Category Archives: child safety

Kids With Low Muscle Tone: The Hidden Problems With Strollers

jeremy-paige-146338-unsplashWhether you live in the city or the ‘burbs, you almost certainly use a stroller for your infant or toddler.  Even parents who use slings or carriers for “baby wearing”  find themselves needing a stroller at some point.  Why are strollers a problem for children with low muscle tone?  The answer is simple:  sling seats and ineffective safety straps.

Strollers, especially the umbrella strollers that fold up into slim spaces, have a sling seat, not a flat and firm seat.  Like a hammock or a folding lawn chair, these seats won’t give a child a solid surface that activates their trunk.  When a child sits in a sling seat, they have to work harder to hold their body in a centered and stable position.

Why is that important when you are transporting your child in a stroller?  Because without a stable and active core, your child will have to work harder to speak and look around.  A child with low muscle tone or hypermobility that is in a sling seat may be inclined to be less active and involved, even fatigued from all that work to stay stable.  It could appear that they are shy or uninterested, but they might be at a physical disadvantage instead.  A collapsed posture also encourages compensations like tilting the head and rounding the back.  Will it cause torticollis or scoliosis?  Probably not, but it is certainly going to encourage a child to fall into those asymmetrical patterns.  Kids with low tone don’t need any help to learn bad habits of movement and positioning.

Safety strap location and use in many strollers is less than optimal.  There are usually hip and chest straps on a stroller.  Some parents opt to keep them loose or not use them at all, thinking that kids are being unnecessarily restrained.  I think this is a mistake for kids with low tone.

Good support at the hips is essential when a child with low tone sits in a sling seat.  It is their best chance to be given some support.  Chest straps are often not adjusted as the child grows.  I see two patterns:  Straps too low for an older child, and straps too high for a younger one.  The latter issue usually occurs when parents never adjusted the straps after purchase.  They left them in the position they were in from the factory.  Make sure that the straps are tight enough to give support but not so tight that a child is unable to move at all.  A child that is used to sliding forward may complain about having their hips secured so that they can’t slouch, but they will get used to it.

You may have to reposition a child with low tone from time to time you go about your errands or adventures.  They often don’t have the strength or body awareness to do so themselves.  They could be in a very awkward position and not complain at all.  Check their sitting position as you stroll along.  Good positioning isn’t “one and done” with these kids, but doing it right will benefit them while they are in the stroller, and also when they get out!

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Picking The Best Trikes, Scooters, Etc. For Kids With Low Tone and Hypermobility

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Welcome to the world of faster (and faster) movement!  After mastering walking and possibly even running, older toddlers and preschoolers are often eager to jump on a ride-on toy and get moving.  If a child has had motor delays and has had to wait to develop the strength and balance needed to use a trike or another ride-on toy, they may be a bit afraid or they may throw caution to the wind and try it all as soon as possible!

Selecting the best equipment for kids that have low tone or hypermobility doesn’t end with picking a color or a branded character ( Thanks, Frozen, for bringing up my Disney stock almost single-handedly!).  In order to find the right choice for your child, here are some simple guidelines that could make things both easier and safer:

  1. Fit matters. A lot.  Hypermobile children are by definition more flexible than their peers.  They stretch.  This doesn’t mean that they should be encouraged to use pedals so far away from their bodies that their legs are fully extended, or use handlebars that reach their chins.  In general, muscles have their greatest strength and joints have their greatest stability and control in mid-range.  Fit the device to the child, not the other way ’round. Choose equipment that fits them well now,  while they are learning, and ideally it can be adjusted as they grow.
  2. Seats, pedals and handlebars that have some texture and even some padding give your child more sensory information for control and safety.  These features provide more tactile and proprioceptive information about grip, body positions and body movements.  You may be able to find equipment with these features, or you can go the aftermarket route and do it yourself.  A quick hack would be using electrical tape for some extra texture and to secure padding.  Some equipment can handle mix-and-match additions as well.  Explore your local shops for expert advice (and shop local to support your local merchants in town!)
  3. Maintain your child’s equipment, and replace it when it no longer fits them or works well.  Although it is more affordable to receive second-hand items or pass things down through the family, hypermobile kids often find that when ball bearings or wheels wear down, the extra effort required to use a device makes it harder to have fun.  The additional effort can create fatigue, disinterest in using the equipment, or awkward/asymmetrical patterns of movement that aren’t ergonomically sound.  Repair or replace either than force your child to work harder or move poorly.

