There are a few equipment and toy recommendations that every home-based pediatric OTR makes to a child’s parents: Play-Doh, puzzles, tunnels, …and a vertical easel. Found in every preschool, children from 18 months on can build their reach and proximal (upper body) control while coloring and scribbling on a vertical surface, rather than a tabletop.
But WHERE a child is directed to aim their stroke matters. Here is why:
Grasp and reach have a range of efficiency. I tell adults to imagine that they are writing on a whiteboard for a work presentation. Your boss is watching. Where will your writing/drawing be the most controlled? Everyone immediately knows. It is between your upper ribs and your forehead, within the width of your body or a few inches to either side. Beyond that range, you have less stability and control. Its an anatomy thing. If you are an OTR, you know why. If you are a parent, ask your child’s OTR for a physiology and ergonomics lesson.
Visual acuity (clarity of focus) is best in the center of your visual field (the view looking directly forward with your head centered). Looking at something placed in this range is called using your “central vision”. Your eyes see more accurately in that location, children can see an adult’s demonstration more clearly, and therefore they can copy models and movements more accurately. Kids with ASD like to use their peripheral (side) vision because it is cloudy, and the distortion is interesting to them. This is not good for accomplishing a visual-motor task or maintaining social eye contact, but they find this is a way to perform sensory self-stimulation and avoid the intensity of direct eye contact with others.
Young children have little self-awareness of how their environment impacts them. Until they fail. Then they think it is probably their fault. The self-centeredness that is completely normal in children gets turned around, and a child can feel that they are the problem. Telling children where to place their work on an easel gives them the chance to do their best work and feel great about it.
Children move on when a task is too hard, or when an adult doesn’t provide enough supportive strategies. Telling a child to try again, or telling them that their results weren’t too bad” isn’t nearly as helpful as starting them off where they have the best chance of success.
Using the non-dominant hand to support the body while standing is an important part of vertical easel use. For kids with low muscle tone or hypermobility, it is very important. Standing to the side or draping the body on the surface to write are both poor choices that OTRs see a lot in kids with these issues. Make the easel a piece of therapy equipment and teach a child to place their non-coloring/painting hand on the side of the easel in the “yes zone”. Look at the picture of the older boy at the beginning of this post, then at the gentleman below. Note each person’s posture and try to embody it. Which posture provides more ease, more control?
Here is a graph of where an adult should place their demonstration on a page or board for optimal vision and motor control, and where adults should encourage a child to draw. “NO” and “YES” refer to the child’s optimal location for drawing or writing.
The exception is for height. A very tall child will need to draw higher on the chart, and a smaller child will only reach the lowest third of the easel. This should still allow them to use their central vision and optimal reach. If the easel doesn’t fit the child, place paper on a wall at the correct height.
Now that COVID -19 is pushing EI into telehealth, I see exactly what parents have at home when they hunt around for pre-writing tools. These egg-shaped crayons, and crayons where the child pokes a finger inside a cone-shaped crayon, are popping out of bins and drawers like little spring flowers. I (mostly) hate them.
Because the only kids that benefit from them are infants and kids who have such limited grasp that a cylindrical crayon isn’t a realistic choice. For absolutely everyone else, they teach kids nothing about grasp, and they make it harder to control a stroke. They are fun to bang together and on a table, but they are really difficult to control to make more than a poorly executed mark. This isn’t pre-writing at all.
So why are they in the house? That is simple: marketing.
Parents are eager to give their toddlers and preschoolers an edge, and these are heavily promoted on sites and in stores (remember when we used to go into stores?) They are uniquely shaped and colorful, sold with excellent packaging. A standard box of crayons gets none of this kind of love.
Please, please: don’t believe the hype.
Just like those spoons shaped like bulldozers, these crayons aren’t helping anyone but the people selling them. They are gimmicks, not tools for motor development. If your child is older than 12 months and has enough motor control to hold a spoon in a fisted grasp to eat, they are ready to hold a thick crayon and make a stroke. Experience picking up and using a crayon, and watching an adult demonstrate how to make a stroke on a large sturdy piece of paper is so much more helpful.
