Category Archives: hand coordination

Why Joint Protection Solutions for Hypermobility Aren’t Your Granny’s Joint Protection Strategies

I spent almost 10 years working in adult rehab before I transitioned to pediatrics.  I still teach joint protection, but I teach it differently to kids and their parents.  Kids rarely have JRA or joint damage in general.  What they have in spades are serious degrees of hypermobility.  And the methods to use joint protection strategies so that tissue damage is minimized are different:

Joint protection strategies for hypermobility need to be adapted from those for other disorders, in order to obtain the best results and put clients at low risk of accidental injury.

What’s So Different?

  • Hypermobility can create a different type of joint strain than OA or other joint damage, and different types of soft tissue damage.  Understanding the way placing force on hypermobile joints can damage them is essential to understanding how to guide clients correctly.
  • Excess mobility reduces sensory feedback even when pain isn’t a factor, and can create different types of pain that aren’t as common as in RA, OA, or other joint deformities.  It can also diminish the protective function of pain.  Hypermobile people are often not in enough discomfort when they are overextending their joints.  The next day they find out that they overdid it.  Too late!  This isn’t just about the knees and ankles, guys.  I laugh a little bit , and then groan a lot, when I see articles on proprioceptive loss in hypermobility that focus on only lower extremities.  There are a whole bunch of joints above the waist, guys, and hypermobility affects each and every one of them as well.  Just because you aren’t using them to walk doesn’t mean you don’t need proprioception to use them…..!  I wonder who thinks this is just a lower extremity issue?
  • Hypermobility appears to cause dyspraxia that can “disappear” after a few repetitions, only to reappear after a while or with a new activity.  How can that be?  It can’t.  Praxis doesn’t work like that.  What you are seeing is a lack of sensory feedback that improves with repetition, only to be replaced with a lack of skilled movement from fatigue, or from overuse of force, or pain.  This is really poorly understood by patients, and even by some therapists, but makes perfect sense when fully explored.
  • Hypermobility is seen in a wide range of clients, including younger, more active people who are trying to accomplish skills that are less common in the over-60’s set that we see for OA.  Different goals lead to different needs for joint protection strategies and solutions.
  • Joint damage isn’t evident until long after ligament damage has been done.  People with hypermobility at every age need to protect ligaments, not just joint surfaces.  This isn’t always explained.
  • Their “normal” was never all that normal.  Folks with RA and OA often have years, even decades, of pain-free life to draw on for motor control.  Hypermobility that has been with a person for their entire life deprives them of any memory of what safe, pain-free movement, should feel like.  They are moving “blind” to a degree.  Incorporate this fact into your treatment.
  • So many people are hypermobile in multiple joints that the simple old saws  like “lift with your legs, not your back”  won’t cut it.  Whatever you learned in your CEU course on arthritis won’t be exactly right. Think out of the box.
  • The reasons for hypermobility have to be accounted for.  Genetic disorders like PWS, Down syndrome, and Heritable Disorders of connective Tissue (HDCTs) bring with them other issues like poor skin integrity and autonomic nervous system dysfunction.  Always learn about these before you provide guidance, or you risk harm.  We therapists are in the “do no harm” business, remember?

This fall I may start writing a workbook on addressing the use of joint protection, energy conservation, pacing and task adaptation for hypermobility.  There is certainly nothing out there currently that is useful for either therapists or patients.  If you want or need this book, send me a comment and let me know!!

in the meantime, please read Need a Desk Chair for Your Hypermobile School-Age Child? Check out the Giantex Chair , Hypermobility and Music Lessons: How to Reduce the Pain of Playing and Why Injuries to Hypermobile Joints Hurt Twice

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Better…unless that shoulder and elbow are as hypermobile as that wrist and those MCPs!

Teach Kids How to Cut With Scissors…The Easy Way

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terrific safe scissors for little hands!

As a pediatric occupational therapist, scissor use is something I assess but also something I teach.  And I teach it early.  I also teach safety early, and teach it with a focus on early success.

What makes it easier to teach children to cut with scissors?

  1. Good timing.  Typically-developing children have the visual-motor skills to start snipping with scissors at 24 months.  YUP; that early.  What they don’t have is safety awareness and the ability to select what they should be using.  To teach scissor skills this early, you have to know about fine motor development, child behavior, learning skills, and have access to the right tools.  If a child is unable to attend to your demonstration, unwilling to tolerate assistance of any kind, or unable to use both hands at midline, then 24 months of age is too soon.
  2. Good tools.  My long-time readers know that I use only one type of scissor until a child is 4 or 5:  Lakeshore Scissors for Toddlers That Only Cut the Paper, Not the Toddler  Nothing derails training like needing a bandage!  In addition to the right scissors, beginning to cut is helped when the paper is a bit stiff.  The cheap printer paper most teachers and even therapists use to make copies of cutting sheets is difficult to cut.  We don’t experience it as difficult, because adults have better graded grasp.  We can control the scissor more easily as well.  Young children do much better with card stock or at least high-quality printer paper.  Try getting the administration to pay for it, though.  But if you want success, use the right tools.  My private clients learn using the Kumon “LET’s Cut Paper” series of books, or “Paper Playtime”.  Read more about these excellent books here: Kumon Learn to Cut Books: Paper Truly Worth Snipping Up   . 
  3. Good demonstration.  Some children watch every move you make.  Others are completely oblivious.  Most are somewhere in the middle.  But learning to cut isn’t intuitive.  Not any more intuitive than changing the air filter in your car is.  Could you learn to do it?  Sure, but it would really help if you could watch someone before you tried it.  I make sure that a child is able to observe me, and being that close to a scissor is another reason to use Lakeshore’s brand of safety scissor.  If a child grabs my hand or my scissor, I might not be happy about it, but the will not be injured.  If they ONLY watch me the first or second time I use a scissor in front of a child, that is just fine.  Some kids are risk-averse, and pushing them to try isn’t smart.  The next time I bring the scissors out, they may be more eager to try to use them, and they will have some information stored away about how they work.
  4. Good experiences.  Learning should be fun.  Play should be fun.  Learning to use scissors should be play, not work.  Make it fun.  I will demonstrate cutting on a page that results in something fun to play with.  The “Let’s Cut Paper” books make some cut things.  Another thing that is fun is cutting pieces of paper that fall to the table.  I am doing telehealth during the pandemic, so I am teaching parents to cut 1/2-inch strips of paper and have kids cut across the paper.  They joy in a child’s face when they snip across the strip is wonderful.  It isn’t the same as snipping on the side of the page.  You need to make it fun, or it isn’t going to work.

