Category Archives: low tone

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

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

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

The effects of low tone and poor tissue integrity on toilet training are legion. Many of them are sensory-based, a situation that gets very little acknowledgment from pediatricians. These children simply don’t feel the pressure of their full bladder or even a full rectum with the same intensity or discomfort that other children experience. They are “camels” sometimes, with no urge to pee, and have to be reminded to void. It can be convenient for the busy child to keep playing rather than go to the bathroom, or it can save embarrassment for the shy child who prefers to wait until she returns home to “go”.

This is not a good idea. The bladder is a muscle that can be overstretched in the same manner as the hip muscles that are the concern of children who “W-sit”. Don’t overstretch muscles and then expect them to work well. The ligaments that support the bladder are subject to the same sensory-based issues that affect other ligaments in the body: once stretched, they don’t bounce back. A weak pelvic floor is nothing to ignore, and age doesn’t help anyone. Ask older women who have had a few pregnancies how that is going for them. The stretch receptors in the abdomen that should be telling a child with low tone that it is time to tinkle just don’t get enough stretch stimulation to do so when they have been extended too far. The time to prevent problems is when a child is developing toileting habits, not when problems have developed.

So….an essential part of toileting education for children is when to head to the bathroom. If your child has low muscle tone or a connective tissue disorder that creates less sensory-based information for them, the easiest solution is a routine or a schedule. They use the bathroom whether they feel they need to or not. The older ones can notice how much they are voiding, and that tells them that they really did need to “go”. Understanding that the kidneys will fill up a bladder after a large drink in about 35-45 minutes is helpful. But it can be a trip after a meal, before leaving the house, or when returning home. As long as it is routine and relatively frequent, it may not matter how a toileting schedule is created. Just make sure that as they grow up, they are told why this is important. A continent child may not believe that this could prevent accidents, but a child who has a history of accidents may be your best student.

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

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

If you are interested in purchasing my book, please visit my website, tranquil babies.com, and click on “e-book” at the top ribbon. It is filled with readiness checklists and detailed strategies for every stage of training!

Want A Stronger Pencil Grasp? Use a Tablet Stylus

The trick? They need to use a short stylus and play apps that require primarily drag-and-drop play. Stop them from only tapping that screen today, because tapping alone will not make much of a difference in strength and grading of force.

Why will drag-and-drop play work? The resistance of the stylus tip on the screen builds strength and control at the same time. They gain control as they get the immediate feedback from game play. Too much force? They get stuck and can’t move the styluses the target. Too little force? Again, the target doesn’t move. Could they revert to a fisted grasp and accomplish this? Sure, but that is exhausting, and you are within view of them anyway….right?

For this to work, young children need supervision, but not helicopter supervision. And they need to know that how they hold any utensil matters to you. My best approach to build grasp awareness is to appeal to their desire to be older. Tell your child that you have been watching them, and you believe they are ready to hold a stylus like an older kid. Oh, and you can explain to them how to hold the stylus the easy way. They just have to watch your example and play some games for practice. Yup, you ASK them to play on a tablet!

Best drag-and-drop games for young children? I like the apps from Duck Duck Moose, especially the Trucks and Park Math. Every app has some tapping, but you can select and “sell” the games that require drag-and-drop. There are apps that little girls can play to dress up princesses, mermaids, etc. Pick the ones where they have to drag the items over to the characters. Same with wheels on trucks, shapes into a box, etc. The Tiny Hands series of educational apps have a lot of drag-and-drop play.

Finally, mazes are wonderful, and so are dot-to-dots that require drag-and-drop play.

Have a really young child, or a child who struggles to keep their fingers in a mature grasp pattern without any force? Then apps that require just a tap are fine. I set the angle of my tablet at various heights (my case allows this) to prompt more wrist extension (where the back of the hand is angled a bit toward the shoulder, not down to the floor). When a child’s wrist is slightly extended, the mechanics of the hand encourage a fingertip grasp without an adult prompting them.