Looking for more information about low tone and hypermobility?  Read The Hypermobile Hand: More Than A Strength Problem and How Hypermobility Affects Self-Image, Behavior and Activity Levels in Children.  My new e-book on living and thriving with hypermobility is coming soon on Amazon.com!

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How Parents Can Teach Healthy Body Boundaries To Young Children

 

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One of the greatest horrors of the Larry Nasser story is that parents were often mere feet away from these girls while they were being molested.  The people most invested in a child’s safety had no idea that anything violent was occurring, and these girls did not reveal their discomfort at the time.  These parents are beyond distraught now, and often filled with guilt.  I do not blame them for what happened.  They were deceived by Nasser and their children weren’t able to communicate their distress or confusion.

Parents who read these news reports are wondering how they would react; would they recognize abuse?  And they are wondering what to say and do to prevent this from ever happening to their own children.

My strong belief is that there will always be people like Larry Nasser in the world, and that children who have experience with being touched with respect could be more likely to recognize and report abusive touch, even when it comes from an authority or a family member.

I would like to share my best suggestions to teach children the difference between healthy touch and invasive touch, drawn from my practice as a pediatric occupational therapist who treats children with ASD and sensory processing disorders.  I would also like to say very clearly that there is never any reason for any occupational therapist to make contact with a child’s genital area.  Ever.  But since parents and caregivers perform diaper changes, dress children, and provide bathroom assistance, it is important to me to teach the following strategies for respectful contact in therapy so that children have a sense of what type of touch is unacceptable:

With non-verbal children of any age, I use a combination of observation, use of my own body language before I begin physical contact in therapy.  If children can make eye contact, I use visual regard to establish a connection, and I do not initiate physical contact quickly.  If they cannot meet my gaze, I read their cues, and often wait for them to come closer to me and reach out.  I use intermittent touch that avoids hands, face and feet initially.   Deep pressure is less alerting to the nervous system than light touch, so my contact is stable, slow and steady.  I will describe what I am doing therapeutically, in simple statements with calm tones, even if I am not sure that they will understand me.   I remove my contact when I see any indication of agitation, and before a child protests strongly.  What I am communicating is “I get you.  I see you and I respect you.  I will not force you, but I will invite you to engage with me”.

With children that can communicate verbally, I do all of the above strategies, and I ask permission.  Not always in complete sentences, and not always using the word “touch”.  I constantly tell them what I am going to do or what movement I am going to help them to accomplish.  It doesn’t matter if they fully comprehend my words; they can read the tone in my voice.  If they protest, I will voice their protest without criticism “You want no more _______; no more __________.  OK.”  I reconsider my approach, adjust, and either begin contact again or shift activities to build more tolerance and trust.

With slightly older children that can understand my question and can respond clearly, I will teach them that they have a choice about greetings.  I teach “Handshake, Hug or High-Five?“.  Children get to choose what kind of physical contact they wish to have when greeting me or other adults.  I must agree to their choice.  I encourage parents to teach their family members to offer this choice and to never force a child to kiss/hug or accept a kiss or a hug from anyone.  Children need to feel that they have agency over their bodies without criticism.

Anyone who remembers enduring a sloppy smooch or a crushing hug from a relative can relate.  You may or may not have actively protested.  It doesn’t matter.  Allowing an adult to have this form of contact with a child is not just an irritating experience for them.  It is a serious message that children of all genders are given:  The people that are in power have the right to do things to your body that you don’t like, and you have no right to complain.

