Category Archives: child safety

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, 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.
  • 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.

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.
  • 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.  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 (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.

 

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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.

 

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 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, 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!

Help Your Newborn Adjust to Daycare By Using Happiest Baby on the Block Strategies

ID-100108085.jpgReturning to work soon after delivery can mean putting your 3-month old in daycare.  As challenging as this can be emotionally, it can also be a struggle for your baby, especially if her only self-calming strategy has been nursing.  Should you (or could you) quit your job or just tough it out?  There is another alternative:  teach your little one to respond to  a wider variety of self-calming cues.

Self-calming at 3 months?  Well, yes and no.  Babies at this age are learning to respond to messages that we send.  This is the very beginning of self-regulation.  Actions and sensory inputs that tell their nervous system ” You are safe”, “It’s time to sleep” and “I get it; you need a little more help to calm down and I know what to do”.  They aren’t able to devise  their own solutions yet, but they can begin to self-calm if we read their behavior correctly and understand what they need developmentally and neurologically.  This is where Dr. Harvey Karp’s Happiest Baby on the Block strategies, and his other great sleep solutions, can save your sanity and your child’s sleep.  Many of the 5 S’s that worked so well in the first 12 weeks of life can be adjusted to support this transition into daycare.

The weeks between 3 months and 6 months are almost the 5th trimester (Dr. Karp refers to the first 3 months of life as the “4th trimester”).   I think it is a bridge period in which babies need more help to calm down than many realize.  At this age, they suck their fingers to self-soothe while awake.   But… they aren’t strong enough to keep their hands or their thumbs in their mouth when they are lying down and falling asleep.  Gravity pulls those heavy hands down to the crib mattress. They don’t babble their way to sleep the way a 6 month-old does, and they are barely ready to listen to lullabies. So what can you do?  Be creative and use the 5 S’s as a launching point for your new routines.

Swaddling may not be as effective, or even safe, at this stage.  Babies who are rolling could be strong enough to roll onto their bellies.  With their arms swaddled, they are at risk for suffocation.  Once your baby is in that “I’m gonna practice this rolling thing all day” stage, swaddling becomes more of a risk than a solution.

There are swaddle garments that convert to safer solutions for this stage.  The garments that still give firm pressure over the chest but leave legs and arms free are specifically designed to keep that nice calm feeling going.  They allow your child to roll freely.  Dr. Karp also suggests that swaddling in an infant swing is another safe choice for those babies that are experimenting with rolling but still need swaddling to pull it all together.  REMEMBER:  your baby needs to be put into the swing calm, and securely strapped in.  If she is too big for the swing, then don’t use it.  Just because it is calming for her is not a reason to use a too-small swaddling blanket or a tiny infant swing.

Pacifiers are recommended by both Dr. Karp and the American Academy of Pediatrics, but some babies don’t love them, and some parents are afraid of creating a paci addict.  For those nervous parents, I wrote a special post: Prevent Pacifier Addiction With A Focus on Building Self-Calming Without Plastic.  The truth is that sucking is a normal developmentally-appropriate self-calming behavior, and addiction really doesn’t become an issue until your child has nothing else that works at all.

Between 3-6 months, your little one is still benefitting from sucking, and she can learn to use a paci in daycare.  She isn’t at risk of nipple confusion, unlike a 2 week-old, and she won’t reject your breast because of paci use.  Nursing is the total package of love, warmth and nutrition.  If she says “no more” to nursing, it is likely that she would have done so without the paci.  Some babies are just ready to be done early.  Use Dr. Karp’s paci learning technique to teach a baby how to handle a paci and keep it in her mouth.  By 3 months, she has strong oral muscles, so it is a matter of practice and helping her to realize how handy pacis can be to calm a bit for sleep.  If she spits it out while asleep….well, mission accomplished!

White noise is the one HBOTB strategy that never needs to end.  But for these little guys, the new noises of daycare are so different from home that this may be the secret weapon.  Dr. Karp sells his carefully designed white noise CD.  It can be loaded onto a phone as well from iTunes. Select the track that matches your child’s state (crying, drowsy  and calm, etc.) and watch the magic begin.  Encourage your daycare to use this totally safe method of soothing.

Rocking a baby in your arms can replace the infant swing, and some older newborns still calm down when held on their sides or stomach.  Again, this is never a sleep position, just a calming position.  But if it works for your baby, feel free to use it when you hold her.

Once you have created an updated HBOTB routine that works, share it with the daycare staff.  You may find that they have rules and regulations, and some staff aren’t open to new ideas.  My suggestion is to emphasize how easily you can get her calm.  Even the most rigid care provider’s ears perk up when she thinks that there is a way to make her job easier.  These people work long hours and work hard.  Think of this as helping her and your little one have a better day!

Low Tone In The Summer: Why The Heat Affects Your Child’s Safety

If you have a child with low muscle tone, you may have seen them wilt like flowers in the sun.  Even if they are well-hydrated, even if they are having fun, they just can’t run as fast or sit as steadily when they are warm.  Add a SPIO vest or other compression garment, and the tripping and falling seems to happen more often.  What gives?

Just like a warm bath relaxes your tight shoulders after a long day, heat relaxes muscles.  It doesn’t matter if the heat is environmental or neutral warmth, the kind that is generated by your child’s own body and is held in by the SPIO or her clothes.  It is still heat.  And some kids with low tone don’t sweat efficiently, using the body’s natural method of heat reduction.  This isn’t a minor concern if you have a child that is pretty unsteady on a cool day.  Kids with low tone that are out and about in the heat can become so floppy that they stumble and get injured.  That is a problem.

What can you do?  Well, you may not be able to wear that SPIO in the heat.  Try kineseotaping instead.  (ask your OT or PT if they have been trained in it’s use).  Alternate time in air conditioning and time outside.  Offer cold drinks and ice pops if they can lick and swallow an ice pop safely.  Dress lightly and choose clothes with fabrics that evaporate body heat.  Choose shoes that offer more support, not Crocs or sandals.  This is not the time to pick the least-supportive footwear.

Most importantly, monitor them for safety and be aware that children really cannot judge whether or not they should come in and cool off.  They are counting on you to keep them safe!