Category Archives: low tone

Kids With Low Muscle Tone: The Hidden Problems With Strollers

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

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

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

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

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

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

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

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

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

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

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

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For Kids With Hypermobility, “Listen To Your Body” Doesn’t Teach Them To Pace Themselves. Here’s What Really Helps.

 

chen-hu-664399-unsplashI ran across a comment piece online that recommended parents teach their hypermobile  children to “listen to your body” to pace activities in an effort to avoid fatigue, pain or injury.  My reaction was fairly strong and immediate.  The sensory-based effects of hypermobility (HM) reduce interoception (internal body awareness)  and proprioception/kinesthesia (position and movement sense, respectively).  These are the  main methods of “listening” we use to know how we are feeling and moving.  For children with HM, telling them to listen to their body’s messages is like telling them to put on their heavy boots and then go outside to see how cold the snow is! 

Relying primarily on felt senses when you have difficulty receiving adequate sensory feedback doesn’t make…..sense.  What often happens is that kids find themselves quickly out of energy, suddenly sore or tripping/falling due to fatigue, and they had very little indication of this approaching until they “hit a wall”.  They might not even see it as a problem.  Some kids are draped over the computer or stumbling around but tell you that they feel just fine.  And they aren’t lying. This is the nature of the beast.

I am all for therapy that helps kids develop greater sensory processing (as an OTR, I would have to be!), but expecting HM kids to intuitively develop finely tuned body awareness? That is simply unfair. Kids blame themselves all too easily when they struggle.  What begins as a well-meaning suggestion from a person with typical sensory processing can turn into just another frustrating experience for a child with HM.

What could really help kids learn to pace themselves to prevent extreme fatigue, an increase in pain and even injury due to overdoing things?

  1. Age-appropriate education regarding the effects of HM.  Very young children need to follow an adult’s instructions (“time to rest, darling!”), but giving older kids and teens a medical explanation of how HM contributes to fatigue, pain, injuries, etc. teaches them to think.   Understanding the common causes of their issues makes things less scary and empowers them.  If you aren’t sure how to explain why your child could have difficulty perceiving how hard they are working or whether they are sitting in an ergonomic position, read Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children for some useful information.  You could ask your child’s OT or PT for help.  They should be able to give you specific examples of how your child responds to challenges and even a simple script to use in a discussion.  Explaining the “why” will help children understand how to anticipate and prepare for the effects of HM.
  2. Consider finding a pediatric occupational therapist to teach your child postural, movement and interoceptive awareness, adapt your child’s learning and living environments for maximal ease and endurance, and teach your child joint protection techniques.  Occupational therapists are often thought of as the people that hand out finger splints and pencil grips.  We are so much more useful to your child than that narrow view!  For example, I have adapted desks for optimal postural endurance and decreased muscle tension.  This has immediate effects on a child’s use of compensations like leaning their chin on their hand to look at a screen.  OT isn’t just for babies or handwriting!
  3. Pacing starts with identifying priorities.  If you don’t have boundless energy, attention, strength and endurance, then you have to choose where to spend your physical “currency”.  Help your child identify what is most important to them in their day, their week, and so on.  Think about what gives them satisfaction and what they both love to do and need to do.  This type of analysis is not easy for most kids.  Even college students struggle to prioritize and plan their days and weeks.  Take it slow, but make it clear that their goals are your goals.  For many children with HM, being able to set goals and identify priorities means that they will need to bank some of their energy in a day or a week so that they are in better shape for important events.  They may divide up tasks into short components, adapt activities for ease, or toss out low-level goals in favor of really meaningful experiences.  Can this be difficult or even disappointing?  Almost certainly!  The alternative is to be stuck at an event in pain, become exhausted before a job is completed, or end up doing something that places them at higher risk for injury.
  4. Help your child identify and practice using their best strategies for generating energy, building stamina and achieving pain-free movement.  Some kids with HM need to get more rest than their peers.  Others need to be mindful of diet, use relaxation techniques, wear orthotics regularly, adapt their home or school environment, or engage in a home exercise program.  Learning stress-reduction techniques can be very empowering and helps kids think through situations calmly.    Sports can be an issue or they can be a wonderful way to build endurance and body awareness.  Read  Should Your Hypermobile Child Play Sports? for some ideas on managing pain, endurance and coordination.  Creating a plan together and discussing the wins and failures models behaviors like optimism and resourcefulness.  Children depend on adults to show them that self-pacing is a process, not an endpoint.

