Category Archives: occupational therapy

Is Your Child With Low Tone “Too Busy” to Make it to the Potty?

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Since writing my first e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, I have fielded a ton of questions about the later stages of potty training.  One stumbling block for most children appears to be “potty fatigue”.  They lose the early excitement of mastery, and they get wrapped up in whatever they are doing.  What happens when you combine the effects of low tone with the inability of a  young child to judge the consequences of delaying a bathroom run?  This can lead to delaying a visit to the bathroom until it is too late.  Oops.

Kids with low tone often have poor interoceptive processing.  What is that?  Well, interoception is how you perceive internal sensory information.  When it comes to toileting, you feel fullness in your bladder that presses on your abdominal wall, in the same way you feel a full stomach.  This is how any of us know that we have to “go”.  If you wait too long, pressure turns to a bit of pain.  Low muscle tone creates a situation in which the stretch receptors in the abdominal muscles and in the bladder wall itself don’t get triggered until there is a stronger stimulus.  There may be some difficulty in locating the source of pressure as coming from the bladder instead of bowel, or even back or stomach.  This leads to bathroom accidents if the toilet is too far away,  if you can’t walk fast enough, or if you cannot pull down your pants fast enough.

Add in a child’s unwillingness to recognize the importance of the weak sensory signals that he or she is receiving because they are having too much fun or are waiting for a turn in a game or on a swing.  Not being able to connect the dots is common in young children.  That is why we don’t let them cross a busy street alone until they are well over 3 or 4.  They are terrible at judging risk.

What should parents do to help their children limit accidents arising from being “too busy to pee?”

  1. Involve kids in the process of planning and deciding.  A child that is brought to the potty without any explanations such as “I can see you wiggling and crossing your legs.  That tells me that you are ready to pee” isn’t being taught how to recognize more of their own signs of needing the potty.
  2. Allow kids to experience the consequences of poor choices.  If they refused to use the potty and had an accident, they can end up in the tub to wash up, put their wet clothes in the washer, and if they were watching a show, it is now over.  They don’t get to keep watching TV while an adult wipes them, changes them, and cleans up the mess!
  3. Create good routines.  Early.  Just as your mom insisted that you use the bathroom before leaving the house, kids with low tone need to understand that for them, there is a cost to overstretching their bladder by “holding it”  Read  Teach Kids With Ehlers-Danlos Syndrome Or Low Tone: Don’t Hold It In! to learn more about this.  The best strategy is to encourage a child to urinate before their bladder is too full, make potty routines a habit very early in life, and to develop the skills of patience stretching Stretch Your Toddler’s Patience, Starting Today!  from an early age.  Creating more patience in young children allows them to think clearly and plan better, within their expected cognitive level.

Looking for more information on managing low tone and hypermobility in daily life?

I wrote three e-books for you!

My e-book on toilet training, The Practical Guide to Toilet Training Your Child With low Muscle Tone, and my e-books on managing pediatric hypermobility, are available on Amazon as read-only downloads, and on Your Therapy Source as printable downloads.  Your Therapy Source has bundled my books together for a great value.  You can buy both the toilet training and the Early Years books together, or both hypermobility books together!

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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 Preschool Camp at Home This Summer? This is the Water Table You Want!

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I just found this online after a parent asked me for recommendations for equipment.  She isn’t sending her two kids under 5 to camp this year, and needs some ideas to turn her backyard into a fun place to spend the summer.  This is the Little Tikes Magic Flower water table.

Why do I love this one?

Watch their video on Amazon and you will understand!  But before you do, here are my reasons, as an occupational therapist, for recommending this water table:

  • Multiple levels mean that children of different ages can both have fun.
  • Multiple ways to explore helps kids take turns without having to choose between “the fun thing” and the “barely OK things” on the water table.
  • The animal theme works for lots of kids.  Not everyone likes pirates.  Or even understands pirates.
  • It is big enough to have at least 2 kids playing at the same time, maybe 3.
  • They include 2 duckies (who doesn’t love duckies?), 2 frogs, 3 turtles, a fish, and three pouring choices.  I hate tables where you STILL have to go out and buy stuff to make it fun.  This table is “one-and-done”.
  •  All of my clients with low tone and hypermobility that can stand will be motivated to do so; there isn’t really any way to lean on this water table.  They can stabilize by holding an edge, but they cannot drape themselves over it.  They will be bending and reaching.  A lot.  That is a good thing.
  • Kids that use a wheelchair or need to sit while playing due to mobility issues will still be able to have fun with their friends and siblings that can stand and bend.  This water table is inclusive.