Is this the message that parents intend?  Of course not, but that doesn’t make it any less a clear communication.  Larry Nasser and his kind depend on a combination of authority, status and compliance to perpetrate abuse, even if the child’s parents are in the room.  I believe that children who know that any uncomfortable touch from any adult, even those closest to them, can be refused, they are more likely to recognize and report abuse. They will be believed and they will not be shamed.

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Hypermobile Kids, Sleep, And The Hidden Problem With Blankets

 

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Everyone knows that sleep is important.  Research in sleep science (yes, that is a thing) tells us that our brains are working to digest the day’s learning, the immune system is active during sleep, and our bodies are repairing and renewing tissues and organs while we slumber.  As much as we need sleep, kids need it more.  They are building the brains and bodies they will carry into their future.  Children need good quality sleep as much as they need healthy food.

Helping children to sleep well is usually a combination of creating good and consistent bedtime routines, giving them a full day of physical action and warm social interaction, and developing a healthy sleep environment.  This means providing a sleep-positive environment and removing any barriers to sleeping well.  But giving kids the chance to get a good night’s sleep can be harder when a child has hypermobility.

Some of the challenges to sleep for hypermobile kids are sensory-based, some are related to activity during the day, and some are orthopedic.  Here is a list of things that make sleep more challenging for these kids:

  • Children with limited proprioception and kinesthesia due to low tone or excessive joint mobility can have difficulty shifting down into a quiet state for sleep.  They spend their day seeking sensory input;  not moving reduces the sensory information that makes them feel calm and organized.  Being still is a bit similar to being in a sensory deprivation tank, and it’s not always calming.  To understand more about the sensory concerns of hypermobility, take a look at Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children.
  • Some hypermobile kids have joint or muscle pain that keeps them up or wakes them up in the middle of the night.  Pain also makes kids more restless sleepers.  Restless sleepers thrash around a bit under the covers, becoming trapped in multiple layers of bed linens, or they can fall asleep in awkward positions that result in pain.
  • Children that are sedentary during the day for any reason (preference for tablet or video play, fatigue, pain, etc) may not be physically tired enough at night.  They may also be staying up too late at night.  Good sleep hygiene includes enough daytime activity combined with a conscious wind-down hours before bedtime occurs.
  • Some children with generalized low tone or joint hypermobility (especially with a connective tissue disorder) have issues with the partial collapse of their airway during sleep.  They snore or gasp in their sleep, and appear exhausted even after a full night’s sleep.  This is a serious issue.  Sleep apnea should be evaluated and addressed by a professional.
  • Hypermobile kids can get arms and legs caught in their bedclothes or between crib slats and mattresses.  Any layer can be a potential problem, from the sheet to the decorative afghan that Granny sent for his birthday.
  • Limbs can slide off the mattress during deep sleep and create strain on ligaments and tendons.   You and I depend on our brain to perceive an awkward position and take corrective action by waking us slightly.  The same child who “w” sits and slides off a chair without noticing is not going to wake up when her arm is hanging off the bed during sleep, even though the tissues are stretching beyond their typical range of motion.
  • Waking up to go to the bathroom or having to clean up a nighttime accident ruins sleep.  It isn’t uncommon to have older kids wear protective garments well past 5 at night, and some children need to practice holding in their urine to expand the bladder’s ability to hold it all night long.  This is something to discuss with your child’s urologist or pediatrician, since “holding it in” can be it’s own problem.  Read Teach Kids With EDS Or Low Tone: Don’t Hold It In! to learn more about the pitfalls of too much “holding”.