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Try “Rainbow Tracing” to Build Pre-Writing Skills With Creativity

delfi-de-la-rua-zolFYH_ygpw-unsplashI am not a huge fan of teaching preschool children to trace strokes.  I am very interested in the use of simple drawing to build pencil control and other pre-writing skills.  But done right, tracing can be fun and useful for both the child and the adult.  Here is one way to use tracing effectively:  Rainbow Tracing.

What is it?  The child traces the same target stroke with at least 3 different colors before moving onto the next stroke.   If needed, the adult can initiate/demonstrate first, and the child can repeat with additional colors.  It isn’t necessary for the child to be incredibly accurate, but they do have to start at the correct spot and attempt to end their stroke at the correct spot.

The target tracing line has to be sufficiently wide and simple enough to allow for reasonable expectation of success.  An example would be that a three year-old is asked to trace a curved line, not a series of diagonals.  The developmental progression assumes that most threes aren’t ready to execute diagonal lines independently.

Why is Rainbow Tracing helpful?  By repeating a traced line, a child receives more practice for stroke control and grasp.  It is colorful, and the colors are the child’s choice.  This allows some creativity and agency in an activity that might otherwise be boring and produce very little motivation in a child.

What about a child who traces over their errors?  If a child’s initial stroke is wildly off the target, they are more likely to re-trace their error.  If the adult knows that this is going to be an issue for this child, they can offer another copy of the same sheet, or the adult can be the first “tracer”.  They could also offer an easier and wider stroke to trace.

What do you do with the results?  Celebrate it, of course!  Kids love to put their drawings in an envelope and mail them.  Scanning them isn’t as exciting to a young child.  They like doing things “old school”.  So do a lot of grandparents and great-grandparents!

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Should You Use Pre-Mixed Dough to Bake With Your Toddler?

food-photographer-jennifer-pallian-OfdDiqx8Cz8-unsplashOK; this is a trick question.

Using prepared dough is one of the easiest ways to introduce very young children (or special needs kids of any age that are functioning at the 18-36 month level) to food preparation.  With the right mindset, it is the beginning of a wonderful way to share practical skills, build sensory and motor skills, and enjoy the company of very young cooks.

The greatest objections to using prepared dough, whether pre-cut or just pre-mixed, are that these are high-carb/low nutrition foods, and that they include preservatives.  Both of these statements are true.  They are also true of most of the food I see served to young children and consumed by parents.  I can count on one hand the number of families I have worked with in 25 years that do not consume any foods containing either preservatives or sugar.

Most families limit their consumption of both, and that makes a lot of sense.  Nobody is going to make cookies of any kind every day of the week, and maybe not even every month.  These are treats.  The dough can be purchased, already made with very wholesome ingredients, in specialty stores.  Adults can also make their dough from scratch well before including the child, as you would do with “refrigerator cookies” and pre-slice it, so that a child only has to place circles of dough on a cookie sheet to bake them off.

The greatest benefit of using pre-made dough is the ability to have only a few steps in the entire process of baking, so that a child is introduced to the experience of making food in an easy and positive manner.  Beginning with many ingredients and many steps that only the adult can perform is a sure-fire way to create a huge mess and create a negative experience for both the child AND the adult.  Young children have no sense that food is prepared.  They aren’t often witness to any preparation or cleaning.  This is a wonderful way to introduce them to the process.  Of course, no child can be involved with the use of an oven or touching hot pans.  That is OK; we want children to build their patience and attention!

Most kids are quickly ready to progress to using pre-mixed dry ingredients and blending them with wet ingredients, and then helping to measure and mix all ingredients.  The use of pre-made dough is simply a first step in a long process of involving kids in the kitchen!

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The Preschool Water Arcade Game You Need This Summer If Camp is Cancelled (and maybe even if it isn’t)

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I cannot BELIEVE how much fun this Step 2 Waterpark Arcade toy could be!  You hook it up to your outdoor garden hose and play.  As an occupational therapist, I want all of my older toddler and all my preschool clients to get one of these arcade games to work on visual-motor coordination and hand strength.

What kid isn’t right for this toy?

  • This isn’t a toy for a child that cannot resist the impulse to spray others, as the water flow could be pretty strong.   Almost every child is going to have some experimentation with controlling the hose.  That isn’t the same as intentionally nailing their baby brother in the face.
  • Nor is it a good choice for a child that is really unsteady on their feet.  It won’t be easy to handle a hose while sitting down, and too much failure is really hard on kids that are already stressed because of missing camp.
  • They have to have enough hand strength, even with two hands together, as shown, to squeeze the trigger while aiming.  Older kids can stand farther back from the toy and use one hand.
  • Kids with significant problems with strabismus may not be able to aim from a distance.  Strabismus will force them to use one eye to avoid “seeing double” at a distance.  Again, failure isn’t fun.  Weakening one eye isn’t a great idea either.  If this motivates a child to wear their special glasses or eye patch, on the other hand, it could help you get some compliance.

Can You Incorporate This Toy Into Fine Motor or Handwriting Practice?  SURE!!!!

  1. Parents can come up with a score sheet on the sidewalk with chalk, on a white board with a marker, or use a bucket with pebbles.  Every time a child hits the mark, they get a point.
  2. They can write a hash mark or erase the previous score and write the new one, which is great for preschoolers and kindergarteners to practice writing numbers over the summer.
  3. Of course, they have to write their names and their opponent’s name as well.
  4. Counting the pebbles without writing them could be great practice for younger kids.