One of my colleagues with a hypermobile third-grader told me this chair has been a great chair at school for her child. It hits a lot of my targets for a good chair recommendation, so here it is: The Giantex chair.
Why do I like it so much?
It is a bit adaptable and it is sized for kids. No chair fits every child, but the more you can adjust a chair, the more likely you are to provide good supportive seating. This chair is a good balance of adaptability and affordability. My readers know I am not a fan of therapy balls as seating for homework when a child is hypermobile. Here’s why: Should Hypermobile Kids Sit On Therapy Balls For Schoolwork?
It isn’t institutional. Teachers, parents, and especially kids, get turned off by chairs that look like medical equipment. This looks like a regular chair, but when adjusted correctly, it IS medical equipment, IMPO.
It’s affordable. The child I described got it paid for by her school district to use in her classroom, but this chair is within the budget of some families. They can have two; one at school and one at home for homework or meals. Most kids aren’t too eager to use a Tripp Trapp chair after 6 or 7. That chair is a hit with many therapists, but it’s untraditional looks bother a lot of older children. This chair isn’t going to turn them off as easily. It gives better back support as well: Why Using a Chair Correctly is SO Difficult for Hypermobile Kids and Adults
This chair looks like it would last through some growth. I tell every parent that they only thing I can promise you is that your child will grow. Even the kids with genetic disorders that affect growth will grow larger eventually. This chair should fit kids from 8-12 years of age in most cases. The really small ones or the really tall ones? Maybe not, but the small ones will grow into it, and the tall kids probably fit into a smaller adult chair now, or in the near future.
And of course, if you are a parent who is frustrated with how little help you are getting from your pediatrician or your therapy team, look below to learn more about my e-book that is designed to empower you today!
Want more information to help your older child and make life easier? My newest book has finally arrived!
The JointSmart Child: Living and Thriving With Hypermobility Volume Two: The School Years is now available as a read-only download on Amazon and a printable download on Your Therapy Source . It is filled with the practical information that parents and therapists need to make kids’ lives easier, safer, and more independent. Your Therapy Source has created book bundles, discounting all of my bookswhen you buy more than one, making it more affordable to get the information you need.
Parents are staying home with their toddlers and preschoolers now. All day. While this can be a challenge, it can also be the right time to do potty training.
Here’s how to make it work when you want to teach your toddler how to “make” in the potty:
You don’t have to wait for readiness. What you might get instead is a child that has lost the excitement of being praised by adults, and fears failure more than seeks praise or rewards. If that sounds like your child, quickly read Waiting for Toilet Training Readiness? Create It Instead!
Have good equipment. If you don’t have a potty seat that fits your child or a toilet insert and a footstool that is stable and safe, now is the time to go online shopping for one. Without good equipment, you are already in trouble. Children should be able to get on and off easily and not be fearful of falling off the toilet. If you are training a preschooler and not a toddler, you really need good equipment. They are bigger and move faster. Safety and confidence go hand in hand.
Have a plan for praise and rewards. Not every child will want a tiny candy, but nobody should expect a new toy for every time they pee in the potty. Know your kid and know what gets them to try a new skill. Some children don’t do well with effusive praise Sensitive Child? Be Careful How You Deliver Praise , so don’t go over the top if this is your kid.
Know how to set things up for success. If your child is typically-developing, get Oh Crap Potty Training by Jamie Glowacki, because she is the best person to tell you how to help you be successful. She even has a chapter just on poop! If your child has hypotonia or hypermobility, consider my e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone. It is inexpensive, available on Amazon and Your Therapy Source, and gives you checklists and explanations for why you need to think out-of-the-box to potty train these kids. You don’t leave for vacation without a map. Don’t wing this. Just don’t.
Looking for more information on potty training? I wrote an e-book for you!