Here are some simple strategies that may improve your child’s sleep:

  • Try a duvet or a flannel sheet set to minimize the number of layers of bedclothes.
  • Use a rashguard suit instead of pajamas.  I am particularly fond of the zip-front style so that less force is needed to get arms in and out while dressing.  You can peel it off more easily.  The lycra creates sensory feedback that can support body awareness while keeping them cozy.  An all-in-one suit also gives a bit of support so that limbs don’t easily overstretch.  A little bit of proprioceptive input in a breathable fabric that can also generate a bit of neutral warmth (from body heat) to keep tissues from getting too stiff.
  • Avoid footie sleepers that are too short.  Too-small footie sleepers create compressive forces on joints and could even encourage spinal torque.  Hypermobile kids will be the last ones to complain since they often don’t feel discomfort right away.  My preference is not to use these sleepers at all with hypermobile kids or kids with low tone.  See the next suggestion for another reason why I feel this way.
  • Make them take off those footie sleepers when they wake up and walk around.  As fabric twists and children stand/walk on the fabric, not the soles, it creates a safety risk underfoot.  Less sensory feedback and slippery soles!!  Get them dressed once they wake up.
  • Address sleep apnea, lack of daytime activity, and toilet training/scheduling rather than waiting for things to improve.  Not all young children achieve night time dryness on pace with other children, but ignoring the impact isn’t going to help things.
  • Carefully consider the issues before you try a weighted blanket.  Originally sold for kids on the autistic spectrum and for kids with sensory processing disorders without muscular or orthopedic issues, these blankets have become popular with other groups.  The biggest concern for hypermobile kids is that placing weight (meaning force) on an unstable joint over time without conscious awareness or adult monitoring is a safety issue.  It is possible to create ligament injury or even subluxation of a joint with weights, depending on limb position, length of time weight is applied, and the amount of force placed on a joint.  Talk the idea of a weighted blanket over with your OTR or PT before you order one of these blankets.
  • Consider aromatherapy, gentle massage, white noise machines, and other gentler sleep strategies to help your child sleep well.  consider techniques like gentle joint compression and/or deep pressure brushing, but ask your therapists how to adapt it for your child’s specific  needs  Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome?.  For kids who sleep well but wake up stiff, learn how to use gentle massage and possibly heat to help them get going.  do not ignore pain at bedtime, or complaints of pain on awakening.  These are important clues that you need to address.   Ask your occupational therapist or your pediatrician for ideas to adapt your bedtime routine (OT)  or your pain plan (MD) to handle nighttime pain.
  • Try K-Taping or Hip Helpers for stability.  Kineseotape stays on for days and gives joint support and sensory input while your child sleeps.  Hip Helpers are snug lycra bike shorts that limit extreme hip abduction for the littlest kids ( when legs rotate out to the sides excessively).  They gently help your child align hip joints correctly.  As with weighted blankets, I strongly recommend consulting with your therapists to learn about how to use both of these strategies.  When used incorrectly, both can create more problems for your child.

Looking for more information about managing hypermobility in children?  Take a look at Should Your Hypermobile Child Play Sports? and Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior.

 

Looking for more personal assistance in addressing bedtime issues?  Visit my website and purchase a consultation session to ask questions, get resources, and even make a sleep plan that works!

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Should Hypermobile Kids Use Backpacks?

 

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Yo! A photo shout-out to my old life in Brooklyn! I loved coming to work to see this iconic view!

It is back-to-school season here in the US.  One of the items on shopping lists is a new backpack.  But for kids with low muscle tone or hypermobility, backpacks can be more than a way to carry books and water bottles.  They can be a source of pain, headaches, even numbness in hands and fingers.  The important question isn’t how to lighten the load of a heavy backpack.  It is whether these kids should be using them at all.

The standard recommendations from occupational therapists and orthopedists regarding backpacks are simple:  lighten the load, use both straps (select one with wide straps), and make sure the heaviest items are placed close to the body.  All good suggestions.  But if a child already has pain or weakness around their spine and/or shoulder joints, reduced stability and endurance, and limited ability to judge posture and force, then the picture changes.  Using a backpack may be a significant physical risk, no matter how well designed or used.  And still many kids will insist that it isn’t possible to go without one.

