Category Archives: occupational therapy

Hypermobile Child? Simple Dental Moves That Make a Real Difference in Your Child’s Health

As the OT on a treatment team, I am the ADL (Activities of Daily Living) go-to person.   Why then, do so few parents ask me what ideas I have about ADLs, especially dental care?  Probably because OT as a profession has developed this reputation as either focused on handwriting or sensory processing.  Maximizing overall health and building skills by improving ADLs is often pushed to the side.  Not today.

People with connective tissue disorders have a greater chance of cavities and more serious dental problems.   Knowing what to do for your child and why it is important helps parents make changes in behavior with confidence and clarity.

Here are my suggestions to support a child that has been diagnosed or is suspected of having Ehlers-Danlos hypermobility or any connective tissue disorder:

  1. Teach good dental hygiene habits early.  Why?  Habits, especially early habits, seem to be harder to dislodge as we age.  Good self-care habits can and should last a lifetime.  Automatically brushing and flossing gently twice a day is cheap and easy.  Make it routine, not optional.  I know how this can become a fight for young children.  This is one of those things that is worth standing your ground on and making it fun (or at least easy) for children to do.  Brush together, use brushes and pastes with their favorite characters, pair it with something good like music or right before bedtime stories, but don’t think that dental care isn’t important.
  2. Research on people with typical connective tissue suggests dental care reduces whole-body inflammation.  Inflammation seems to be a huge issue for people with connective tissue problems, and no one needs increased inflammation to add to the challenges they have already.  Enough said.
  3. Tools matter.  Use the softest toothbrushes you can find, and the least abrasive toothpaste that does the job.  Tooth enamel is also made from the same stuff and skin and bone, and so are gums.  Treat them well.  Water-powered picks and battery-operated brushes may be too rough, so if you want to try them, observe the results and be prepared to back off it becomes clear that your child’s tissues can’t handle the stress.
  4. Think carefully about acidic foods.  Lemonades, orange juice, energy drinks, and those citrus-flavored gummies all deposit acids on teeth that are also mixed with natural or added sugars.  Those sugars become sticky on teeth, giving them more time to irritate gums and soften enamel.  Easy hack?  Drink citrus/acidic drinks with a straw.  Goes to the back of the mouth and down the hatch.  At the very least, drink water after eating or drinking acidic foods to rinse things out.
  5. Baby teeth count.   Because your young child hasn’t lost even one baby tooth, you may think this doesn’t apply to you.  Those permanent teeth are in there, in bud form.  Children can develop cavities in baby teeth as well as permanent teeth.  Gum irritation is no different for young children, and they are less likely to be able to tell you what they are feeling.
  6. Consider sealants.  I know…some people are nervous about the composition of sealants.  I would never criticize a parent who opted out of sealants.  It is a personal decision.  But be aware that they don’t increase tissue irritation and they protect tender tooth roots and the surrounding gums.  At least have an open discussion with your pediatric dentist about the pros and cons.  I am mentioning sealants here because some parents aren’t aware that this treatment option can reduce cavity formation and gum deterioration.

Is is Sensory Or Is It Behavior? Before 3, The Answer Is Usually “Yes!”

If I had a dollar for every parent that asked me if head banging when frustrated means their child has a sensory processing disorder...well, I would be writing this post from a suite in Tahiti.  Modulation of arousal is the most common sensory processing concern for the parents that I see as a pediatric occupational therapist.  Their children struggle to transition, don’t handle change well, and can’t shift gears easily.  But hold on.  A lot of this behavior in children  under 3 is developmental in nature.  Not all, but a lot.  Parsing it out and addressing it takes a paradigm shift.  Not every annoying or difficult behavior is atypical for age and temperament.

Everyone knows that you can’t expect your infant to self-regulate.  Nobody tells their baby “Just wait a little; why can’t you be like your brother and sit quietly for a minute?”  But why do adults assume that once a child can speak and walk a bit that they can handle frustration, wait patiently, and calm down quickly?

I know parents WANT that to be the case.  Toddlers are a handful on a good day.  Adorable silliness can melt your heart, but getting smacked by an angry child that was just given a consequence for trying to put your cell phone in the toilet to see if it would float?  Nah, that isn’t going to put a smile on your face.  Parents tell me “If they could only understand that when I say “wait”, I mean that you will get what you want, just not immediately.”  But no.  The toddler brain grows very slowly, and even the super-bright children who read at 3 cannot make their emotional brain grow any faster.  Sorry.  Really.   This brain thing means years of developing communication and regulation skills.