I really hate sand tables.  You would think that as an OTR, I would love them.

Nope.  Sand gets everywhere.  In clothes, in body folds, everywhere.  Kids get sand in their mouth and in their eyes.  It tracks into the house unless you shower your kid outside, and maybe it will be found inside even then.  Sand is a pain in the neck.

As long as you empty your water table and hit it regularly with some soap or a diluted bleach solution to keep it clean, it is much easier on everyone to have a water table rather than a sand table.  This one is going to be a lot of fun!

Need more ideas for fun this summer?  Read The Preschool Water Arcade Game You Need This Summer If Camp is Cancelled (and maybe even if it isn’t) and 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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Gifted Child? Try “How Does Your Engine Run” For Sensory Processing

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I love working with gifted children.  OTs get referrals to work with gifted kids whether or not they have been tested by a psychologist.  Some have motor delays amplified by the asynchronous development, but many are sloppy at handwriting because their motor skill cannot keep up with their language skill.  Some are sensory avoiders or sensory seekers.  Or both.  They aren’t always in distress.  They are almost always out of synch with their families, peers, and teachers.  Without understanding how to manage sensory processing issues, these kids are driven by the need to handle motor demands and sensory input, often driving their teachers and parents a little bit nuts.

Some gifted kids really do need motor skill training and sensory processing treatment.  They are struggling with tolerating their world, and can’t achieve their potential in school, with peers, and at home.  While many kids are “twice exceptional”  and have a learning disability or other disorder in addition to being gifted, simply being gifted creates permanent processing challenges.  The gifted brain will always be driven, and it will always prefer intensity and complexity to an extent that exceeds people with typical skills.   Almost all younger gifted kids need help to understand that their brains will always respond this way, and they will constantly bump up against the typical world in ways that can create problems.  Knowing how to manage this conflict in daily life is our wheelhouse.  Occupational therapy is focused on function.  Always.  We don’t stop with a neurological explanation of giftedness.  We have solutions.

One of the most useful strategies to address a child’s aversions or sensory seeking behaviors is to create a “sensory diet”.  This can be very simple or very complex.  A sensory diet provides activities and equipment that help people tolerate sensory experiences that overwhelm them, but it also “feeds” the desire for sensory experiences that can derail them from interaction and participation.

Avoidant kids learn that more proprioception will help them tolerate noise without wearing headphones and blocking out all interaction.  Sensory seekers learn that they don’t have to kick another kid’s chair to get input; they can do wall push-ups or wall sitting quickly in the hall between classes.  Therapy that includes a sensory diet helps the child who has such pressure to speak that they interrupt everyone, and it helps the child that learned to escape bright lights and scratchy clothes through daydreaming.

Developing a sensory diet that a child can use independently is the goal of Mary Sue Williams and Sherry Shellenberger’s book “How Does Your Engine Run?  Children learn about sensory modulation by thinking about their ability to perform sensory processing as an engine.  Running too fast or too slow doesn’t allow for great performance.  Running “just right” feels good internally and allows a child to learn, respond appropriately and achieve mastery.  Finding the right activities and environments that allow for “just right” processing is based on what therapists know about neuropsychology, but this program asks the client to assess what works for them, and asks them to use these strategies effectively.

This book isn’t new, and it isn’t perfect.  But it is a good place to start.  It explains behaviors using neurological strategies that work, and provides a framework for inexperienced therapists to move from prescribing to guiding.  A gifted child can begin the process of using a self-directed sensory diet far earlier than their typical peers. I have seen 4 year-olds start to master their own drives once it is explained to them.  They feel terrific when their abilities are recognized, and adults are seen as supporters instead of controllers.

The biggest problem I encounter is unlearning the behaviors that children have developed before their parents and teachers understood that giftedness is more than a big vocabulary.  Children may have learned to push a parent to exhaustion to get what they wanted.  They may have bullied adults or intentionally alienated adults to be allowed to do what they want.  They may have become extremely bossy and gotten away with it.  They may have decided that any skill that takes time to develop isn’t worth it.  They will lead with the things that they find effortless.  This will trip them up over time, but without understanding the life of the gifted child, these behaviors sprout like weeds.

Gifted children are still children, and they need guidance and support to grow into their gifts!  Occupational therapists can help them and their families do just that.

