Category Archives: occupational therapy

Should Hypermobile Kids Sit On Therapy Balls For Schoolwork?

They are everywhere; colorful therapy balls have migrated from the clinic to the classroom.  You can buy a base or a whole chair with a ball attached.  But do kids with hypermobility benefit from using them, or will they create more problems than they solve?

Hypermobility in infants and very young children is common, and decreases over time in typical children.  And then there are the kids with low muscle tone or connective tissue disorders.  These kids do not commonly see a decrease in their loose joints over time.  They do become stronger, and they can become more stable and steady.  But they can still display considerable flexibility over time.

In fact, hypermobility can increase with each overstretched ligament or damaged joint.  It is as simple as basic construction principles:  when the foundation is shaky, the structures around the foundation receive some of the forces from action and movement that the foundation should have absorbed.  A child who has an unstable pelvis will experience more forces in their upper spine and in their knees as the muscles try to compensate for the extra movement at the pelvis.  Over-stretching, excessive tightening of the wrong structures, and damage to joint surfaces are the result of excessive force absorption.

In this situation, another symptom becomes more and more obvious:  fatigue.  Well-aligned joints are designed to decrease effort during movement, like a Swiss clock.  Damaged joints and joints that don’t glide correctly due to lax ligaments and weak muscles require more effort to do the same job.  Hence fatigue sets in just from the extra effort required.  This is true even if the connective tissue that creates muscles and ligaments is of good quality.  Some genetic connective tissue disorders are characterized by incomplete or faulty construction of connective tissue.  These children are starting out with a foundation that is unstable and weak before any forces have been applied.  They will become weak and tired more quickly than a child with the same level of instability but with stronger connective tissue.

While sitting on a therapy ball-chair, the expectation is that the dynamic movement of the ball will activate core musculature and provide a dynamic position that helps a child  achieve core stability.  Sounds great!  But…this assumes that the physical structures needed are capable of doing so, and that the child is also able to write or play, using his arms and hands effectively at the same time.  It also assumes that the child will notice when his alignment has decreased and will take action to prevent compensation.  I think that is a lot to ask of most kids, even most teens.  They just want to get their homework done and over.

Based on all of these concerns, I recommend that children with hypermobility be closely evaluated and monitored by a therapist before they use a therapy ball set-up as a chair for play or schoolwork.  The extra effort to sustain and achieve good alignment is likely to be difficult to manage as they concentrate on a task like handwriting.  The risk is that they fatigue the supporting musculature, recruit compensatory muscles for support, and place more strain on joints and ligaments without awareness.  Yes, I am saying that there is a chance that the use of these chairs with some kids can make things worse.

A better idea for kids with hypermobility?  A more supportive seating set-up.  Reduce the physical demands while your child is working, and leave exercising on a ball to therapy sessions and your therapy home program.  Therapists are skilled at designing programs that target specific muscles to develop balanced control around a joint while protecting it at the same time.  They are also great at assessing work stations and chairs to determine which designs will give your child support and dynamic positioning at the same time without excessive fatigue.  This is one of my favorite tasks as an OT.  I know that a well-designed seating set-up will provide a pay-off every time a child sits down for a meal, plays at a table, or does their homework.  Sometimes it means that joint protection and support have to be blanked with dynamic control, and my training helps families to parse it out for the best result possible for their child.

Looking for more ideas with your hypermobile child?  Check out Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior and Should Hypermobile Kids Use Backpacks? to start the school year.

I am working on a new e-book on hyper mobility, and welcome parents and therapists to suggest topics that are rarely discussed online or in the clinic.  My goal is to create a book that helps kids thrive!

 

 

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Go Back To School With Target’s Sensory-Friendly Clothing Line

 

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A boy’s tee from the Cat and Jack collection at Target

Here in the US, kids are getting ready to start the school year.  A mom mentioned to me that Target is now carrying sensory-friendly clothing by Cat and Jack; attractive and functional clothes for kids who find tags, seams and textured clothing uncomfortable.  I went to check them out online.  Here is what I learned:

The selection is limited but sufficient for kids who don’t have to wear a uniform for school.  It includes clothes for toddlers up through grade school.  I saw leggings and tees, both long and short-sleeved.  There aren’t any tags and the seams are sewn flat.  The garments have been pre-washed for softness, which saves parents some work.  I know that there are kids who insist their new clothing be repeatedly laundered to get out the stiffening agents that have been applied to fabrics.