The Practical Guide to Toilet Training Your Child With Low Muscle Tone was my first e-book. It is still my best seller. There is a reason: it helps parents and kids succeed. This unique book explains why learning this skill is so tricky, and it gives parents and therapists detailed strategies to set kids (and parents) up for success! Understanding that the sensory and social-emotional impacts of low muscle tone are contributing to potty training deals is crucial to making this skill easier to learn. I include a readiness guide, strategies to pick the best equipment and clothes (yes, you can dress them so that they struggle more!), and how to move from the potty seat onto the adult toilet.
It is available on Amazon and on Your Therapy Source, a great site for materials for therapists as well as parents looking for homeschooling ideas.
My clients know that I use therapeutic music called Quickshifts and Gearshifters in many pediatric therapy sessions. They use binaural beat technology (Binaural Beats and Regulation: More Than Music Therapy ) to induce an alpha brainwave state. This is the brain’s calm-alert state. Due to the unprecedented stress we are all under, I am using them myself. Every day, twice a day, minimum. Here is why:
I am no good to anyone if I am vibrating with anxiety. There is only so much breath work can do for me. I need brain work.
The calm-alert brainwave state that Quickshifts and Gearshifters rapidly induces is effortless. Turn it on, (they can be purchased and loaded onto your phone through the free Therapeutic Listening app) wear the headphones, and it works perfectly without me doing anything else. I do have to stay off the screen stuff, but then, I should anyway. Mostly I take a walk (alone) or crochet.
I love music. Most of us do. I need music. Most of us do. I won’t listen to some droning boring sounds if I can listen to fun music instead. Quickshifts have children’s music, classical music and gentle techno music that isn’t aggravatingly boring.
The effects of altering brainwave states boost my immunity. And there has never been a better time for it.
I can bring it with me on a walk, so I get a double dose of healthy input.
It isn’t tiring or distracting.
I could use it more often than 2x/day. There is no danger or downside, unlike modulated music. Modulated music is a workout for your brain, and using it too close to bedtime can be a challenge. Quickshifts and Gearshifters are designed for anxiety and even trauma recovery. This pandemic is a trauma if I ever saw one.
I can use it alone at home. No one is getting massages, going to psychotherapy, or getting acupuncture. There is no neurofeedback machine in my house. I couldn’t go anywhere even if I wanted to. Enter Quickshifts.
Quickshifts and Gearshifters are best used when selected for a client by a trained OTR. Listening to the wrong album will not damage you or your child, but it is a waste of money and time. Two things most of us are running out of right now.
I had to look twice. A private client showed me the picture her 4 year-old made in his school OT session (not the picture above!). A picture decorated using a dot marker. He can copy a vertical cross and a circle using a pencil. I showed him how to draw a triangle in less than 4 minutes during that session. He is very risk-averse and is probably intellectually gifted. He has lots of sensory issues and mildly limited fine motor skills.
Why was he using a dot marker foranything?
I know his therapist isn’t very experienced, and I am sure the supplies budget isn’t huge. But neither are good excuses for using tools that don’t raise the skill level of a child that is so hesitant to be challenged. Those markers are great for toddlers under 2 or older children with motor skills under a 24-month level, especially kids with neurological or orthopedic issues that don’t allow them to easily grasp and control crayons. Dot markers get children excited to make a mark on paper (an 11-month fine motor skill) and can be the first step to holding a tool to develop early pre-writing.
They aren’t good at all to develop any kind of mature pencil grasp due to their large diameter and large tip. It would be like writing your name with a broom!
The ink tends to splatter with heavy quick contact with paper (fun to make a mess, but not therapeutic!), and doesn’t dry quickly enough. Repeated contact bleeds colors together, and it is hard to keep within the borders of a design unless the target is very large. I can assure you that the design above was done by an adult, an adult with some art training.
Dot markers aren’t building pre-writing skills for this child I treat. There are so many options for activities that do build skills in kids at his ability level. Their use can discourage a risk-averse child from working on pencil grasp. Whatever the activity it was that they were doing, unless he was swinging on his belly on a platform swing or going down a ramp on a scooter (I don’t think he was doing anything nearly that intense) while using a dot marker, there were other, better choices to make.