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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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How To Pick A High Chair For Your Special Needs Child

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My first Early Intervention home visit always involves seeing the child sitting in their high chair.  I learn a few things.  I learn how the child is handled by the parent or caregiver, including whether they use the available strapping to secure them.  Many don’t, and don’t realize that it is part of the problem.  I learn how well the child fits into the chair, and how well the child can balance and reach in this chair.  And I hear about what problems the parent or caregiver is having with using this seating system.

This post is intended to share some of what therapists know about seating, and how to pick a better chair for kids that have challenges.

Every parent reading this post should know that their child’s therapists are their best source for getting the right high chair.  Never consult Dr. Google when you have licensed professionals available.  There is a reason for that license!  The folks you meet online cannot evaluate your child and provide safe recommendations for you.  This includes me; my comments are meant to educate, not prescribe.  That would be unethical and unsafe.

Typical children need a high chair when they can maintain their head balanced in the center and can start reaching and holding a bottle or finger food.  Before that, they use a feeding seat.  Feeding seats are slightly-to-moderately reclined and do the job of a parent cradling a child while feeding.  A child in a feeding seat usually isn’t expected to independently steady their head or hold a bottle. There are usually straps that stabilize a child’s chest and shoulders as well as a strap that stabilizes their pelvis.

Again, not every adult uses these straps correctly to give a young child the best support.  I will always do some education on methods to correctly position and adjust strapping.  The adult’ reaction (relief, curiosity, resistance, disinterest) tells me a great deal about what is coming down the pike.  Some special needs kids will use a feeding chair well past 12 months of age.  The commercially-made feeding chairs aren’t large, so some kids won’t fit  into one much past 18 months.  After that happens, we have to think about either a commercial high chair or adaptive seating.

Commercially-made high chairs in the US are gigantic.  They could hold a 4 year-old! This is always a problem for special needs kids.  Too much room to move in the wrong way isn’t helpful.   These chairs may or may not have chest/shoulder straps, and they may not have an abductor strap (the one between a child’s legs, that prevents them from sliding under the waist belt).  The best chairs have the waist belt low enough that it sits across a child’s lower hips like a car’s seat belt.  This is always preferable to sitting at the bellybutton level.  It provides more stability.

If a special needs child collapses their posture while sitting in a high chair, when I stabilize their hips in a way that doesn’t allow them to collapse, they might complain.  They were allowed to slouch so much that this new position, with appropriate core activation, feels wrong to them.  It can take a while for a child to learn that eating and playing in a chair requires them to use their core.  I allow them to gradually build up their abilities with short periods of eating and playing.  Not every parent is comfortable finding out that they were contributing to core weakness by allowing a collapsed posture.  I don’t add to that feeling; you know more, you do better.  Simple as that. No guilt.

Some providers insist that every child, at every age and stage, have a place to put their feet.  The strongest proponents of this idea are usually not therapists but educators or speech therapists who attended a positioning lecture or inservice.  Occupational therapists know that a child that doesn’t have the hip control and emerging knee and foot control to place weight into their feet will not be able to use their feet to steady their trunk.  They will, however, figure out how to use a footplate incorrectly.  Unless a child is older than 2 and requires lower leg stabilization to avoid tightening their hamstrings (which will derail their positioning) and sliding forward, or to prevent sensory-seeking or ataxic movements, I don’t strap a child’s feet onto a footplate, or even worry about providing a footplate.  A child that is in a feeding chair, or just beginning to use a high chair, isn’t going to use a footplate correctly, and is more likely to use one to ruin previously decent positioning.  A child that is able to bench-sit or is starting to take weight into their feet?  That child can use a footplate to build sitting control.  Here is a post to help you use one well: A Simple Strategy To Improve Your Child’s Posture In A Stokke Tripp Trapp or Special Tomato Chair

Special needs kids that have very limited head and trunk control will often need an adaptive seat that gives them more support.  It can transform them!  More support can allow more freedom, not less.  These chairs are able to be customized, are obtained through DME vendors and can be paid for by insurance or EI.  They are expensive, and considered medical equipment, not chairs.  Parents need instruction in their use to avoid harming a child by too intensive strapping and incorrect adjustments.  But when done right, they can transform a child’s abilities in ways that no commercially-available chair can accomplish.  Giving a child a seating system that frees them to reach and look and eat and communicate is a wonderful feeling.  Those of us that are trained in seating evaluation know that the right chair can build skills, not substitute for them!

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