Looking for more information to help your child with hypermobility?  Take look at The Hypermobile Hand: More Than A Strength Problem and How Hypermobility Affects Self-Image, Behavior and Activity Levels in Children.  My e-books on pediatric hypermobility are coming out soon!  Check back here at BabyBytes for updates.

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The Cube Chair: Your Special Needs Toddler’s New Favorite Seat!

 

 

Finding a good chair for your special needs toddler isn’t easy.  Those cute table-and-chair sets from IKEA and Pottery Barn are made for older kids.  Sometimes much older, like the size of kids in kindergarten.  Even a larger child with motor or sensory issues will often fall right off those standard chairs!

Should you use a low bench?  I am a big fan of the Baby Bjorn footstool for bench sitting in therapy, but without a back, many toddlers don’t last very long without an adult to sit with them.  Independent sitting and playing is important to develop motor and cognitive skills.   The cute little toddler armchairs that you can get with their name embroidered on the backrest look great, but kids with sensory or motor issues end up in all sorts of awkward positions in them.  Those chairs aren’t a good choice for any hypermobile child or children with spasticity.

Enter the cube chair.  It has so many great features, I thought I would list them for you:

  • Made of plastic, it is relatively lightweight and easy to clean.  While not non-slip, there is a slight texture on the surface that helps objects grip a little.  Add some dycem or another non-slip surface, and you are all set.
  • Cube chairs can be a safe choice for “clumsy” kids. Kids fall. It happens to all of them.  The design makes it very stable, so it is harder to tip over. The rounded edges are safer than the sharp wooden corners on standard activity tables.
  • It isn’t very expensive.  Easily found on special needs sites, it is affordable and durable.
  • A cube chair is also a TABLE! That’s right; turn it over, and it is a square table that doesn’t tip over easily when your toddler leans on it.
  • Get two:  now you have a chair and table set!  Or use them as a larger table or a surface for your child to cruise around to practice walking.  That texture will help them maintain their grip.  The chairs can stack for storage, but you really will be using them all the time.
  • It has two seat heights.  When your child is younger, use the lower seat with a higher back and sides for support and safety.   When your child gets taller, use the other side for a slightly higher seat with less back support.
  • The cube chair is quite stable for kids that need to hold onto armrests to get in and out of a chair.  The truly therapeutic chairs, such as the Rifton line, are the ultimate in stability, but they are very expensive, very heavy, and made of solid wood.

Who doesn’t do well with these chairs?  Children who use cube chairs have to be able to sit without assistance and actively use their hip and thigh muscles to stabilize their feet on the floor.  Kids with such significant trunk instability that they need a pelvic “seatbelt” and/or lateral supports won’t do well with this chair.  A cube chair isn’t going to give them enough postural support. If you aren’t sure if your child has these skills, ask your occupational or physical therapist.  They could save you money and time by giving you more specific seating recommendations for your child.

Your child may be too small or too large for a cube chair.  Kids who were born prematurely often remain smaller and shorter for the first years, and a child needs to be at least 28-30 inches tall (71-76 cm) to sit well in a cube chair without padding.

You may add a firm foam wedge to activate trunk muscles if they can use one and still maintain their posture in this chair, or use the Stokke-style chair A Simple Strategy To Improve Your Child’s Posture In A Stokke Tripp Trapp or Special Tomato Chair or the Rifton chair until your child has developed enough control to take advantage of a cube chair.

Looking for more information on positioning and play?  Check out Kids With Low Muscle Tone: The Hidden Problems With Strollers,  Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children and How To Pick The Best Potty Seat For Toilet Training A Child With Low Tone.  I am in the process of writing a series of practical guides for parents of children with hypermobility, so keep checking back on my site for the launch this summer!!