Many families have toddlers that are not attending daycare or preschool now. They are at home. All day. They are off their schedules, and sometimes seem off their rockers! Here are some ideas to help their parents retain their sanity:
Create a routine for them. This means that they get snacks at a certain time, outdoor play at a certain time, look at books, take a nap, listen to music, etc. all in a predictable sequence. Paint rocks, tear up scrap paper and glue it onto a bigger piece of paper, etc. Crafts are fun and they can be cheap. You don’t have to reproduce the school routine, you just have to be consistent about your home routine. They will learn to anticipate what comes next, with all the calmness that consistency provides.
Have some emergency items/activities. Bake off some pre-made cookie dough, open up some new toy you saved for a special time. It is special now! Root through the back of the gift closet or the toy box and find something that is new or seems new.
Turn on music and calm everyone down. Music is powerful, and these days we need it. Sing out and be silly. You probably could blow off some steam too. Consider using Quickshifts Binaural Beats and Regulation: More Than Music Therapy if your child has sensory processing or low muscle tone.
Make sure they get to move. Every day. Even if all you do is dance around the room, make it active. Jump on pillows, log roll around safely, etc. I treated kids in tiny NYC apartments, so I know it can be done. It isn’t about having a lot of space.
Reconsider the use of screens as rewards. I know it works, but there is a price to pay after that initial quiet time. Think carefully about what will happen when time is up, or when meals of bedtime come. It could get ugly. I have used screen activities in treatment, but NEVER EVER a reward, or even a consistent activity every session. It is another fun thing we do that isn’t always available, and certainly not received by howling for it. For apps that teach instead of entertain, read Screen Time for Preschoolers? If You Choose to Offer Screen Time, Make it Count With These Apps
Parents of hypermobile kids are taught early on not to pull on limbs while dressing them or picking them up. It is less common to teach children how to protect their own joints.
In fact, parents may be encouraged by their child’s doctors to let them be “as active as they want to be, in order to build their strength”. Without adding in education about good joint protection, this is not good advice. This post is an attempt to fill in the space between “don’t pull on their limbs” and “get them to be more active”.
Why? Because hypermobile joints are more vulnerable to immediate injury and also to progressive damage over time. Once joint surfaces are damaged, and tendons and ligaments are overstretched, there are very few treatments that can repair those situations. Since young children often do not experience pain with poor joint stability, teaching good habits early is essential. It is always preferable to prevent damage and injuries rather than have to repair damage. Always. And it is not as complicated as it sounds.
The basic principles of joint protection are simple. It is the application that can become complex. The more joints involved in a movement or that have pre-existing pain or damage, the more complex the solution. That is why some children need to be seen by an occupational or physical therapist for guidance. We are trained in the assessment and prescription of strategies based on clinical information, not after taking a weekend course or after reading a book. Because hypermobile joint issues can be different from arthritic joints, read Why Joint Protection Solutions for Hypermobility Aren’t Your Granny’s Joint Protection Strategies and understand the principles below that apply to almost everyone:
Some of the basics of joint protection are:
Joints should be positioned in anatomical alignment while at rest and as much as possible, while in use. Knowing the correct alignment doesn’t always require a therapist. Bending a foot on it’s side isn’t correct alignment. Placing a wrist in a straight versus an angled position is.
Larger joints should execute forceful movements whenever possible. That means that pushing a heavy door open with an arm or the side of your body is better joint protection than flattening your hand on it. The exception is if there is damage to those larger structures. See below.
Placing a joint in mid-range while moving protects joint structures. As an example, therapists often pad and thicken handles to place finger joints in a less clenched position and allow force to dissipate through the padding. We discourage carrying heavy loads with arms held straight down or with one arm/hand.
Remember: once joints are damaged, if joints are painful, or the muscles are too weak to execute a movement, activity adaptations have to be considered. There is no benefit to straining a weak or damaged joint structure.