Here is the good news:  Even young children with clear sensory-based behaviors do better when your responses to their behaviors help them self-calm.  The recipe is simple to describe.  You give limits based on age, use familiar routines, teach emotional language and responses by modeling, and communicate effectively.  The Happiest Toddler strategies have transformed my work because children feel listened to but I don’t give in to toddler terrorists.  Everybody wins.

Here is the bad news:  You have to change your behavior in order to help them.  And you have to do it consistently and with loving acceptance of their limitations.  “Behavior” isn’t just their problem.  It is both of yours.  Take a look at my posts on Happiest Toddler techniques that really work for the little ones, and see if your suspicions of a sensory processing disorder wane or even evaporate as you and your child learn some valuable communication and self-calming skills.  The posts that can alter things today might be Nip Toddler Biting in the BudToddlers Too Young For Time Out Can Get Simple Consequences and Kind Ignoring, and How To Get Your Toddler To Wait For Anything (Hint: They hear “Wait” as “No”)

Good luck, and let me know what works for you!

 

Can Hypermobility Cause Speech Problems?

 

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As a pediatric OT, many of my clients have speech and feeding problems that are attributed to low muscle tone.  Very often, that is where assessment ends.  Perhaps it shouldn’t.  Joint hypermobility can create issues such as dysarthria, disfluency and poor voice control.  It isn’t only about muscles and muscle coordination.  Being able to identify all the causes of speech delays and difficulties means better treatment and better results.

I have had the privilege to know a handful of master speech pathologists whose manual evaluation skills are amazing.  These clinicians are capable of identifying joint laxity and poor tissue integrity (which contribute to injury, weakness and instability) as well as identifying low muscle tone, sensory processing issues and dyspraxia.  They can assess whole-body stability and control instead of ending their assessment at the neck.

It is more difficult to clearly differentiate low muscle tone from hypermobile joints in young children.  Assessing the youngest clients that cannot be interviewed and do not follow instructions carefully (or at all!)  is a challenge.  Many times we are forced to rely on observation and history as much as we use responses from direct interaction with a child.  In truth, laxity and low tone often co-exist.  Lax joints create overstretched or poorly aligned muscles that don’t contract effectively.  Low muscle tone doesn’t support joints effectively to achieve and maintain stability, creating a risk for overstretching ligaments and injuring both tendons and joint capsules.  A vicious cycle ensues, creating more weakness, instability and more difficulties with motor control.

Some children that are diagnosed with flaccid dysarthria, poor suck/swallow/breathe synchrony, phonological issues and poor respiratory control may be diagnosed later in life (sometimes decades later) as having Ehlers-Danlos Syndrome or generalized benign joint hypermobility syndrome.   They often drop the final sounds in a word, or their voice fades away at the end of a sentence when they are younger. These kids might avoid reading or speaking front of the class when older.  This isn’t social anxiety or an attitude problem.  They are struggling to achieve and maintain the carefully graded control needed for these speech skills.

You may notice a breathy-ness to their voice that makes them sound more like their grandparents than their peers.  Children that avoid running in sports like soccer or hockey aren’t always unable to continue because they are globally fatigued or in pain.    Being unable to stabilize their trunk results in inefficient muscular recruitment and limited grading of breath.  Ask any runner or singer and they will tell you what that means: game over.

If your child is struggling with these issues and isn’t receiving speech therapy, now may be the time to explore it.  You and your child may be relieved to learn that there is effective therapy out there!

 

 

Problems With Handwriting? You Need The Best Eraser

 

 

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A good eraser can make a frustrated child more willing to fix writing errors.  A bad eraser confirms their failure as a writer.

Occupational therapists in some schools hand out HWT pencils and a variety of pencil grips like candy, but many forget about how important it is for kids to erase mistakes successfully in order for their work to be truly legible.  The Pentel Hi-Polymer eraser is the one that gets the job done.

I will confess that I did not discover this eraser on my own.  A smart parent turned me onto this amazing school tool, and I am over the moon about how much it helps children complete their writing assignments.   It would be almost criminal to let kids go back to school this fall with those nasty pink erasers that leave more of a mess than they remove!

Here is an example of how well this eraser works.  I used my fave mechanical pencil for younger children, the one I blogged about in Great Mechanical Pencils Can Improve Your Child’s Handwriting Skills , and wrote a few numbers in the darkly shaded boxes of a Handwriting Without Tears sheet.  Notice that the shading wasn’t removed along with the pencil marks:

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Numbers 5 and 6 have been erased so well that tracing-over the original mistake is impossible!