The Hypermobile Hand: More Than A Strength Problem

 

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I just received another referral for a kid with “weak’ hands.  Can’t hold a pencil correctly, can’t make a dark enough mark on paper when he writes or colors.  But his mom says he has quite a grip on an object when he doesn’t want to hand something over.  He plays soccer without problems and otherwise functions well in a regular classroom.  Could it be that hypermobility is his underlying problem?

Some children display problems with fine motor skills due to low muscle tone.  Many times, their low tone is significant enough to create poor joint alignment and stability, resulting in joint hypermobility as well as low muscle tone.  But kids can also have joint laxity with typical muscle tone.  Assessing the difference between tone, strength, alignment/stability and endurance is why you get an evaluation from a skilled therapist.  And even then, it can be tricky to determine etiology with the youngest children because they cannot follow your directions or answer questions.  Time to take out your detective hat and drill down into patient history and do a very complete assessment.

With older kids, both low tone and joint laxity can lead them over time to develop joint deformity and soft tissue damage.  Like a tire that you never rotated on your car, inappropriate wear and tear can create joint, ligament, tendon, and muscular imbalance problems that result in even worse alignment, less stability and endurance, and even pain.  And yes, weakness is often observed or reported, but it often is dependent on posture and task demands, rather than being consistent or specific to a nerve distribution or muscle/muscle group.

What does the classic hypermobile hand look like?  Here are some common presentations:

  • The small joints of the fingers and thumb look “swaybacked”, as the joint capsule is unstable and the tendons of the hand exert their pull without correct ligament support.  When they slide laterally and the joint is unable to move smoothly, people say that their fingers “lock” or they are diagnosed with “trigger finger”.
  • The arches of the hand aren’t supported, so the palm looks flat at rest.  By late preschool, the arches of the hand should be evident in both active and passive states.
  • The fleshy bases of the thumb and pinky ( the thenar and hypothenar eminences, for all you therapists out there) aren’t pronounced, due to the lack of support reducing normal muscle development during daily use.
  • Grasp and pinch patterns are immature and/or atypical.  A preschooler uses a fisted grasp to scribble, a grade-school child uses two hands to hold an object that should be held by one hand and uses a “hook” grasp on a pencil.
  • Grasp and pinch may start out looking great, and deteriorate with the need for force.  Or prehension begins looking poor and improves for a while, until fatigue sets in.  This bell-curve pattern of grasp control is often seen with kids that have poor proprioceptive discrimination.  As they use their hands they receive more input, but as fatigue sets in, they cannot maintain a mature grasp and good control.
  • The typical arches of the hand that create the “cupping” of the palm when pretending to scoop water from a stream, for example, will be somewhat flattened. Unless there is nerve damage, you won’t see the “claw hand” pattern or another atypical posture.
  • Fine grasp will often be accomplished with the thumb and third finger to achieve greater stability through the MCP (knuckle) joints and to avoid full opposition of the thumb.  Another common compensatory pattern is using digits II and III together to gain greater stability.  Some kids can even wrap one digit partially around another to do this.  Now that’s hypermobility!

Don’t forget that hypermobility creates poor sensory processing feedback loops.  Reduced proprioception and kinesthesia will result in issues when children try to grade force and control movement without compensations such as visual attention and decreased speed. This can result in kids being labeled clumsy or careless.

Looking for ideas to address the difficulties children face when they have hypermobility in their hands? Take a look at For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance and Does An Atypical Pencil Grasp Damage Joints or Support Function In Kids With Hypermobility?.  Depending on the age and skill level of the child, adaptations and education can be just as important as therapeutic exercise.  Your pediatric occupational therapist can help with more than pencil grasp; we are able to help with so many real-life issues!

Need help with toilet training?  My e-book will give you the support to make this less of a struggle!  Read The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived! and find out what parents have to say about the only manual on the market to address potty training and low tone.

Would you like more ideas about managing your child’s hypermobility?  Visit my website,  tranquil babies , and purchase a consultation session.  You can ask questions, get equipment sources and find out about treatment techniques that you can pursue with your team at home.  This is your chance to learn more about what low tone is, how it may be affecting your child’s progress, and have someone help you problem-solve for your child (or yourself)!

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Improving Daily Life Skills for Kids With Special Needs

 

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Therapro, the terrific source for a lot of handy therapy equipment and especially for items that help kids with sensory processing issues, has posted another piece from me on ADLs.  Take a look: What Helps Special Needs Kids Tolerate Grooming and Hygiene?

