Category Archives: occupational therapy

How To Correctly Reposition Your Child’s Legs When They “W-Sit”

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Hypermobile kids, kids with low muscle tone, and kids with sensory processing issues are champion “W-sitters”.  What’s that?  If your child sits with their thighs rotated inward, knees bent, and their feet rotated so their toes point outward, you have a W-sitter.   This sitting pattern isn’t abnormal if it is only one of many positions your child uses while playing on the floor.  It really isn’t.  But if it is the ONLY  way they like to sit, the only way they are able to sit without falling over, or the only way they are comfortable sitting on the floor, you may have a problem.

What kind of problems?

Persistent W-sitting can tighten hip and leg muscles to the point at which walking is negatively affected.  It also overstretches and discourages the development of the muscles needed for good walking and postural control.  It can loosen important hip and knee ligaments that are also essential for walking.  W-sitting inhibits active trunk muscle activation (that core thing again!).  We all know that having a weak core is a problem for good quality movement.  And finally…poor gait quality is a safety issue.  More falls, more tripping, more leaning on things and people.  Read Safety Awareness With Your Hypermobile Child? Its Not a Big Thing, Its the Biggest Thing for a deeper dive into safety awareness.

There is a sensory impact as well.

What isn’t always so obvious is that having a weak core and only using a sitting position that locks the lower body into a collapsed position tells a sensory-sensitive kid that their brain is telling the truth; they are vulnerable and it is not that easy or safe to move.  This inhibits movement exploration and opportunities to build balance, strength, etc.

So….What is the best way to reposition your child’s legs?

  1. Don’t pull their feet out and around.  If your kid has issues such as hypermobility, you may be contributing to more joint problems if you place force on delicate tissue.
  2. You can demonstrate alternate sitting patterns and see if they will copy your position.  This requires the language, cognitive and motor skills to do so, and the willingness to comply.  Young children and special needs kids may not be able to follow your directions.  Some parents tell their child “Legs out” or “Fix your feet” and they slowly learn what that means.
  3. Try practicing regularly and rewarding other sitting patterns.  Praise will work for some kids but not all kids.  You know if you have a child that will take the bait.
  4. Tilt their trunk to one side, and wait for their brain to elicit a “righting reaction”; kicking the opposite leg out and forward.  Repeat on the other side.  A child with CP may not be able to overcome their spasticity to perform this, but you certainly can try it with any child.  If your child fights you on this, tip them to the side faster so that the reflexive response overs before they realize it, and use all your Happiest Toddler techniques Use The Fast Food Rule For Better Attunement With Your Child to decrease the oppositional behavior.
  5. Think of other more dynamic positions for play.  Read Three Ways To Reduce W-Sitting (And Why It Matters)
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Does Your Older Child Hate Writing? Try HWT’s Double-Lined Paper

 

This paper has been more useful to older kids (6+) that I see for handwriting help than any other paper on the market, and almost any other tool Problems With Handwriting? You Need The Best Eraser , Great Mechanical Pencils Can Improve Your Child’s Handwriting Skills .  Why?  Regular lined paper, and almost all worksheets, are usually jam-packed with lines.  Red lines, green lines, lines with airplanes and worms.  There are papers designed by occupational therapists that are even more complex than the mass-market choices.

All this is often visual noise to kids with sensory processing issues and ocular or visual-perceptual issues.  These problems are sometimes subtle and appear to be behavioral.  The kids who “hate to write”.  The kids who look away when you are demonstrating how to write a letter or spell a word.  The kids who cannot seem to remember where to start a letter, even after repeated practice.  These children often do much better with HWT’s double-lined paper.

Let’s drill down into the design of this unique paper:

  • Double-lined paper provides just two lines; the baseline and the midline.  Knowing where to start uppercase letters and tall lowercase letters is important, and this paper encourages practice and awareness while still giving some structure to writing.
  • There is a wide empty space between sets of lines.  This is intentional; children have room to place the tails of lowercase “y” and “j”, for example, without blocking the uppercase or tall lowercase letters of the next line of writing.  For many kids, not knowing what to do about crowding and spacing is a good reason to stop trying to write well, or sometimes even write at all.
  • This sturdy paper is pre-punched to be used in a 3-ring binder.  The quality of the paper is very high, which means that it doesn’t tear easily when a child erases a mistake.  Most schools provide the thinnest paper for teachers to use as handouts, creating the potential for a disaster when given to a child that struggles with grading their force on an eraser, or makes multiple errors in a word.
  • Brains get practice in sizing and proportion.  Once kids have a pattern of letter formation, it is easier to accomplish without the extra midline.  But so many kids need that “training wheel” effect much longer than scrolls recognize.  Many kids need a day or two of double-lined paper use to start understanding the way a letter “h” is twice as tall as a letter “a” and the same size but aligned differently than the letter “y”.  Of course, pointing it out is important, and so is working on other writing qualities such as letter and word spacing.
  • Kids write faster.  Because they are guided to proportion and start letters correctly, they don’t waste time thinking about it or erasing incorrect letters.  Again, this doesn’t mean their brain isn’t taking it all in.  If that were true, we would start every kid on single-lined paper in preschool.
  • There are three line sizes, so you don’t have to abandon the double-lines when your kid enter middle school.  I will admit that I wish the pre-k/K paper were thicker.  But it is still fairly sturdy.
  • You can alternate using this paper with single-lined paper to see when to “take the training wheels off” and stop using double-lined paper.  Kids should always have a chance to practice with standard paper, but when the choice is between fighting and crying, and quickly executing a homework assignment, it is no contest.