Try drag-and drop play with a stylus on your tablet today, and see if your child’s grasp strength starts improving right away!

Low Tone and Toilet Training: Learning to Hold It In Long Enough to Make It to The Potty

 

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If your child can’t stay dry at night after 5, or can’t make it to the potty on time, there are a number of things that could be going wrong.  I won’t list them all, but your pediatrician may send you to a pediatric urologist to evaluate whether there are any functional (kidney issues, thyroid issues, adrenal issues etc.) or structural issues ( nerve, tissue malformations).  If testing results are negative, some parents actually feel worse rather than better.

Why?  Because they may be facing a situation that is harder to evaluate and treat:  low tone reducing sensory awareness and pelvic floor control.

Yes, the same problem that causes a child to fall off their chair without notice can give them potty problems.  When their bladder ( which is another muscle, after all) isn’t well toned, it isn’t sending sensory information back to the brain.  The sensors that respond to stretch aren’t firing and thus do not give a child accurate and timely feedback.  It may not let them know it is stretched until it is ready to overflow.  If the pelvic floor muscles are also lax, similar problems.  Older women who have been pregnant know all about what happens when you have a weak pelvic floor.  They feel like they have to “go”  but can’t hold it long enough to get to the bathroom!   Your mom and your daughter could be having the same problems!!

What can you do to help your child?  Some people simply have their kids pee every few hours, and this could work with some kids in some situations.  Not every kid is willing to wear a potty watch (they do make them) and the younger ones may not even be willing to go.  The older ones may be so self-conscious that they restrict fluids all day, but that is not a great idea.  Dehydration can create medical issues that they can’t fathom.  Things like fainting and kidney stones.

Believe it or not, many pediatric urologists don’t want kids to empty their bladder before bedtime.  They want kids to gradually expand the bladder’s ability to hold urine for a full 8-10 hours.  I think this is easier to do during the day, with a fully awake kid and a potty close at hand.  Too many accidents make children and adults discouraged.  Feeling like a failure isn’t good for anyone, and children with low tone already have had frustrating and embarrassing experiences.  They don’t need more of them.

There are a few ideas that can work, but they do take effort and skill on the part of parents:

First, practice letting that bladder fill up just enough for some awareness to arise.  You need to know how much a child is drinking to figure out what the right amount is, and your child has to be able to communicate what they feel.  This is going to be more successful with children with at least a 5-6 year-old cognitive/speech level.  Once they notice what they are feeling down there right before they pee, you impress on them that when they feel this way that they can avoid an accident by voiding as soon as they can.  Try to get them to create their own words to describe the sensation they are noticing.  That fullness/pressure/distention may feel ticklish, it may be felt more in their belly than lower down; all that matters is that you have helped your child identify it and name it.

You have to start with an empty bladder, and measure out what they are drinking so you know approximately how much fluid it takes them to perceive some bladder stretching.    It helps if you can measure it in a way that has meaning for them.  For me, it would be how many mugs of coffee.  For a child it might be how many mini water bottles or small sport bottles until they feel the need to “go”.  You also need to know how long it takes their kidneys to produce that amount of urine.  A potty watch that is set to go off before they feel any sensation isn’t teaching them anything.

The second strategy I like involves building the pelvic floor with Kegels and other moves.  Yup, the same moves that you do to recover after you deliver a baby.  The pelvic floor muscles are mostly the muscles that you contract to stop your urine stream.  Some kids aren’t mentally ready to concentrate on a  stop/start exercise, and some are so shy that they can’t do it with you watching.  But it is the easiest way to build that pelvic floor.  There are other core muscle exercises that can help, like transverse abdominal exercises and pelvic tilt exercises.  Boring for us, and more boring for kids.  But they really do work to build lower abdominal strength.  If you have to create a reward system for them to practice, do it.  If you have to exercise  with them, all the better.  A strong core and a strong pelvic floor is good for all of us!