Looking for more outdoor fun this summer?  Read Doing Preschool Camp at Home This Summer? This is the Water Table You Want!  Worried about rainy day fun?  Read Doing OT Telehealth? Start Cooking (And Baking)!

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Doing OT Telehealth? Start Cooking (And Baking)!

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Parents are looking for ways to survive the lockdown without daycare and preschool.  Even the easiest child is starting to chafe under the oppression of the COVID quarantine.  As an OT, it is my job to help parents support growth and development, but I don’t have to make it feel like work.

Enter cooking and baking as OT activities!

The simplest recipe I know has two ingredients and cannot be ruined unless you step on it:  Chocolate rolls.

You need:

  • Baking sheet, preferably non-stick or lined with parchment paper.  This dough is sticky, and the melted chips are a pain to clean off a surface.
  • Work surface: possibly another baking sheet, non-stick foil, or parchment paper.  
  • One container of crescent rolls (8 to a package, usually) Keep it cold until you are going to use it.  When it gets warm it gets very goey.  Kids either love it and mash it about, or won’t touch it.
  • 1 to 1 1/2 cups chocolate chips, separated into two small bowls.  You will need only about 1 cup, but have extra since kids will taste a few.  Or a lot.  A mom only had a chocolate bar, and she broke it up into small pieces.  I think she needed to smash something that day!   COVID has made us adaptable….

DIRECTIONS:

Preheat the oven to 350 degrees F.

Unroll two triangles of dough, one for the adult, and one for the child.

Demonstrate how to gently push the chips into the dough, then roll up, starting at the wider end.  Assist your child to imitate you. Don’t over-fill with chips.   If it becomes a squishy mess when they roll it up, don’t panic.  This will bake off just fine.  I promise.

Repeat with all dough triangles.

Place both rolls on the baking sheet, and once filled, place the baking sheet on the center rack of the oven.

Bake for about 8-12 minutes or just until the bottom of the rolls turns light golden brown.  You will have to check them after 8 minutes, as they bake quickly.  They keep baking a bit after you take them out of the oven, and if you overbake, you will have 8 chocolate hockey pucks.

Cool and enjoy!

NOTES:

I ALWAYS make a recipe by myself first before baking with kids.  Why?  Two reasons:

  1. I need to know what can go wrong and how my oven responds.  Every minute counts in baking.  Kids take failure personally, so I want to make mistakes and fix them before I ask a child to try a recipe out.
  2. You have a finished product to show them.  Young children cannot look at dough and chips and imagine what it will be like when it is done.  Showing them the actual, real, tasty end product makes it understandable to them.

Is your child likely to snack on the supplies?  Use an “eating bowl”.  I often tell parents to assemble a small amount of chocolate chips in a separate bowl and designate this as an “eating bowl”.  Rather than criticize a child’s desire to sample, they can eat from this bowl without altering the amount needed for the recipe.  Even Julia Child liked to snack on her supplies!!

If you want to get fancy, you can place a few raspberries at the wide end of the dough.   Toddlers and preschoolers aren’t gourmets, and they can reject things that aren’t simple, so don’t insist that they copy you.  But this is a way to expand a child’s awareness of food variety as well as make your chocolate roll tastier.

 

 

 

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Child Struggling With Pencil Grasp During COVID-19? Flip Crayons Restore Skills

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All of my kindergarten clients and some of my preschool clients are using them.  None of them are backtracking into a fisted grasp with pre-writing or early handwriting.  Flip crayons from Learning Without Tears (formerly Handwriting Without Tears) are one of those simple grasp development strategies that keep on giving.

Why?  Their design does all the work for me.  Well, almost all the work.

Flip crayons have the same diameter of a standard school crayon, not a toddler crayon, or those ridiculous and useless egg/fingertip crayons Egg Crayons or Fingertip Crayons: When Good Marketing Slows Down Fine Motor Skill Development  .  They are shorter, so they do not allow a fisted grasp or even a palmer pronate grasp.  The crayon demands finer grasp, not the adult.

Selling an item to a child is important. They have to want to try these out.   I “sell” them as kindergarten crayons.  Every preschooler wants access to something they think is for older kids.  Their unique appearance is almost always appealing to kids.  I have met very few rigid kids, even with ASD, that are unwilling to give them a try.  Within a month of regular use, I see huge improvements in grasp without manhandling a child, begging them to “fix your fingers”,  or any of the other methods to address grasp issues.

COVID-19 is dragging us all down.  Why work harder than you have to?  I need children’s parents to see me as a problem solver, not someone asking them to work harder.  Flip crayons are an easy answer to a challenging problem.  I have another huge box of them sitting in my office to drop off as “gift baggies” at the end of the month!

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Want Your Child to Show Hand Preference (Righty/Lefty?) Where You Place Their Spoon Matters

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I get a lot of questions about this issue, based on my experience as a pediatric OTR.  Starting at 12 months, some children show a strong hand preference and never look back.  Other kids are switching hand use long after 4.  Without the existence of disorders that directly affect hand dominance such as orthopedic disorders, cerebral palsy, or untreated torticollis, hand dominance is hard-wired and emerges naturally.  But there are situations in which it is delayed or incomplete long after the typical window of skill development.

Here is what can be happening, and here is what you can do as a parent or a therapist:

Hand dominance only emerges with the development of refined hand control and the child’s awareness that they need more skilled control for an activity.  I tell parents that I can pick up my coffee cup with either hand to drink, but that doesn’t make me a lefty.  If you paid me $100, I probably couldn’t thread a needle with my left hand.

Children that aren’t practicing refined skills like feeding or assembling blocks, or even intent on picking up every darn piece of lint on the carpet…they don’t need refined grasp, and they probably will not demonstrate hand dominance on time.  Kids that are scribbling wildly but haven’t tried to draw a circle with closure ( a 36-month skill, BTW) also have no need to develop dominance.  The self-starter, the baby and toddler that watches you intently and decides to learn all these skills?  They won’t need much help.  But the child who avoids challenge or gets help because it is easier and faster for an adult to feed them or help them build a tower?  They may lag behind in hand development.