 

The best paper wins.

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Does Your Child “Trace” the Room’s Perimeter or Hate Big Spaces? There is a Sensory-Based Explanation

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Space; the final frontier?

When you see it, it looks like Helen Keller crossed with a Roomba.  A child enters a space, even a familiar space, and runs the perimeter without stopping to play or examine things.  They may trace the room with their fingers, or repeat this process many times before they “land” and engage in some kind of purposeful activity.  If they get upset or challenged, they may resume this behavior.

One explanation for this behavior is that it is a solution to spatial processing difficulties.  When a typical child over the age of, let’s say 14 months, enters a room, they use their visual and auditory skills to tell them about the shape, height, and contents of the room.  As we mature, we use higher-order sensory input to inform our awareness and thinking.  We use sound in particular to tell us about the space to our sides and behind us that we cannot see.  Kids with ASD and SPD are stuck using immature types of information, and need to use them more often and more intensely to get the same knowledge.

How does this feel for them? Think of Notre Dame cathedral (before that awful fire).  The soaring ceilings and the long aisles create an other-worldly feeling you cannot escape.  Your brain knows you are not in your living room, or even in your own place of worship back home.  The medieval architects knew this too.  That was exactly the effect their were aiming for.  To set you back on your heels with the wonders of G-d.  How?  By making the spatial characteristics very unfamiliar and difficult to square with everyday experience.  To have you feel smaller and less in control in the presence of the almighty.

Now imagine that every space you inhabit gives you that feeling.  You enter a room and your eyes go everywhere.  You want to walk around to give yourself more information about where you are.  You don’t, but your nervous system is suggesting it.  You feel off balance and vulnerable.  Sound familiar?

What can you do?  Treating spatial processing issues isn’t easy.  Addressing limitations in vestibular and visual processing can really help, but I think that sound-based treatments are some of the easiest and most effective.  I use Quickshifts effectively to address spatial processing issues  Quickshifts: A Simple, Successful, and Easy to Use Treatment For Processing, Attention and Postural Activation.  Of course, it is best to address all the sensory processing issues any child has to get the best results.  You want to cement in the skills of better sensory processing by achieving good functioning in multiple situations.  But spatial processing problems have to be addressed to achieve a calmer and more organized state.  You want every child to feel safe and supported wherever they go!

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Effective sensory processing treatment helps kids feel safe in big spaces

Quickshifts: A Simple, Successful, and Easy to Use Treatment For Processing, Attention and Postural Activation

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Every child loves music, but not every music is therapy!

What if you could add a sensory-based treatment that could target specific sensory and behavioral goals, doesn’t require expensive equipment or a large therapy space, and you could see the effects within a very short time?

Since adding Quickshifts to my therapy sessions, I have been able to address some of the more difficult behaviors and sensory processing issues I encounter in EI.  Very young children are often afraid of being on therapy balls and swings, and they don’t always tolerate the Wilbarger or Astronaut protocols.  But everyone can listen to music.  Enter Quickshifts.

I am primarily using them over speakers, since even older kids are struggling with wearing headphones.  I find that this isn’t preventing progress, and I periodically try to reintroduce headphones with children over 2.  They can change so quickly that I never know when “NO” will turn into “maybe”.

Why Modulated Music Wasn’t Working For Me

I stopped using Modulated music a long time ago.  Not because I didn’t think it was an effective treatment.  Because I couldn’t get any compliance at home and I saw very little progress with use just in my sessions.  There was often a learning phase in which I had to adjust the amount of listening time to prevent overwhelming young or very challenged children.  Using them only in treatment sessions seemed to make little meaningful difference in my little customers.  The way Modulated music needed to be scheduled and used (two daily 30-minute sessions, 2-3 hour wait before sleep times and between listening times) made it almost impossible for the EI population at home, regardless of how willing parents seemed to be.  And very few were that willing.  Maybe they would be able to do insulin injections on a schedule, but not music.