Finally, don’t forget that the same things that make adult bladders edgy will affect kids.  Caffeine in sodas, for example.  Spicy foods.  Some medications for other issues irritate bladders or increase urine production.  Don’t forget constipation.  A full colon can press on a full bladder and create accidents.

Interested in learning more about toilet training?  My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone is available on my website, tranquil babies.  Just click ‘e-book” on the ribbon at the top of the home page, and learn about my readiness checklists, and how to deal with everything from pre-training all the way up to using the potty in public!

 

 

 

 

Does An Atypical Pencil Grasp Damage Joints or Support Function In Kids With Hypermobility?

As a pediatric OT, I am often asked to assess and teach proper pencil grasp.  Once you start looking, you see a lot of interesting patterns out there.  When a child clearly has low muscle tone and/or hypermobile joints, the question of what to do about an atypical pencil grasp used to puzzle me.  I could spend weeks, or even months, teaching positioning and developing hand strength in a child, only to find that they simply couldn’t alter their grasp while writing.

Now I triage grasp issues by determining if it is a problem for the child now or in the future.  An atypical pencil grasp can be an acceptable functional compensation or it can be a contributor to later joint damage.  What’s the difference?  You have to know a bit about hand anatomy and function, how to adapt activities, and how to assess the ergonomics of writing.

Children aren’t aware of most of the problems that low tone and/or hypermobility create when they hold a pencil.  They just want to create. The effects of their unique physiology often results in grasp patterns that cause parents pain just to observe; fingers twisted around the shaft of the pencil, thumb joints bent backward, etc.  The kids aren’t usually complaining; their lack of sensory receptor firing at the joints and muscles gives them no clues to the strain they are inducing.  None.  Occasionally children will complain of muscular fatigue or pain after writing a few paragraphs or completing an art project.  For the most part, they are unconcerned and unaware of what is really going on.  For a more detailed explanation, please check out Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children,

Do these funny grasp patterns reduce legibility?  Only sometimes.  There are atypical grasp patterns that are good choices for children with hypermobility.  One is to place the shaft of the pencil directly between the index and third finger, and allow the thumb to support the side of the pencil.  The knuckle joints of those fingers provide more stability than the standard tripod grasp.  I allow preschoolers who need to keep more than 3 fingers on the shaft of the pencil to do so, and wait to see what happens as they develop more overall hand control.  Forcing a tripod grip isn’t always in their best interest now or for the future.

What can be done?  My favorite method to help children with low tone or hypermobility is to look at the problem with both a wide-angle lens and with targeted analysis.  I think about changing overall posture, altering any and all equipment, and examine the mechanics of movement.

These kids often need better proximal support, meaning that changing their chairs and writing/drawing surfaces could result in less strain in their hands and wrists.  To understand one way your whole body is involved in writing, take a look at Better Posture and More Legible Writing With A “Helper Hand” Using writing tools that reduce joint force by enlarging the shaft diameter or changing out lead for gel pens or markers is another strategy.  Take a look at Strengthening A Child’s Pencil Grasp: Three Easy Methods That Work for more good ideas that actually make a difference.  I will teach kids how to pace themselves to reduce force and fatigue throughout their bodies.  A little awareness can be a big help.  Finally, I may suggest a pencil grip, but I assess this carefully in order to avoid forcing a typical grasp on a child that can’t manage it due to instability or profound weakness.  I might start with the Grotto Grip The Pencil Grip That Strengthens Your Child’s Fingers As They Write., in the hope that we can strengthen and train a stable grip, but I will move on quickly if it doesn’t work within a month or causes more difficulty in writing.

Atypical pencil grasp can be a problem, but it can also be a solution to a child who is struggling to write and draw in school.  If you have concerns, ask your OT to evaluate and explore the issue this week!

Strengthening A Child’s Pencil Grasp: Three Easy Methods That Work

 

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Dreaming of summer fun!

