporting a child to handle the flood of emotion, and help them channel their feelings into productive actions and interactions that build social skills, not isolation and a negative self-image.
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Can HWT’s Flip Crayons Transform Pencil Grasp in Preschoolers?

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I gave a mom a few of Handwriting Without Tear’s flip crayons this week. She was amazed at what her son did with them. He picked them up, examined them and proceeded to figure out how best to hold them without a word from me. He automatically achieved the mature grasp that we had been talking about all spring. Bingo!

Will that happen with every child? Probably not, but flip crayons are a popular tool in my OT arsenal for a reason. They work more often than they fail. There is less effort from an adult, less redirection, which is often perceived as criticism by young children. Remember, children often hear “wait a second…” as “you did it wrong”. These small two-sided crayons are very visually appealing to young children, and become even more so when I introduce them as “kindergarten crayons” that I think a child might try. Every child wants to be seen as older and more skilled, even the anxious ones. I “sell” the use of these crayons as an advanced writing tool that we can use in therapy and at home.

Then I offer to show them how the older kids use them, and flip them from one color to the other while holding the crayon’s center between my thumb and index finger. This is actually an exercise and an evaluative tool for me. A child that doesn’t have the control and coordination to flip the crayon may not be able to achieve the stable tripod grasp needed to use a flip crayon.

The next step is demonstrating HWT’s wiggle stroke on paper. I use their preschool pages, but I created my own as well. Most of my clients need more practice than the 3-4 pages in the book.

Now it is time to trace the gray shapes and color in the shape pages in the workbook. Again, I created my own pages to expand and enrich. I could only do this because I took the HWT course (twice) and understand the principles behind the pages. If your teacher is riffing off of the workbook but her pages don’t have the same immediate success as the HWT workbook, that could be the reason. Knock-offs that aren’t true to the concept won’t work as well, or maybe even at all.

Order some flip crayons from HWT today at Handwriting Without Tears, and watch the magic happen!

Are YOU A Sensory Sensitive Parent?

If you fill out the Infant/Toddler Sensory Profile for your child and see yourself on the page too, don’t be too surprised. Actually, you might feel relieved, and even a bit excited. Because now you know that you aren’t “crazy” or “weird” or even “difficult”. If you have some sensory processing issues of your own, you can learn how to address them and improve your situation while you are helping your child learn to build her own sensory processing skills.

About one in four of the families I work with will admit that at least one parent has or had difficulties with sensory processing at one time. They rarely offer this information at the evaluation. Only with the reframing that occurs as I explain the process of therapy for sensory processing disorder for their child do I hear about how they or their partner only eats certain textures of food or cannot tolerate wearing clothes with long sleeves.

Now, that revelation is just the beginning of a conversation about themselves, because one or two issues with sensory experiences doesn’t indicate a sensory processing problem. Eventually I will hear about all the small and sundry things that this person avoids or alters in order to manage life as a functioning adult. Then it becomes clear to both of us: the story they told themselves about their preferences or personality quirks is likely to be based in sensory processing struggles, not psychology.

Older children and adults who have never had treatment are told (or tell themselves) that they are difficult, rigid, controlling, and too sensitive. This sounds very demeaning, but in fact it is often not intended to be hurtful. Behavior is often seen as only occurring for cognitive or emotional reasons. You have a feeling, and the reason is how you are thinking or feeling.  But behavior is now understood to have many drivers, and it isn’t always cognitive or emotional.

The truth is that sensory processing creates the impetus for many of our behaviors in childhood and beyond. Not seeing the effect of the body on behavior is a huge impediment to addressing issues effectively.  Yes, people who are overwhelmed with sensory input can and do try to control their environment and the people in it. It looks like they are rigid and difficult. But it is not the same as being manipulative and aggressive due to interpersonal or emotional events.

Avoiding touch or movement can also appear to be relational when it is a sensory-based issue. The relational problems begin when the person or other people interpret the behavior as indicating something else, such as shyness or social aversion. How you define yourself and how others define you is like choosing which road to travel. It means that you may not see all the reasons for behavior and all the possibilities for change.

Adults rarely receive effective treatment for long-standing sensory processing issues. Sometimes they have come up with their own solutions, such as doing yoga to receive deep pressure input. They may tell their friends that they can’t digest certain foods, when in fact just seeing some foods makes them nauseous. I am more than happy to work with parents and help them creatively explore solutions for themselves when it is indicated. I have even treated adults formally as an OT from time to time. When parents see themselves more clearly as they support their child, both parties can address sensory processing issues more effectively.