 

Quickshifts:  More Flexible, More Easily Tolerated, More Effective in EI

Quickshifts have been much more flexible but just as successful.  They can be used often throughout the day, any time of the day.  I haven’t seen one small child react in a way that indicated that they were overwhelmed.  The ability to target specific types of sensory-based goals means I can deliver results.

Parents are happy to be able to download the albums and use them to improve transitions, sleep, attention and more. The use of technology to entrain an alpha brainwave state means that if the album isn’t a perfect fit, I don’t get an overwhelmed child; there is always some improvement in regulation and arousal.  But when I have seen kids generate more postural activation, calm down and even laugh, or tune into their environments in ways they never have before Quickshifts, I wonder why I waited so long to get this treatment on board.

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The Subtle Ways Chronic Medical Care Affects Infant and Toddler Development

 

hannah-tasker-333889-unsplashThe good news:  more and more extremely premature and medically complex babies are surviving.  The bad news: there is a cost to the extended and complex treatment that saves their lives and helps them to thrive.  This post is an effort to put out in the open what pediatric therapists know only too well goes on after the medical crisis (or crises) are over.   Only when you know what you are seeing can you change it.

This is not an exhaustive list; it is a list of the major complications of a complex medical course of treatment on behavior:

  1. Your child is likely aware that their coughing, crying, or other reactions will stop parents and even some medical professionals in their tracks.  I have had kids who didn’t get what they wanted learn to hold their breath until they turned blue.  If you have worked in medicine, you should know that if a child does this and faints, they will immediately begin breathing again.  It doesn’t scare me.  But it can terrify family members, teachers, and other caregivers.  They will stop whatever they were doing and may give in to any demand right away.  Many kids learn who will take the bait impressively fast.  It is very damaging to a child’s relationships and destroys their ability to handle frustration.
  2. Invasive treatments have been done while distracting your child and often without involving your child in any way.  This has taught your child not to attend to an adult’s actions or words in the same way a typically developing child will do naturally.  Since learning language and fine motor skills are highly dependent on observation, these skills are directly impacted by this consequence.  This pattern can be reversed, but it is highly resistant and has to be addressed directly.  Don’t think it will simply go away as your child recovers medically.  It doesn’t.  As soon as your child can be involved in self-care any way (holding a diaper, etc) you need to engage your chid and demonstrate the expectation that they respond and interact to the degree that they can manage.  All the time.
  3. Typical toddler attitudes are ignored because “He has been through so much already”  If your child is kicking you while you change his diaper ( a real question to me by a private duty nurse) then you react the same way you would if your child didn’t have a G-tube or a tracheostomy.  The answer is “NO; we don’t kick in this house”.  You don’t get into why, or what is bothering them right away.  The immediate answer is “no kicking”.  Not now, not ever.  Aggression isn’t unusual or abnormal, but it has to be addressed.  With understanding and as little anger as you can manage as your beloved child is aiming for your face with his foot.
  4. Children who are unable to speak to engage you or able to move around their home will come up with other methods to gain and hold your attention.  Some children throw things they don’t want and HOPE that you make it into a big deal.  Or they throw to gain attention when they should be using eye contact, vocalization or signing.  They wanted your attention, and they got it.  Without speaking, signing or any other appropriate method of communication.  This is not play, this is not healthy interaction.  This is atypical past 10-12 months, and should be dealt with by ignoring or removing the items, and teaching “all done” or “no” in whatever method the child can use.  And then teaching the correct methods of gaining attention and rewarding it immediately.  The biggest roadblock is that if one caregiver takes the “throwing” bait, the child will dig in and keep using that method.  Adults have to act as team managers, and if they fail, the behavior keeps on going.
  5. Children can request being carried when they don’t need the assistance, but they want the attention.  This can delay their advancement of mobility skills.  One of my clients has learned which adults will hold his hand even though he can walk unaided.  He likes the attention.  The clinic PT doesn’t know this is happening, even though the family brings him to therapy.  Like a game of telephone, each caregiver assumes that the child needs the help he is requesting.  He is not developing confidence in his own home, which should be the first place to feel safe and independent.  He depends on adults to feel safe.  Oops.

 

In many ways, my job as an OTR is to alter some of these behaviors to allow normal development to take place.  Long after those medical crises are terrible memories, the consequences of those days, weeks, months and sometimes years can have significant effects on learning and independence.

Looking for more ideas to help children grow and develop?  Read Need to Support A Child’s Independence? Offer to Help Them! and The Not-So-Secret Solution for Your Child With Motor And Sensory Issues: Dycem.  Do you have issues with your child’s siblings?  Read Are Your Other Children Resentful of Your Special Needs Child?