Some kids are very tuned into adult actions, and copy the hand that a parent or teacher uses.  These are the children that are great mimics.  They can see that you are using your right hand, and even if they naturally grab with their left hand, they transfer objects into the same hand you are using.  Adults are naturally inclined to assume dominance as well.  I cannot count the number of times I absent-mindedly handed a pen to a left-handed parent into their right hand.  If you do that to a child under 5 , they assume that you want them to use that hand, and will struggle on.  This is where spoon placement matters.  I encourage parents to place the utensil in the center of the placement or tray, and watch which hand (both of the child’s hands must be free) their child chooses over many trials.

If a child is inconsistent but clearly uses their left hand more often, placing their spoon on that side of the tray should boost use, and with skilled use comes more skill and awareness.  I never pull objects out of a child’s hand.  I don’t need to.  They will drop their crayon or spoon frequently enough for me to have another chance to offer it back to them.

What if I (or a parent) picked wrong?

Dominance isn’t that easy to alter.  Ask your grandmother what the nuns in Catholic school did to alter dominance in lefties (it was considered “the devil’s hand”, and what they did wasn’t pretty).  Children will eventually simply transfer their spoon over to the other hand.

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How Therapeutic Listening Enhances Motor Skills

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My readers know that I am a huge fan of Quickshifts in treatment.  I have had some amazing successes with Quickshifts for regulation and modulation.  Their focus on combining binaural beat technology with instrumentation, rhythm, melody and tone makes these albums effective, and it eliminates the challenges of modulated music for very young or fragile kids.  But many parents (and a few therapists!) think that if a child doesn’t have severe sensory processing issues, then therapeutic listening isn’t going to be helpful.

That indicates that they don’t understand the principles and the rationale for the use of therapeutic listening.

Since every movement pattern has rhythm and sequence, it is completely logical that enhancing brain function with an emphasis on a calm-alert state with music will affect movement quality.  (This includes speech.  Speech is a highly skilled series of very small movements in a precise sequence! )

I am currently treating a toddler who experienced encephalopathy in infancy.  A virus affected the functioning of his brain.  The residual low muscle tone and praxis issues are directly improved by using Gravitational Grape in sessions.  He is safer and shows more postural activation while listening.  Endurance while standing and walking is significantly improved.

Another client with low tone has Prader-Willi syndrome.  Her movements are so much more sequenced with the Bilateral Control album.  Her ability to shift her weight while moving is significantly better during and immediately after listening.

All of us are more skilled when we are in the calm-alert (alpha brainwave) state that Qucikshifts entrain.  For people without motor or sensory issues, alpha states can help us think clearly and organize our thought and movement for higher level performance.  For children with movement control issues, it can improve their safety and stability.  They move with greater ease.  Therapy sessions are more productive, and play or school functioning is less work.

Due to COVID-19, I have been forced to do telehealth and use therapeutic listening with more children, rather than rely on equipment or complex sensory processing activities.  The silver lining is that parents are more involved in my sessions and can see what benefits this treatment is having on their children.   When social distancing retreats, I hope that therapeutic listening will be seen for the powerful treatment it most definitely can be!

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Egg Crayons And Fingertip Crayons: When Good Marketing SLOWS DOWN Fine Motor Skill Development

 

411VIzKWneL._AC_SL800_.jpgNow 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.

Why?

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.

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Think Using Dot Markers Is “Therapy” for Kids in Preschool? Think Again!

 

S495361_2I 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 for anything?

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.

Read Using A Vertical Easel in Preschool? WHERE You Draw on it Matters! and Deluxe Water Wow Pads Offer More Challenge And More Fun To Preschoolers and Kindergarteners for more good ideas on fun at home that builds pre-writing skills.

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Hypermobility and Music Lessons: How to Reduce the Pain of Playing

 

kelly-sikkema-jrFNMM6K0VI-unsplash.jpgMost kids want to learn how to play an instrument in grade school.  Most parents encourage some form of musical training for the benefits of musical training: social, coordination, attention and focus, even the suggested connection between math skills and musical ability.  Hypermobile kids can struggle with the physical demands of playing an instrument sooner and more severely than a typically developing child.

There are ways to make it easier and less painful, right from the start.

  • Steer them into the right instrument for their physical abilities.  Heavy instruments are a questionable choice for kids that have back and shoulder issues, as they will be moving their instrument around a lot.  Children with very hypermobile wrists could find the hand positions for violin or guitar much more challenging than the positions for piano or clarinet.  There will still be a lot of fingering, but it occurs in a different plane of movement.  Read Joint Protection And Hypermobility: Investing in Your Child’s Future for some details.
  • Understand that as hypermobility changes, so may the type of instrument that best fits your child.  This is a tough thing for kids to accept, but if they are experiencing repeated strains and injuries, or an increasing amount of pain, they may have to switch to an instrument that is less risky.  Remember:  hypermobility syndromes don’t disappear, and most hypermobile children will not become professional musicians.  This isn’t life-or-death, no matter what they say about their passion.  Injuries that affect the ability to attend school and eventually affect working…THAT is something to avoid.  Cumulative trauma can result in surgeries or even ending up needing disability payments.  Don’t contribute to a less-bright future by permitting a child with recurrent overuse injuries to continue to injure their body in the present.
  • Positioning matters.  Just as with sitting at a desk or a table, hypermobile kids need to use the best possible postural control with the least amount of effort.  Children playing the piano may need a chair with low back support rather than a piano bench.  Seats for all kids may need to have cushions that give more support, and any seat should definitely provide solid foot placement on the floor at all times.  Some kids may need the support of a brace or braces.  Back, shoulder, wrist, and even finger splints aren’t slowing them down; they are supporting performance.  The biggest problem will be resistance from the musician.  Children rarely want to wear these devices, and if they aren’t well designed and fitted, you will hear about it.  Ask their OT or PT for direct assistance or find one that can do a consultation.  Ask their instructor to explain why wearing a well-chosen brace makes playing easier and better.  And don’t wait until an injury happens.  Get in front of this one.
  • Musical skills require practice, but hypermobile kids may need to break up their practice or do targeted practice to shorten the total amount of time spent and reduce the physical strain.  Targeted practice requires that their instructor knows which types of practice are the most likely to build skills, rather than just adding minutes to a practice session.  Breaks are important, and most kids don’t have the ability to know when and how to take them.  They need to be taught, and the little ones need to be supervised on breaks.