I know that this limited line doesn’t solve the problem of getting your child into formal clothing for a big wedding, and it may not have every color under the sun, but it is nice to see affordable clothing options for kids who struggle with this issue.

In my experience as a pediatric OT, children could still have issues with tolerating sleeves and pant legs.  Some kids find the movement of fabric on skin irritating, regardless of the level of softness.  I suggest that you ask your OT about desensitization techniques that can help you and your child have better experiences when dressing, regardless of the type of garment.

Happy Back-To-School shopping!

 

 

Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior

 

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There is nothing worse than using a scientific study that correlates two variables and assuming causation. Translation:  If behaviors typical of disorder “A” are seen in a lot of people with problem “B”, we cannot assume that “A” is the cause of their behavior.   But we do it all the time.  People who love coffee adore studies that say coffee drinkers seem to live longer.  People who hate to exercise are validated by reports that find the number of heart attacks after exercise “is increasing”.

When it comes to labeling children’s behavior, we should take a couple of big steps back with our erroneous reasoning.  And when the label is ADHD, take three more.  Not because ADHD isn’t a big issue for families.  The struggles of kids, parents and educators shouldn’t be minimized.  We should be cautious with labels when two situations occur:  very young ages and multiple diagnoses that are determined largely by clinical observation, not testing.  Seeing ADHD in a child with hypermobility is one of those situations.

Hypermobility without functional problems is very common in young children.  Super-bendy kids that walk, run, hit a ball and write well aren’t struggling.  But if you have a child that cannot meet developmental milestones or has pain and poor endurance, that is  a problem with real-life consequences.  Many of them are behavioral consequences.

Yes, I said it.  Hypermobility is a motor problem that has a behavioral component.  I don’t know why so little has been written on this subject, but here it is:  hypermobile kids are more likely to fidget while sitting, more likely to get up out of their chairs, but also more likely to stay slumped on a couch.  They are more likely to jump from activity to activity, and more likely to refuse to engage in activities than their peers.  They drape themselves on furniture and people at times.

Why?  Hypermobility reduces a child’s ability to perceive body position and degree of movement, AKA proprioception and kinesthesia.  It also causes muscles to work harder to stabilize joints around a muscle, including postural muscles.  These muscles are working even when kids are asleep, so don’t think that a good rest restores these kids the same way another child gets a charge from a sit-down.

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When a hypermobile child starts to move, the brain receives more sensory input from the body, including joints, skin and muscles.  This charges up a sensory system that was virtually starving for information.  Movement from fidgeting and movement by running around the house are solutions to a child’s sense that they need something to boost their system.  But fatigue can set in very quickly, taking a moving child right back to the couch more quickly than her peers.  It looks to adults like she couldn’t possibly be tired so soon.  If you had to contract more muscles harder and longer to achieve movement, you’d be tired too!  Kids  develop a sense of self and rigid habits just like adults, so these “solutions” get woven into their sense of who they are.  And this happens at earlier ages than you might think.

Then there is pain.  Some hypermobile kids experience pain from small and large injuries.  They are more likely to be bruised,  more likely to fall and bump into things, and more likely to report what pediatricians may call “growing pains”.  Sometimes the pain is the pull on weak ligaments and tight muscles as bones grow, but sometimes it isn’t.  Soreness and pain lead some kids right to the couch.  After a while, a child may not even complain, especially if the discomfort doesn’t end.  Imagine having a lingering headache for days.  You just go on with life.  These kids are often called lazy, when in truth they are sore and exhausted after activities that don’t even register as tiring for other children their age.

How can you tell the difference between behaviors from ADHD and those related to hypermobiilty?  I think I may have an idea.

When a hypermobile child is given effective and consistent postural support, is allowed to rest before becoming exhausted (even if they say they are fine), and any pain issues are fully addressed, only then can you assess for attentional problems.  Occupational therapists with both physical medicine and sensory processing training are skilled at developing programs for postural control and energy conservation, as well as adapting activities for improved functioning.  They are capable of discussing pain symptoms with pediatricians and other health professionals.

I think that many children are being criticized for being lazy or unmotivated, and diagnosed as lacking attentional skills when the real cause of their behaviors is right under our noses.  It is time to give these kids a chance to escape a label they may not have.