“Activities of Daily Living” don’t have the cache’ of kineseotaping or therapeutic listening, but helping families improve the little things in life is something I haven’t ignored.  The basics of life are still the basics, and when they are a struggle, life gets harder.  Every single day.

Sometimes using SI techniques like the Wilbarger Protocol Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome? makes self-care activities better, but sometimes you need a targeted approach.  This post describes some of my best strategies to make face-washing, tooth-brushing, dressing and bathing easier for kids to tolerate and they also help them to become independent at these important skills.  After all, one of the best techniques to reduce defensiveness/aversion is to have a child do the task independently.  They can control the pace, the amount of force and the timing.  And they are empowered.  So many kids with special needs develop the impression that they don’t have the ability to do things for themselves.

So check out my post on Therapro, and then go shopping for some of their terrific materials for your child or for your therapy practice!

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The view north from West Point.  Welcome spring!

Which Improves Pencil Grasp Best: A Pencil Grip Or A Thicker Pencil?

 

kelli-tungay-324329A a pediatric occupational therapist, I am often asked to weigh in on this debate.  Not often enough, it seems.  There are a lot of kids out there using pencils with wonky grasp patterns because no one has made an effort to improve the way they hold a pencil, or they doubt that it matters.  Oops.  Although grasp isn’t often or evn usually the biggest issue with writing problems, a really poor grasp can reduce control and increase pain and fatigue.  Not every kid with poor pencil grasp is a hot mess.  Some of them just need good instruction and good materials.  For the others, it might be time to get an OT involved.

Kids that struggle with pencil grasp are often (in my opinion, too often) given a pencil grip and told to use it when they write. It may help, but it may not.  An yet, I will still hand out my favorite pencil grip if I think that it will build control and strength. The Pencil Grip That Strengthens Your Child’s Fingers As They Write.

I thought I would drill down into the ways that OTs think about the use of pencil grips, and present a few alternatives to reflexively sending kids home with a bit of plastic on the end of a pencil:

  • Change the pencil.  Triangular pencils give more sensory feedback during writing, and they offer a flat surface for finger pads.  Thick mechanical pencils still have a standard-thickness lead, but they also are easier to hold for some children.  Short pencils, including golf pencils, force more fingertip contact and can be helpful (but not if grasp is really weak or awkward).
  • Don’t jump into pencil use too early.  Until a child can manage a mature grasp, I try very hard to keep them using crayons when they are not yet in kindergarten.  I like the flip crayons from Learning Without Tears because they are so very small, but not all kids in kindergarten are ready for them.  I break a toddler crayon in two so that they get the benefits of a thick shaft but they will be unable to use a fisted grasp.
  • Like markers?  I only use them if they are the Pipsqueak markers from Crayola.  Nice thick, short shafts for little fingers.  Markers don’t give a child any resistance at all, so they don’t give enough sensory feedback or strengthening for my kids that need both.  And they make a mess most of the time.  I don’t have the time to scrub off markers.
  • Build strength and control with play.  Yes, fine motor play.  Totally outdated (just joking) but necessary.  I use the iCreate tablet stylus, bead stringing, therapy putty and lots of tiny toys like travel Connect Four games.  Even baking.     Utensil use counts too. How Using Utensils To Eat Prepares Your Child To Write    Children are spending less time with toys and more with tablets, so I insist that they use a tablet stylus with me in sessions.  They have no idea that the physical “drag” of the plastic point on the glass screen as they move objects around is creating resistance that helps their fingers get stronger.
  • Color with children, draw with children. A lot.  Coloring is less stressful to the risk-averse child who thinks he can’t write. Drawing simple shapes is directly applicable to writing letters and numbers.  Think “T” and a vertical cross, “A” and a volcano.  Watching an adult and listening to their narration, such as ” I am coloring around and around to fill in the balloon, since it is a circle shape”  is very helpful to young children who resist direct instruction.  The child that doesn’t naturally gravitate to coloring may need downloads of their fave character or stickers to add to the picture to make it exciting.  But the key is the adult interaction.

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