Here are some suggestions that further minimize the risk of injury but can be acceptable to kids who may be sensitive to being perceived as different if they don’t have a backpack:

  • Request a set of the heaviest books for home use.  This can be part of an IEP or a 504 plan, or the school may be willing to do so without anything formal on paper.
  • Select the smallest size backpack possible.  Stores like Land’s End and L.L. Bean  are great sources for a variety of backpack sizes.  Bigger backpacks encourage kids to load more stuff inside.
  •  Have your child carry lighter and fewer items.  Pick the smallest water bottles and travel sizes of anything they really need.  Think “weekend in Paris on a shoestring” not “trekking the Himalayas”.  At least they have a backpack like the other kids.
  • Teach your child to carry their pack in their arms, close to their chest, instead of wearing it.  I know that sounds a little weird.  But if the pack is small to medium in size, this is the best way to carry it to reduce strain on the back and neck.  And they still have a backpack like the other kids.  It might be a long shot to get a kid to change how they carry a pack.  Some kids can respond to reminders of how awful it is to be in pain, and how not being able to sleep or play sports is much worse than carrying that pack in their arms.
  • Considering a rolling case?  Not so fast.  The twisting of the spine and the use of one arm to drag a rolling case may be worse than using a backpack.  Then there is the lifting and lugging of a case up non-ADA stairs.  Out of the frying pan……

Looking for more information about hypermobility, low tone and back-to-school planning?  Check out Does An Atypical Pencil Grasp Damage Joints or Support Function In Kids With Hypermobility? and Great Mechanical Pencils Can Improve Your Child’s Handwriting Skills.  Before you wonder if all that fidgeting and leaning over the desk is a behavior problem, read Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior.  There are pencil grips that can really help kids with a weak grasp, so check out The Pencil Grip That Strengthens Your Child’s Fingers As They Write.

If your child is older and thinking about a career, please read Career Planning for Teens with JRA, EDS, and Other Chronic Health Issues for some important strategies to get them thinking about how to navigate higher education and make plans that make sense.

Hypermobile Toddlers: It’s What Not To Do That Matters Most

 

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Do you pick up your toddler and feel that shoulder or those wrist bones moving a lot under your touch?  Does your child do a “downward dog” and her elbows look like they are bending backward?  Does it seem that his ankles are rolling over toward the floor when he stands up?  That is hypermobility, or excessive joint movement.

Barring direct injury to a joint, ligament laxity and/or low muscle tone are the usual culprits that create hypermobility.  This can be noticed in one joint, a few, or in many joints throughout the body.  While some excessive flexibility is quite normal for kids, other children are very, very flexible.  This isn’t usually painful for the youngest children, and may never create pain for your child at any point in their lifetime.  That doesn’t mean that you should ignore it.  Hypermobility rarely goes away, even though it often decreases a bit with age in some children.  It can be managed effectively with good OT and PT treatment.   And what you avoid doing at this early stage can prevent accidental joint injury and teach good habits that last a lifetime.

  1. Avoid over-stretching joints, and I mean all of them.  This means that you pick a child up with your hands on their ribcage and under their hips, not by their arms or wrists.  Instruct your babysitter and your daycare providers, demonstrating clearly to illustrate the moves you’d prefer them to use. Don’t just tell them over the phone or in a text.  Your child’s perception of pain is not always accurate when joint sensory aren’t stimulated (how many times have they smacked into something hard and not cried at all?) so you will always want to use a lift that produces the least amount of force on the most vulnerable joints.  Yes, ribs can be dislocated too, but not nearly as easily as shoulders, elbows or wrists.  For all but the most vulnerable children, simply changing to this lift instead of pulling on a limb is a safe bet.
  2. Actively discourage sitting, lying or leaning on joints that bend backward.  This includes “W” sitting.   I have lost count of the number of toddlers I see who lean on the BACK  of their hands in sitting or lying on their stomach.  This is too much stretch for those ligaments.  Don’t sit idly by.  Teach them how to position their joints.  If they ask why, explaining that it will cause a “booboo” inside their wrist or arm should be enough.  If they persist, think of another position all together.  Sitting on a little bench instead of the floor, perhaps?
  3. Monitor and respect fatigue.  Once the muscles surrounding a loose joint have fatigued and don’t support it, that joint is more vulnerable to injury.  Ask your child to change her position or her activity before she is completely exhausted.  This doesn’t necessarily mean stopping the fun, just altering it.  But sometimes it does mean a full-on break.  If she balks, sweeten the deal and offer something desirable while you explain that her knees or her wrists need to take a rest.  They are tired.  They may not want to rest either, but it is their rest time.  Toddlers can relate.