 

Looking for more information on raising a child with hypermobility?

My latest e-book, The JointSmart Child:  Living and Thriving With Hypermobility  Volume Two:  The School Years is now available on Amazon as a read-only download and on Your Therapy Source as a clickable and printable download!  It has practical information about improving independence and safety for kids 6-12, including sports and the hypermobile child, improving communication with your child’s teachers and coaches, and how to address handwriting and keyboarding problems.  It has more forms and checklists than the first book (Volume One: The Early Years), but still covers all the important self-care issues like toileting and how to make your home safer for your child while keeping it comfortable and attractive.

 

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Hypermobility Or Low Tone? Three Solutions to Mealtime Problems

 

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Many young hypermobile kids, with and without low muscle tone, struggle at mealtimes. Even after they have received skilled feeding therapy and can chew and swallow safely, they may continue to slide off their chair, spill food on the table (and on their body!) and refuse to use utensils.

It doesn’t have to be such a challenge.  In my new e-book coming out this year, I will address mealtime struggles.  But before the book is out there, I want to share three general solutions that can make self-feeding a lot easier for everyone:

  1. Teach self-feeding skills early and with optimism.  Even the youngest child can be taught that their hands must be near the bottle or cup, even when an adult is doing most of the work of holding it.  Allowing your infant to look around, play with your hair, etc. is telling them “This isn’t something you need to pay attention to.  This is my job, not yours.”  If your child has developmental delays for any reason, then I can assure you that they need to be more involved, not less.  It is going to take more effort for them to learn feeding skills, and they need your help to become interested and involved.  Right now.  That doesn’t mean you expect too much from them.  It means that you expect them to be part of the experience.  With a lot of positivity and good training from your OT or SLP, you will feel confident that you are asking for the right amount of involvement. Read Teach Spoon Grip By Making It Fun And Sharing a Laugh With Your Child and Teach Utensil Grasp and Control…Without the Food! for some good strategies to get things going.
  2. Use excellent positioning.  Your child needs a balance of stability and mobility.  Too much restriction means not enough movement for reach and grasp.  Too much movement would be like eating a steak while sitting in the back seat of your car doing 90 mph.  This may mean that they need a special booster seat, but more likely it means that they need to be sitting better in whatever seat they are in.  Read Kids With Low Muscle Tone Can Sit For Dinner: A Multi-Course Strategy for more ideas on this subject.  Chairs with footplates are a big fave with therapists, but only if a child has enough stability to sit in one without sliding about and can actively use their lower legs and hips for stabilization.  Again, ask your therapist so that you know that you have the right seat for the right stage of development.
  3. Use good tableware and utensils.  If your child is well trained and well supported, but their plates are sliding and their cups and utensils slide out of their hands, you still have a problem.  Picking out the best table tools is important and can be easier than you think.  Items that increase surface texture and fill the child’s grasping hand well are easiest to hold.  Read The Not-So-Secret Solution for Your Child With Motor And Sensory Issues: Dycem and OXO for Kids: Great Tableware For Older Kids With Sensory and Motor Issues for some good sources.  Getting branded tableware can be appealing to young children, and even picking out their favorite color will improve their cooperation.  Finally, using these tools for food preparation can be very motivating.  Children over 18 months of age can get excited about tearing lettuce leaves and pouring cereal from a small plastic pitcher.  Be creative and have fun!

 

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Does Your Older Child Hate Writing? Try HWT’s Double-Lined Paper

 

This paper has been more useful to older kids (6+) that I see for handwriting help than any other paper on the market, and almost any other tool Problems With Handwriting? You Need The Best Eraser , Great Mechanical Pencils Can Improve Your Child’s Handwriting Skills .  Why?  Regular lined paper, and almost all worksheets, are usually jam-packed with lines.  Red lines, green lines, lines with airplanes and worms.  There are papers designed by occupational therapists that are even more complex than the mass-market choices.

All this is often visual noise to kids with sensory processing issues and ocular or visual-perceptual issues.  These problems are sometimes subtle and appear to be behavioral.  The kids who “hate to write”.  The kids who look away when you are demonstrating how to write a letter or spell a word.  The kids who cannot seem to remember where to start a letter, even after repeated practice.  These children often do much better with HWT’s double-lined paper.

Let’s drill down into the design of this unique paper:

  • Double-lined paper provides just two lines; the baseline and the midline.  Knowing where to start uppercase letters and tall lowercase letters is important, and this paper encourages practice and awareness while still giving some structure to writing.
  • There is a wide empty space between sets of lines.  This is intentional; children have room to place the tails of lowercase “y” and “j”, for example, without blocking the uppercase or tall lowercase letters of the next line of writing.  For many kids, not knowing what to do about crowding and spacing is a good reason to stop trying to write well, or sometimes even write at all.
  • This sturdy paper is pre-punched to be used in a 3-ring binder.  The quality of the paper is very high, which means that it doesn’t tear easily when a child erases a mistake.  Most schools provide the thinnest paper for teachers to use as handouts, creating the potential for a disaster when given to a child that struggles with grading their force on an eraser, or makes multiple errors in a word.
  • Brains get practice in sizing and proportion.  Once kids have a pattern of letter formation, it is easier to accomplish without the extra midline.  But so many kids need that “training wheel” effect much longer than scrolls recognize.  Many kids need a day or two of double-lined paper use to start understanding the way a letter “h” is twice as tall as a letter “a” and the same size but aligned differently than the letter “y”.  Of course, pointing it out is important, and so is working on other writing qualities such as letter and word spacing.
  • Kids write faster.  Because they are guided to proportion and start letters correctly, they don’t waste time thinking about it or erasing incorrect letters.  Again, this doesn’t mean their brain isn’t taking it all in.  If that were true, we would start every kid on single-lined paper in preschool.
  • There are three line sizes, so you don’t have to abandon the double-lines when your kid enter middle school.  I will admit that I wish the pre-k/K paper were thicker.  But it is still fairly sturdy.
  • You can alternate using this paper with single-lined paper to see when to “take the training wheels off” and stop using double-lined paper.  Kids should always have a chance to practice with standard paper, but when the choice is between fighting and crying, and quickly executing a homework assignment, it is no contest.