Here are a few reasons to add this eraser to your back-to-school list:

  • While large enough for small hands to use, it is not so big that it is difficult for children to control.  Think erasing isn’t a real skill?  Take a look at Teach Your Kindergartener How To Erase Like a Big Kid
  • It is latex-free, a necessity for children with latex sensitivity.
  • There are fewer eraser “crumbs” created during use, so less mess (for parents) to clean up, and less visual and tactile distractions for kids with ADHD, SPD and ASD.
  • This eraser doesn’t require substantial pressure to remove marks.   Great for kids with Ehlers-Danlos, JRA, and all the other conditions where strength and endurance are concerns for handwriting.
  • Because of it’s softness and effectiveness, it rarely tears paper, even the thin paper commonly used for school worksheets and workbooks.

Pentel Hi-Polymer erasers are very affordable, and commonly come in packs of three. This is helpful when you know in your heart that the first two will be lost before the week is over, never to be seen again.  When your child realizes that this eraser helps them finish their homework a bit faster (you might want to mention this if they don’t notice it right away), they will work harder to hold onto that last one!

Taping The Paper To The Table For Your Child? Stop!

Many young children between 2 and 5, especially children with low muscle tone or postural instability, will struggle with bilateral control.  In preschool, one way to notice this is to see the paper sliding around the table while a child colors.  The common response of teachers (and parents) is to tape the paper down.  Oops!  This  eliminates any demand for both hands to work together.  Bilateral control only develops if it is needed and practiced.

The better approach, the one that makes the brain work and builds a child’s skills, is to make it even more slippery while making the activity more fun.

Why?  This child,’s brain, as described, needs more information about what is going wrong with the activity.  You can use heavier paper, stickers in a book that need accurate placement, or fun glittery markers.  Really, anything that makes a child care more about placing marks accurately.   I select the smoothest table surface available.  Glass coffee tables are a fave at home.  The alternate choice is a bumpy surface, something that will be slightly uneven and make the paper move more with each stroke.

I have some older kids that really struggle but can use a visual cue.  I make a mark on their paper and tell them to put their “helper hand” – the one not coloring- on this mark.  This is sometimes helpful, but it is limiting the extent that this hand is providing optimal postural support.

Yup, support.  The hand that holds the paper is also performing another function.  It is stabilizing the child’s body so that the dominant hand can execute a skilled movement.

So….no more tape on that paper, OK?

Gifted at Preschool: How to Support The Young Gifted Child In Class

Gifted children often cannot wait to go to preschool.  They may follow an older sibling into their classroom and cry when they have to leave.  After all, look at all those books, art supplies, and science stations to explore!   Things can go right off the rails, however, if the teacher and the classroom aren’t prepared for everything a gifted child brings with them.  And I don’t mean the lunchbox or the fidget spinner!

Gifted children are more intense, use more complex thinking, and more driven than other children.  Even at the preschool level.  This is a child who may teach himself to read, tells wonderful stories, creates wonderful multi-media art, and practices kicking a soccer ball into a goal until it is too dark to see the ball.  At 3.  It can also make a child argue about school routines,  insist on changing the rules of every game, and constantly discuss and examine every item in the room.  Imagine the average teacher’s reaction when a gifted toddler wants to grab the story book from the teacher at circle time to determine exactly which type of dinosaur is displayed.  Is that a T-Rex, a brontosaurus, or a brachiosaurus?  She can pronounce their names and knows the difference at 2, and she wants to figure this out, while her classmates are making growling sounds or picking their noses!

Here are some suggestions for teachers to understand and manage the behavior of their gifted students without crushing their spirits or allowing them to run the classroom:

  • Learn about the child’s gifts.  Knowing who you have, who you really have in your classroom: it will help you make a plan.  What they like, what they love, and what frustrates them.  This doesn’t mean that you focus the class on them, but you know that a module on space will elicit a lot of interest, and a module on the color red will not.  Unless you talk about the red planet, Jupiter.
  • Learn about the multiple sensitivities of gifted individuals.  They are not limited to intellectual gifts.  They can include physical sensitivity, emotional sensitivity, and even spiritual sensitivity.  Some will be easier to deal with than others.  But you want to teach the whole child, right?  That way, you see a three year-old’s intense need for movement throughout the day or wanting to have a formal ceremony for the recently deceased goldfish as normal, not perverse.
  • Explain the rules, negotiate the deal when possible, and acknowledge the frustration of things that seem unfair or arbitrary.  Helping gifted individuals fit into a society that says it loves giftedness but really supports conformity, without crushing their spirit, is tricky.  You can help.  Bring their awareness to the fact that controlling the game and telling people what to do and how to do it makes other children less likely to want to play.  This is real teaching.  Even if their new rules for Candyland are truly innovative.
  • Offer real enrichment, not busywork or babysitting.  I have heard stories from parents of teachers who tell gifted children to read to their classmates, or tell them to “teach” their friends about shapes.  This alters the relationships between classmates and is not a good idea.  These kids are going to be singled out soon enough as different.  Build friendships, not mentorships.  More worksheets that they can race through isn’t better.  Find worksheets that challenge them, even if you have to look at kindergarten or first grade materials.  Better yet, make your own, following their interests.  You will be rewarded by a child that loves school and knows they are truly seen as an individual!

 

Joint Protection for Hypermobile Toddlers: It’s What Not To Do That Matters Most

 

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Do you pick up your toddler and feel that shoulder or those wrist bones moving a lot under your touch?  Does your child do a “downward dog” and her elbows look like they are bending backward?  Does it seem that his ankles are rolling over toward the floor when he stands up?  That is hypermobility, or excessive joint movement.

Barring direct injury to a joint, ligament laxity and/or low muscle tone are the usual culprits that create hypermobility.  This can be noticed in one joint, a few, or in many joints throughout the body.  While some excessive flexibility is quite normal for kids, other children are very, very flexible.  This isn’t usually painful for the youngest children, and may never create pain for your child at any point in their lifetime.  That doesn’t mean that you should ignore it.  Hypermobility rarely goes away, even though it often decreases a bit with age in some children.  It can be managed effectively with good OT and PT treatment.   And what you avoid doing at this early stage can prevent accidental joint injury and teach good habits that last a lifetime.

  1. Avoid over-stretching joints, and I mean all of them.  This means that you pick a child up with your hands on their ribcage and under their hips, not by their arms or wrists.  Instruct your babysitter and your daycare providers, demonstrating clearly to illustrate the moves you’d prefer them to use. Don’t just tell them over the phone or in a text.  Your child’s perception of pain is not always accurate when joint sensory aren’t stimulated (how many times have they smacked into something hard and not cried at all?) so you will always want to use a lift that produces the least amount of force on the most vulnerable joints.  Yes, ribs can be dislocated too, but not nearly as easily as shoulders, elbows or wrists.  For all but the most vulnerable children, simply changing to this lift instead of pulling on a limb is a safe bet.
  2. Actively discourage sitting, lying or leaning on joints that bend backward.  This includes “W” sitting.   I have lost count of the number of toddlers I see who lean on the BACK  of their hands in sitting or lying on their stomach.  This is too much stretch for those ligaments.  Don’t sit idly by.  Teach them how to position their joints.  If they ask why, explaining that it will cause a “booboo” inside their wrist or arm should be enough.  If they persist, think of another position all together.  Sitting on a little bench instead of the floor, perhaps?
  3. Monitor and respect fatigue.  Once the muscles surrounding a loose joint have fatigued and don’t support it, that joint is more vulnerable to injury.  Ask your child to change her position or her activity before she is completely exhausted.  This doesn’t necessarily mean stopping the fun, just altering it.  But sometimes it does mean a full-on break.  If she balks, sweeten the deal and offer something desirable while you explain that her knees or her wrists need to take a rest.  They are tired.  They may not want to rest either, but it is their rest time.  Toddlers can relate.

Although we as therapists will be big players in your child’s development, parents are and always will be the single greatest force in shaping a child’s behavior and outlook.  It is possible to raise a hypermobile child that is active, happy, and aware of their body in a nonjudgmental way.    It starts with parents understanding these simple concepts and acting on them in daily activities.

Good luck, and please share your best strategies in the comments section so other parents and therapists learn from you!

Wondering about your child’s speech and feeding development?  Take a look at Can Hypermobility Cause Speech Problems? to learn more about the effects of hypermobility on communication and oral motor skills.

Looking for information on toilet training your child with Ehlers Danlos, generalized ligament laxity, or low muscle tone?  My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, gives you detailed strategies for success, not philosophy or blanket statements.  I include readiness checklists, discuss issues that derail training such as constipation, and explain the sensory, motor, and social/emotional components of training children that struggle to gain the awareness and stability needed to get the job done.

My book is available on my website tranquil babies, at Amazon, and at yourtherapysource.com.