Although we as therapists will be big players in your child’s development, parents are and always will be the single greatest force in shaping a child’s behavior and outlook.  It is possible to raise a hypermobile child that is active, happy, and aware of their body in a nonjudgmental way.    It starts with parents understanding these simple concepts and acting on them in daily activities.

 

Wondering about your stroller or how to help your child sit for meals or play?  Read Kids With Low Muscle Tone: The Hidden Problems With StrollersThe Cube Chair: Your Special Needs Toddler’s New Favorite Seat!,  Kids With Low Muscle Tone: The Hidden Problems With Strollers and Picking The Best Trikes, Scooters, Etc. For Kids With Low Tone and Hypermobility for practical ideas that help your child today!

Wondering about your child’s speech and feeding development?  Take a look at Can Hypermobility Cause Speech Problems? to learn more about the effects of hypermobility on communication and oral motor skills.

Looking for information on toilet training your child with Ehlers Danlos syndrome, generalized ligament laxity, or low muscle tone?  My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, gives you detailed strategies for success, not philosophy or blanket statements.  I include readiness checklists, discuss issues that derail training such as constipation, and explain the sensory, motor, and social/emotional components of training children that struggle to gain the awareness and stability needed to get the job done.  You will start making progress right away!

My book is available on my website tranquil babies, at Amazon, and at yourtherapysource.com.

How to Teach Your Child to Cut Food With a Knife…Safely!

ksenia-makagonova-274699After a child scoops with a spoon and pierces food with a fork, time seems to stand still. No one wants to hand a young child a knife. But they should (sort of). Here are some ideas to safely explore knife skills without holding your breath or end up still buttering their toast when they are in middle school!

1. Don’t use a knife. Use a spreader instead. Yes, those little things you put out next to the brie when you have a few adults over for wine and cheese. You can find handles that fit nicely in a child’s hand, improving their control. The spreaders that have a sculptured handle add even more texture for a secure grip. With a rounded blade, these are less dangerous in the hands of young children. Butter knives and plastic disposable knives are actually capable of cutting a child’s fingers. Not a good thing. Save them for Stage 2, where your child has already developed some skills.

2. Pick the right foods for cutting practice. Children who are learning to cut will usually provide too much downward pressure. They aren’t comfortable using a sawing motion at the same time as slight downward pressure, so adding more pressure is often the output you see in the initial stages of learning. Choose foods that can safely handle their initial awkward movements. Soft solids that are familiar to them, such as bananas and firmly cooked sweet potatoes, can be sliced easily. Avocados that aren’t totally ripe or whole carrots that have been cooked in the microwave are other good choices.

3. Demonstrate cutting while cooking dinner. Children really do need to see your demonstration and hear your comments, but they may find pretend play less motivating than watching the real deal. You can absolutely let them practice with you, cutting the same or similar foods if it is safe. Even if you have to come up with a creative way to use the smashed bananas or carrots resulting from their practice, your food should go into a family meal.

4. Take this opportunity to teach good hygiene. Everybody washes their hands before and after cooking. It’s just what we do. It’s the price of admission to the fun of food preparation.

5. Create a “recipe” that allows your child to be the chef. Young children love to spread their bread or sturdy crackers with softened butter, nut butter, cream cheese, or Nutella. They can prepare some for others int he family as well. We all love to see people enjoy our cooking, right? But be creative and remember to initially use foods that they know and love. Would you be excited to cook a meal with foods that you have never eaten? Possibly not.

This is an opportunity to teach a skill while enjoying time with your child. Have fun using these strategies for beginning knife skills!