 

The best paper wins.

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Need to Support A Child’s Independence? Offer to Help Them!

 

irina-blok-192240-unsplashI know; it sounds like I am being sarcastic.  That couldn’t be farther from the truth.  Instead of telling children to “Give it another try” or “I know you can do it”, offering help to a young child can have the paradoxical effect of eliciting more perseverance and attention.

It really isn’t all that complicated:  think of your own responses for a moment.  If you were trying to fill out your tax forms, and ran into difficulties, you might call an accountant for help.  If their response was “Just keep trying; I know you can figure it out!” you probably wouldn’t be excited to try again.  You might feel even more agitated.  I know what I would be thinking:”If I knew what to do, I wouldn’t have called you int he first place!”

If your accountant said “Let me take a look.  Oh, I underlined some of the important numbers.  You got stuck with line 32b, right?” you could see the issue in a new light, and be able to come to a solution without having to walk away or tear up the form.  Your accountant used their advanced knowledge to set you up for success.

We need to do the same thing for children.  Telling them we have faith in them, or insisting that they need to try again when they clearly don’t know how to alter their actions, is not kind or even very educational.  It leaves them feeling abandoned under stress.  Even if we know they can solve for X, they aren’t doing it now.

For the very youngest kids, I have a special solution.  You “wiggle it”.  Young children don’t know how we understand how to do so many things well.  When they get stuck opening containers or assembling objects, I offer to “wiggle it”.  By demonstrating that the container does indeed open, or that the bead will fit on the string, I am assuring them that they could be successful.  More importantly, I am demonstrating the correct grasp pattern and stabilization method.  And finally, I am rebooting their motor plan and their frustration level.  Just handing the object over to me reduces their agitation.  When children aren’t so frustrated, they can think and create better motor patterns.’

All this from a little “wiggling”.

To read more about building confidence and coordination, read For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance and Why Telling Your Child “It’s OK” Doesn’t Calm Him Down (And What To Do Instead)

When Writing Hurts: The Hypermobile Hand

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Many children resist doing their homework, but most kids say “Its so BORING!” not “My hand hurts too much”.  If a child is complaining of pain, and they don’t have a joint disease such as JRA, the first thought is hypermobility.  The good news is that there are a few fast fixes that can decrease or even eliminate hand pain.

It is rare that hypermobility in the hand is directly addressed at the preschool level unless it is generalized throughout the body or severely reduces pencil grasp.  Many children have atypical grasp patterns when they cannot achieve the required stability for a standard pencil grasp.  Children with mild instability and no other developmental issues may still be able to write legibly and even fast enough to complete assignments in the early grades.  It is when the volume of work increases or the joint stability decreases that therapists get a request for service.

Here are a few strategies that can support hypermobile kids to write with less pain:

  1. Use a tabletop easel.  These can be foldable or static.  They support not just the wrist and forearm, but also the shoulder and trunk.  The angle of an easel both supports correct wrist positioning and decreases strain on the wrist and hand.  Some easels come with clips that hold the paper, but they should be placed on an angle to mirror the natural arm position.  This will require more table space, so be aware that the size of the easel could be an issue.  Simple hack:  use a three-ring binder as an easel.
  2. Enlarge the width of the pencil shaft.  My favorite pencils for grades 1+ (see photo above) have a standard #2 lead, but a wider shaft. Joint protection principles tell us that avoiding a closed joint position should lead to less strain on joints and supporting ligament structures.  You could use some of the adaptive pens available, but I find kids reject these as looking strange.  Of course, if you enlarge the shaft oo much you will find that it is more awkward, not less.  Think of those novelty pencils you buy in gift stores on vacation.  Cute but useless.  Nobody really writes with anything that thick.  Match the child’s hand size to the pencil.
  3. Increase the texture of the pencil shaft for easier grip, less pain, and more endurance.   Everyone has seen the rubbery grips you slip onto a pencil.  You can slide 3-4 onto the entire shaft, or add some tape to create a non-slip surface.  I have been adding kineseotape or Dycem to handles this year, with good results.  You are battling grasp stability, but also fatigue.  A hand that is tired is a hand that experiences more pain.  Adding texture reduces the amount of force needed for proprioceptive registration (a fancy way of saying that kids need to squeeze to fully feel what is in their hand).  Reducing force reduces pain and fatigue.
  4. Teach pacing.  Kids think that the faster they write, the faster they will be out of pain.  Breaking up the work can have better results, but it isn’t natural for children to pace themselves.  In fact, I have never seen a young child do so.  You have to teach this to kids who likely will have joint instability throughout their school years.  A schedule, a timer, organizing assignments and breaking them down into heavy writing choices and light writing choices all help.
  5. Splinting can be a real option.  Not a heavy plastic or metal splint (usually).  A neoprene splint can be a lightweight supportive choice.  These splints are comfortable and washable.  These are affordable without insurance for most families, and your OT can help you decide if this is a worthwhile pursuit.  They are durable but easily lost by younger children, so not all families send one to school.  But the support is real, and kids that have been told for years to “fix your fingers” can feel relieved that they can now focus on writing and composing on the paper.