When a child makes fast progress from a fisted grasp to a mature pencil grasp in therapy, parents notice.  This isn’t easy to accomplish, but it is possible.  I spent the first decade of my pediatric OT career thinking that finger exercises were the answer.  Nope.   Here are my three favorite strategies to see quick improvements in children ages 3-5:

  1. Crayons.  Yes, I suggest you go old-school and use crayons, not markers, for scribbling and drawing.  The tackiness of wax on paper  creates slight resistance that builds strength.  Feel free to provide paper with a bit of texture, such as watercolor paper; it is worth the investment!  Just like when you go to the gym, all muscles will respond to resistance by recruiting more fibers and building more strength.  Yeah!
  2. Easels.  Every pediatric OT recommends an easel, and there is a good reason why.  Easels work.  I take if further, and make sure that the paper doesn’t slip at all, and that the target for a child’s scribbling is in the middle 1/3 of the easel surface.  Why?  Unless a child is very tall or very tiny, this will result in a more effective shoulder and wrist angle that allows a mature pencil grasp.  How do I ensure that a child uses the target area?  I color in the top  and bottom 1/3’s, creating either good demos of shapes/designs, or just scribbling away, having fun.  What I draw depends on the child’s needs at the moment.
  3. Tablet Stylus.  I am well aware that some therapists are recoiling in horror at the thought of using a tablet.  They might have to reconsider their stance after reading what I have to say.  Children are using them daily in their homes, many have their own, and sport a newer model than I drag around for work!  Tablets aren’t going away, so use them to your advantage.  Using a stylus (my fave is the iCreate stylus)  produces the tacky resistance that we like about crayons, but on a touchscreen.  When children have to drag-and-drop objects, they are using more muscle strength and better control to maintain a stable yet mobile grasp.  A few years ago, I worked with a very weak child who was dealing with a life-threatening illness.   No one was going to force him to do anything, and all he wanted to do was play on a tablet.  He was told to use the stylus while playing, and 6 weeks later he was eagerly coloring with crayons on paper.  His improved pencil grip was amazing!  As always, my apps are educational as well as fun, and tablet use in therapy is neither a reward nor the focus of my sessions.  I make it clear that lots of fun can be had without it.

As with any therapeutic exercise, I monitor fatigue and adapt my set-up and activities to maximize use of a mature grasp with minimal compensation.  The rule is:  if it looks like a bad grip, it probably is!  If your child insists on using a fisted grasp even with these strategies, you need to use some behavioral motivational tools in addition to good equipment.  Your OT can help you with that!

If your therapists have mentioned that your child has low muscle tone or ligament laxity (loose joints) take a look at Does An Atypical Pencil Grasp Damage Joints or Support Function In Kids With Hypermobility? for some clarity on addressing pencil grasp with these issues.

Hypermobility in Young Children: When Flexibility Isn’t Functional

Your grandma would have called it being ” double jointed”.   Your mom might mention that she was the most flexible person in every yoga class she attended.  But when extra joint motion reduces your child’s performance or creates pain, parents get concerned.  Sometimes pediatricians and orthopedists do not.

Why would that happen?  A measure of flexibility is considered medically within the norm for children and teens.  Doctors often have no experience with rehab professionals, so they can’t share other resources with parents.  This can mask some significant issues with mild to moderate hypermobility in children.  Parents leave the doctor’s office without a diagnosis or advice, even in the face of their child’s discomfort or their struggles with handwriting or recurrent sports injuries.  Who takes hypermobility seriously?  Your child’s OT and PT.

Therapists are the specialists who analyze functional performance and create effective strategies to improve stability and independence.  I will give a shout-out to orthotists, physiatrists and osteopaths for solutions such as splints and prolotherapy.  Their role is essential but limited, especially with younger children. Nobody is going to issue a hand splint or inject the ligaments of a child under 5 unless a child’s condition is becoming very poor very quickly.  Adaptations, movement education and physical treatments are better tolerated and result in more functional gains for most middle and moderately involved hypermobile children.  Take a look at Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children to understand more about what an OT can do to help your child.