How To Teach Your Toddler To Wipe “Back There”

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Potty training is a process.  For most kids, the final frontier is managing bowel movements.  Compared to learning to pee into the toilet, little kids are often more stressed by bowel movements and have less opportunities to practice.  Constipation or just the discomfort of normal elimination can make them wary, sometimes enough to convince some children that this is a process better done in a diaper.  In comparison, urination isn’t an uncomfortable experience for healthy children.  Bowel movements sometimes happen only a few times a week, instead of the multiple times a child needs to urinate per day.  Less practice and fewer opportunities for rewards (even if your reward is warm praise) make bowel training harder.

So when they finally make the leap and manage to do #2 in the toilet, a lot of parents decide to delay teaching their child how to wipe themselves.  After all, wiping can be messy and it has to be done well enough for good hygiene.  Here are my top suggestions to make “making” a complete success:

  1. Teaching should still be part of your narrative while you are the one doing the wiping.  In my book, The Practical Guide To Toilet Training Your Child With Low Tone, I teach parents how to transform daily diapering into pre-teaching.  While you are wiping, and even while you are waiting for them to finish on the toilet, your positive narrative about learning this skill doesn’t end.  You are telling your child how it’s done, in detail, as you are doing it. You convey with your words, your tone and your body language that this is a learn-able skill.
  2. Don’t forget the power of the “dry run”.  Practice with your child when he is in the bathroom, whether it is before bath time, before dressing, or during a special trip to the bathroom to practice.  Dry runs take away the mess but teach your child’s brain the motor planning needed to lean back, reach back and move that hand in the correct pattern.
  3. Will you have to reward him for this practice? Possibly.  It doesn’t have to be food or toys.  It could be the ability to choose tonight’s dessert for the family, or reading an extra two books at bedtime.  You decide on the reward based on your values and your child’s desires.
  4. Use good tools.  The adult-sized wet wipe is your friend.  The extra sensory information of a wet wipe versus a wad of dry paper is helpful when vision isn’t an option.  They are less likely to be dropped accidentally when clean, but having a good hold is especially important after it has been used. “Yucky”stuff  makes kids not want to hold on!  Wet wipes are more likely to wipe that little tush cleanly.  Don’t cut corners.  Allow your child to use more than one.
  5. Take turns.  Who wipes first and who bats “clean-up” (couldn’t resist that one!) is your decision.  Some children want you to make sure they are clean before they try, and some are insistent that they go first with anything.  This can change depending on mood and even time of day.  Be flexible, but don’t stand there like a foreman, ordering work but not willing to help out.  One of my favorite strategies is to always offer help, but be rather slow and inefficient.  This gives children the chance to rise to the occasion but still feel like you are always willing to support them.

 

Looking for more information on toilet training?  Take a look at my e-book, The Practical Guide To Toilet Training Your child With Low Muscle Tone to get a clear understanding of how to prepare for and execute your plan without tears on both sides.  Will it help you even if your child doesn’t have low muscle tone?  Of course!  Most of my techniques simply speed up the learning process for typically-developing children.  And who doesn’t want to make potty independence happen faster?

This e-book is available on my website tranquil babies, at Your Therapy Source (a great site for parents and therapists), and at Amazon.  Read more about my book with Amazon’s “look inside” section, or by reading The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

Make Handwriting Fun While Getting Ready For The New School Year

Here in the US, kids are getting ready to go back to school.  And most of them haven’t been writing much in the last 6-8 weeks.  At the kindergarten level, some children will have forgotten any lowercase letters they knew in the spring.  At the 1-2 grade levels, it is not uncommon for kids to forget how to form letters, where to place them on the baseline, and how to use simple punctuation.   Teachers sometimes need to use the first 1-2 weeks for review alone.

What if they didn’t need to review?  What if your child was ready to hit the ground running (and writing)?  There is nothing like seeing a confident kid sit down to crush her homework instead of struggling through it.  For all those writers who worked hard last year and are a little nervous to pick up a pencil again, here are some ideas that help getting back to writing fun and easy:

  1. Get good materials.  Kids are just like adults.  We like new, cool stuff.  So do they.  I recommend using the best eraser (Problems With Handwriting? You Need The Best Eraser ) and either the small Learning Without Tears (they changed their name!!!)  pencils for kindergarteners, or the Papermate 1.3mm lead mechanical pencils for older kids.  Take a look at my post on these useful pencils Great Mechanical Pencils Can Improve Your Child’s Handwriting Skills
  2. Use fun workbooks like Madlibs and games like Hangman.  Make up games that you think your kids will find funny.  Try the Junior version of Madlibs for grades 2-3, and the regular one for the higher grades.  There are themes for every kid, trust me.  Something will be funny.  Do them together with your child, have a contest for silliest madlib, send them to relatives that can appreciate this humor, etc.
  3. Target any errors made in writing their first and family name first.  Those errors will be repeated over and over in the first few days of school if you do not focus on them.  Time to make this a priority.
  4. Figure out where the gaps are, and hit the low-hanging fruit next.  Why?  Because that builds confidence.  Look for simple errors with easy-to-write or frequently written letters.  Think “a”, “e”, and “t”.  Doesn’t even have to be letters; could be numbers.  Kids need to feel like they can hit singles, and then they will try harder for doubles and triples.  Forgive the baseball reference; I saw a ton of stickers and vanity plates today.   Apparently all of my neighbors are big baseball fans!

There are only a few weeks of summer left, but if you make a small effort,  it can mean a lot to a child’s first weeks of school!

Should Hypermobile Kids Use Backpacks?

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

The standard recommendations from occupational therapists and orthopedists regarding backpacks is simple:  lighten the load, use both straps (select wide straps), and make sure the heaviest items are placed close to the body.  All good suggestions.  But if a child already has pain or weakness around the spine and shoulder joints, less stability and endurance, and less ability to judge posture and force, then the picture changes.  Using a backpack may be a significant physical risk, no matter how well designed or used.

Here are some suggestions that further minimize injury but can be acceptable to older kids who may be sensitive to being perceived as different:

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

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

 

How to Help Sensitive Kids Handle Greeting People (Including Their Own Parents!)

 

Many kids with ASD and SPD struggle with agitation and even tantrums when people enter their homes.  It can happen when their parent returns home from work, eager to scoop them up.  These kids become shy, run away, even hit!

Many, even most parents, believe that this is “bad behavior”, being defiant, or expressing anger at having people entering their space.  As an OT, I think about it differently.  Here is what I think is happening, and how to help your child handle this experience more effectively.

Sensitive children, which includes but isn’t limited to kids with sensory processing disorders, experience transitions as big charges of energy.  We all register a charge when events end or we switch locations, and when people come into our space, but those of us with less sensitivity do not charge up so high and we return to our baseline level of arousal very quickly.  So quickly that it isn’t even on our radar.  You would have to hook us up to a device like a lie-detector set to see the burst of neurological charge.

Not the sensitive person.  They are super-charged, and with little kids, it often is expressed as outsized and inappropriate aversion or agitation.  Thus, the scream, the withdrawal, the running away.  This response is often followed with agitation as the adult walks away and the child is now sad to lose the connection.  It can all seem a bit strange.

The long-term answer?  A good treatment plan that reduces overall, everyday arousal levels.  The short-term answer?  Here is my protocol that helps kids avoid getting so out-of-sorts with greetings, and builds social skills.  The nicest thing about this protocol is that it looks normal, not clinical, and it does indeed lower the brain’s level of arousal.  Keeping calm, but staying in the game socially, trains the brain to handle more interaction, not to flee.

  1. Greet the child from a distance.  This may be 5-15 feet.  Use a warm but not over the top tone.  Keep it short but friendly.  Don’t linger on eye contact.
  2. The child has been provided with an object to handoff to the greeting adult.  It doesn’t have to be meaningful, especially if the child is under 2.  Anything will do.  The idea is that it is a meaningful interaction that the child controls.  They release it to the adult.  You may have to repeat it with two objects.  The adult’s grateful response is also warm but not effusive.
  3. Now is the time to offer a hug or a kiss.  Sometimes it works, sometimes not.  With older kids that have language, I use “Handshake, hug or high-five?”.  I offer the child a choice of contact, and this alone can get them from feeling imposed upon to empowered.
  4. If the child is still protesting, the adult sits near the child, engaged in something that could be fun for the child.  A book, scribbling, something appealing.  No offer or invite; the position and the activity are the invitation.  The child may come over and begin to engage.  Connection accomplished!

Grandparents and others can think that this is coddling, or too much work.  After all, why doesn’t she greet me warmly like other children?  It is hard to parent a child with sensitivities, but your primary focus is on helping the child feel calm and comforted.  Explain that this is helpful and that the child really does love them.  He just needs a bit of help to express it.

We should be able to get out of the way emotionally for the sake of little people.  If a family member cannot wrap their head around the need to support instead of impose themselves on a clearly agitated child, then they need more help to understand sensitivity.