For more information on hypermobility, read The Hypermobile Hand: More Than A Strength Problem and For Kids With Hypermobility, “Listen To Your Body” Doesn’t Teach Them To Pace Themselves. Here’s What Really Helps.

Looking for more assistance with hypermobility?  My new e-book is coming out this summer, and it will address the issues of the early years (0-5).  The series will continue with school age kids and teens.  But you don’t have to wait; visit my website tranquil babies and request a consultation to discuss your child’s treatment plan and make a better plan that works for everyone…today!

The Not-So-Secret Solution for Your Child With Motor And Sensory Issues: Dycem

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Many different ways to use Dycem!

In adult rehab, occupational therapists are regularly providing patients who have incoordination, muscle weakness or joint instability with both skill-building activities and adaptive equipment such as Dycem.  In pediatrics, you see a predominance of skills training.  Adaptive equipment shows up primarily for the most globally and pervasively disabled children.  I think that should change. Why?  Because frustration is an impediment to learning, and adaptive equipment can be like training wheels; you can take them off as skills develop.  When kids aren’t constantly frustrated, they are excited to try harder and feel supported by adults, not aggravated.

 

What Dycem Can Do For Your Child

Dycem isn’t a new product, but you hardly ever see it suggested to kids with mild to moderate motor incoordination, low tone, sensory processing disorders, hypermobility, and dyspraxia.  We let these kids struggle as their cereal bowl spills and their crayons roll away from them.  Dycem matting is a great tool for these kids.  It is grippy on both sides, but it is easy to clean.  Place a terrific bowl or plate on it OXO for Kids: Great Tableware For Older Kids With Sensory and Motor Issues, and it won’t tip over with gentle pressure, and not even if the surface has a slight incline.  It lasts a long time, and can be cut into any shape needed for a booster seat tray or under the base of a toy like a dollhouse or a toy garage.  Placing a piece of Dycem under your child while they are sitting on a tripp trap chair or a cube chair A Simple Strategy To Improve Your Child’s Posture In A Stokke Tripp Trapp or Special Tomato ChairThe Cube Chair: Your Special Needs Toddler’s New Favorite Seat! will help them keep their pelvis stable while they eat and play.  The bright color contrasts with most objects, supporting kids with visual deficits and poor visual perceptual skills.  It catches their eye and their attention.  As you can see, Dycem has a lot to offer children and parents.

How To Use Dycem To Build Motor Skills

Will it prevent all spills or falls?  No.  But it will decrease the constant failures that cause children to give up and request your help, or cause them to refuse to continue trying.  Children are creating their self-image earlier than you realize, so helping them see themselves as competent is essential.  Will it teach kids not to use their non-dominant hand to stabilize objects?  Not if an adult uses it correctly.  Introducing Dycem at the appropriate stage in motor development and varying when and where it is used is the key.  Children need lots of different types of situations in order to develop bilateral control, and as long as they are given a wide variety of opportunities, offering them adaptive equipment during key activities isn’t going to slow them down.  It will show them that we are supporting them on their journey.  When kids are new to an activity or a skill and need repeated successes to keep trying, Dycem can help them persevere.  When children are moving to the next level of skill and see that they are struggling more, Dycem can support them until they master this new level.

Should you buy the pre-cut mats or the roll of Dycem?  It depends on your needs.  Be aware that Dycem doesn’t stay tacky forever, so the cheaper strategy is the roll.

The Cheap Hack:  Silicone Mats

I will often recommend the use of silicone baking mats instead of dycem.  These inexpensive mats often do the job at a lower cost, and can be easily replaced if lost at daycare or school.  Dycem is a specialty item that can be purchased online but not in most stores.  Silicone mats aren’t as grippy, but they are easily washed and dried.  Some families are averse to anything that looks like adaptive equipment, so I may introduce these mats first to build a parent’s confidence in my recommendations.

Looking for more information on helping your child build self-care and safety awareness?

I wrote 2 e-books for you!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone and The JointSmart Child: Living and Thriving With Hypermobility Volume One: The Early Years are unique books that both educate and empower you.

They are filled with understandable explanations for the challenges and all the confusion that comes up during ADL training.   When you aren’t provided with enough information on the motor, sensory and behavioral consequences of low tone and hypermobiilty, you can’t effectively help your child achieve the basic self-care and safety awareness skills that every child needs.  My books have checklists and forms that help you communicate with your babysitters, teachers, even your child’s doctors.

Both books are sold on Amazon.com  as read-only downloads, and on Your Therapy Source   as printable and click-able downloads.  Your Therapy Source also sells both books together as a discounted bundle, saving you money and giving you lots of information all at once!

 

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Teens With Chronic Illness Or Disability Need A Good Guide: Read “Easy For You To Say”

bagas-vg-426755Being a tween or teen isn’t easy, but having a chronic physical illness or disability (not interchangeable) can make it extremely difficult.  Kids aren’t always great at asking for help or even answering questions, so this wonderfully useful book has done the groundwork for you.

Dr. Miriam Kaufman’s book Easy For You To Say is an easy-to read format of questions and answers that is accessible for teens to read and parents of teens will learn a tremendous amount as well.  She has a significant amount of experience with this subject, and has plenty of solid medical knowledge to back up her information.

As a physician, you will find that she includes a great deal of medical information, including medication lists related to teen concerns such as acne and sexual response and functioning.  These lists, of course, are dated the minute the book is published, but the general categories of drugs that have effects that concern teens is helpful as a starting point for discussions with a pediatrician or specialist.

This book isn’t just about the medical concerns that occur with physical illness and disability.  Dr. Kaufman covers the challenges of relationships of all kinds, and practical issues with school, work, and having fun as a teenager while dealing with significant issues.  This book doesn’t mince words but is unfailingly positive.  Kids (and parents of teens) really need that positivity while trying to launch into a life of more independence.  She is a strong proponent of self-advocacy that doesn’t become militant but is always life-affirming.  There is some discussion of higher education and career planning, which is so essential Career Planning for Teens with JRA, EDS, and Other Chronic Health Issues.