Low tech doesn’t mean low quality or low results.  I have done short consults with children that involve only adaptations to sitting and pencil choice for handwriting, with a little ergonomic advice and education of healthy pacing of tasks thrown in.  All together, we manage to extend the amount of time a child can write without pain.  Going full-tilt paperless is possible when pain is extreme, but it involves getting the teachers and the district involved.  Not only is that time-consuming and difficult to coordinate, it is overkill for those mildly involved kids who don’t want to stand out.  Almost nothing is worse in middle school than appearing “different”.  A good OT and a good PT can help a child prevent future problems, make current ones evaporate, or minimize a child’s dependence and pain.

Hypermobile kids are often bright and resourceful, and once they learn basic principles of ergonomics and joint protection, the older children can solve some of their own problems.  For every child that is determined to force their body to comply with their will to compete without adaptation, I meet many kids that understand that well-planned movements are smarter and give them less pain with more capability.  But they have to have the knowledge in order to use it.  Therapists give them that power.

Parents:  please feel free to comment and share all your great solutions for your child with hypermobility, so that we all can learn from YOU!

Is your hypermobile child also struggling with toilet training or incontinence?  Check out Low Tone and Toilet Training: Learning to Hold It In Long Enough to Make It to The Potty  to gain an understanding of how motor and sensory issues contribute to this problem, and how you can help your child today!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

photo-1445800363697-51e91a1edc73  Toilet Training Help Has Arrived!             

My most popular post,  Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!) inspired me to write a manual to help parents with potty training.  There was nothing in books or online that really helped families, just a few lines about being patient and not pushing children….no help at all!

What makes this book so unique?  Media specialists say that you have to be able to explain your product in the time it takes for the average elevator ride.  OK, here is my elevator speech on The Practical Guide to Toilet Training Your Child With Low Muscle Tone:

My book provides a complete explanation of the motor, sensory, and social/emotional effects that low muscle tone has on toilet training.  It does so without being preachy or clinical.  Parents understand whether their child is ready to train, and how to start creating readiness immediately.  They learn how to pick the right potty seat, the right clothes, and how to decide between the “boot camp” or gradual method of training.  A child’s speech delays, defiance or disinterest in potty training are addressed in ways that support families instead of criticizing them.

  • Each readiness quiz helps parents figure out what issues need to be addressed for successful training and reminds them of their child’s strengths.
  • Chapter summaries give a quick review of each section.  Parents decide which chapter they need to read next to get more information.
  • Clinical information is explained in layman’s terminology, so parents don’t have to Google “interoception” to understand the neurology that causes a child not to recognize that they have a full bladder.

Here’s what parents are saying about The Practical Guide”:

The Practical Guide has truly been heaven sent!  Although my globally delayed 5-year old daughter understood the idea of toileting, this skill was certainly not mastered.  Our consultations with Cathy and her guide on how to toilet train have given me the knowledge I’ve needed to understand low tone as a symptom that can be tackled.  Morgan has made visible advances, and I am so encouraged and empowered because I know what piece we need to work on next.  Thank you, Cathy, for writing this book!”      Trish C, mother of Morgan, 5 years old

“I would often say to myself “Cathy has to put all of her accumulated wisdom down into a book”.  I am happy to say-here it is!  You will find no one with more creative and practical  solutions.  Her insights and ideas get the job done!”     Laura D. H., mother of M., 4 years old 

Cathy has been a “go-to’ in every area imaginable, from professional referrals to toilet training.  I can’t say enough positive things about her.  She has been so insightful and helpful on this journey.”  Colleen S. mother of two special needs children

How do you buy my book?  Two ways:  Visit my website  tranquil babies and click on “e-book” at the top of the homepage, or visit your therapy source, a wonderful site for parents and therapists.  Just search for The Practical Guide to Toilet Training Your Child With Low Muscle Tone!

HELP HAS ARRIVED!