This book has it’s limitations.  It doesn’t address cognitive disabilities or psychiatric disabilities like living with bipolar illnesses, nor does it speak about ASD or SPD.  These issues can co-occur in the same teen, and it is then that you might want to think about what an OT has to offer.  This author doesn’t even mention us as helpful professionals that do more than, if you can believe it, help kids look at career options.  Perhaps she missed the class on what “occupation” really references.  Oh well.

As an occupational therapist, I wish my profession had been mentioned as a greater resource for disabled teens, but perhaps I should not be that surprised that it is left out.  Most physicians aren’t aware of how OTs can meaningfully assist kids past the Early Intervention years to enhance their functioning and learn both better skills and work-arounds to accomplish what they would like to do in life.  For example, her book speaks in great detail about the complications of mobility and coordination limitations during sexual activity.  Since just about every teen is curious about this subject, an occupational therapist could help them adapt their environment, equipment and movements to make this part of ADLs a success on many fronts.  Dr. Kaufman has a lot of ideas, but the specifics for each teen are going to be different, and that is where OTs shine.

This book should be on the shelf of most pediatric physiatrists, and most OTs.  It is now on mine!  If your child is no longer a child, I recommend “Life Disrupted” by Laurie Edwards.  This book covers the situations that young adults in their 20’s really need to figure out.  Specifically, learning how to craft a career, develop relationships and become independent when you are dealing with a chronic illness.  None of it is easy, but the author is both supportive and realistic.  I think that helps more than platitudes and positivity without, as Dr. Phil might say, putting verbs in the sentences.

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Deluxe Water Wow Pads Offer More Challenge And More Fun To Preschoolers and Kindergarteners

 

91Wl4b-x3nL._SX425_.jpgMy clients and colleagues know how much I love the original Water Wow books.  They are reusable and mess-free fun for kids at home, at the doctor’s office, the restaurant and the plane ride.  These bigger books are going to be even more fun for preschool kids and kindergarteners!

Here are some great reasons why I love these books:

  • They have more pages, and more pages means they keep kids busy (and happy) longer.
  • They offer more detail and more challenge.  The graphics inspire critical thought (Is this a silly thing to find in the supermarket or not?) and the red lens that looks like a magnifying glass makes kids feel like Sherlock Holmes as they search for secret items.
  • There are mazes, hidden items and pages where kids can compare two almost-identical pictures and find the anomalies.  It is more than just wiping water on a picture.
  • Like the originals, the pages dry quickly and can be used over and over.  It seems like kids would get bored after the first run-through, but children can enjoy the “reveal” and the sensory play of water on a page for a long time after they have solved all the puzzles.  If you are at 30K feet and your kid is getting restless, this could buy you a bit of time without having to resort to screens that they will insist on for the rest of the (expensive) trip.  Genius.
  • Oh, and the pen is easy to grasp, and it develops a mature pencil grasp with repeated use.  Yeah!

I think these would be terrific holiday gifts.  If you are looking for more gift ideas, read Automoblox: For the Discriminating Preschool Gearhead and Melissa And Doug Tape Activity Book Is Reusable Fun for some other good toys that build skills while having fun!

Playing With Toy Food That Connects With Velcro Builds Children’s Hand Skills Faster!

81OGGQRPz8L._SL1500_This set is one of my favorite choices for toddlers of all ages and interests.  Why?  It is a safe, fun, clean-able toy that doesn’t require a USB connection or a battery.  That isn’t a complete oddity, but it getting more rare every year.  This toy is a great choice for kids with ASD, SPD, low muscle tone and hypermobility.  And children will play with it for years.  I like recommending toys that have the possibility of wearing out before they are thrown out.

In this age of edible pouches and pre-cut meal packages, your child might not realize that corn comes on a cob, or that there is a purple food; eggplant.  Learning about food through play is a wonderful way to introduce food preparation and an interest in healthy food choices.

Let’s unpack the benefits of this great set:

  • The theme is food; familiar and fun for most kids.  It encourages imaginative play and can be used by more than one child at a time.
  • The materials are lightweight and easy to clean.  The food toys made of wood sound so great, so holistic …until your toddler has chucked one into the flat screen TV in your family room!  Or at his sister’s head!  And for kids who lick or suck on toys, well, I don’t think most kids should be consuming paint.  I’d prefer it if kids didn’t lick toys, but lots of them do from time to time.  Plastic is a better choice for kids with a weak grasp as well.  Some children will revert to an immature or atypical grasp on a heavy object but can sustain a mature grasp on a lightweight item.
  • Different ages can enjoy this toy.  Very young toddlers simply connect and disconnect the velcro pieces.  Slightly older kids can practice color matching, and preschool kids can practice cutting with the super-safe knife in the set.  Even older kids can create elaborate pretend play.  I have had three and four year-olds preparing a pretend Shabbos meal, using a Kleenex to cover the bread.  Adorable!
  • The shapes are primarily cylinders and spheres.  Why is that good for motor development?  The arches in the hand are developed by hand use, and grasping these shapes encourages the use of the intrinsic muscles, deep in the palm of the hand.  Along with the thumb muscles and some of the hand muscles that originate in the forearm, these are the muscles needed to achieve the support necessary for skilled hand use.

A hint for use with the smallest kids;  don’t match the shapes.  Match contrasting colors and shapes so that it is easier for children to figure out where to place their fingers to assemble and separate the pieces.

A hint for kids with a weak grasp of sensory discrimination issues:  Offer them the most textured shapes.  The irregular textures will help them maintain their grasp as they pull or push.

Looking for more ideas for hand skill development?  Check out The Hypermobile Hand: More Than A Strength Problem and For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance.

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This is my favorite set: Slice-a-Riffic!  The larger size and the textured pepper and corn are easy for even the weakest grip to manipulate.