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Does Your Special Needs Child Have a “Two-tude”? Its Not Just the Age; Its Frustration Minus Skills

 

patrick-fore-557736I spend a lot of my work week with toddlers, and they can be a challenge.  One minute sunny, the next screaming because their cookie broke.  Special needs toddlers can have a “tude as well, but many professionals sweep it under the rug.  They tell parents that this is normal, and that they should be grateful that their child is going through a completely normal stage of development.

Except that many parents who have already raised typically-developing kids KNOW that there is a difference with this child.  It could be the intensity of the ‘tude, or the frequency of the meltdowns, or the types of events that trigger the tantrums.  OR ALL OF THEM!  Parents know that this doesn’t feel the same, but they often shut up when they are told that it is so normal.  Perhaps their eyes and ears and memory isn’t correct.

They aren’t wrong.  Their perception that something is a bit different can be totally correct.  And the reason(s) are quite obvious to me.

Special needs kids come in an almost endless combination of needs.  Some are physical, some are communication needs, and some are cognitive or social skill needs.  Some are all of these.  Having challenges in moving, speaking, comprehending language and/or concepts or struggling to interact will create more frustration for every single day of a child’s life.  That’s the reality of disability.

The image of the placid and sweet special needs child, patiently waiting to be assisted and supported is just that: an image.  Most kids bump into frustrating barriers every day.  The toddler that has just learned to walk but can’t run, the toddler that is talking or signing but still isn’t understood by their older brother, the toddler that cannot handle a change in routines…it goes on and on.

Typical toddlers spend less time frustrated that they are unable to accomplish simple skills.  The typical 14 month-old that can’t tell you what he wants becomes the 18-month old that can say “cakker, pease” for “cracker please”.  A special needs child could be 4 years old and still struggling to explain that he wants another cracker.  That is a long time to be frustrated.  The typical 26 month-old that can’t run after their brother in the backyard becomes a runner at 30 months.  A special needs child may not run for years.  That is a long time to be left in the dust when everyone is running.  Is there any wonder that parents see more frustration, more tears, more stubbornness?

My saddest story of failed inclusion is when a family placed their special needs child in a toddler development group with mobile kids.  Even though this child had a personal aide, he still watched as his peers got up from the snack table and ran outside.  They left him with the aide, who then carried him outside so he could WATCH his peers climb and run.  He became distraught at home when he was left alone in a room.  A puddle of tears.  It was so sad to see.  No one had thought of the emotional cost of inclusion to this toddler, only the social and academic benefits.

What can be done?

I teach families the Happiest Toddler on the Block strategies as soon as they are appropriate.  Dr. Karp’s techniques build a child’s skills while enhancing interpersonal connections.  Yes, sometimes you have to provide consequences for aggression, but mostly it is about building frustration tolerance and emotional intelligence.  For everyone.  I use these techniques all day long.  I could never handle so many toddlers for so many years without them!

Looking for more information on special needs toddlers?  Read Need to Support A Child’s Independence? Offer to Help Them! and Safety Awareness With Your Hypermobile Child? Its Not a Big Thing, Its the Biggest Thing.

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Need to Support A Child’s Independence? Offer to Help Them!

 

irina-blok-192240-unsplashI know; it sounds like I am being sarcastic.  That couldn’t be farther from the truth.  Instead of telling children to “Give it another try” or “I know you can do it”, offering help to a young child can have the paradoxical effect of eliciting more perseverance and attention.

It really isn’t all that complicated:  think of your own responses for a moment.  If you were trying to fill out your tax forms, and ran into difficulties, you might call an accountant for help.  If their response was “Just keep trying; I know you can figure it out!” you probably wouldn’t be excited to try again.  You might feel even more agitated.  I know what I would be thinking:”If I knew what to do, I wouldn’t have called you int he first place!”

If your accountant said “Let me take a look.  Oh, I underlined some of the important numbers.  You got stuck with line 32b, right?” you could see the issue in a new light, and be able to come to a solution without having to walk away or tear up the form.  Your accountant used their advanced knowledge to set you up for success.

We need to do the same thing for children.  Telling them we have faith in them, or insisting that they need to try again when they clearly don’t know how to alter their actions, is not kind or even very educational.  It leaves them feeling abandoned under stress.  Even if we know they can solve for X, they aren’t doing it now.

For the very youngest kids, I have a special solution.  You “wiggle it”.  Young children don’t know how we understand how to do so many things well.  When they get stuck opening containers or assembling objects, I offer to “wiggle it”.  By demonstrating that the container does indeed open, or that the bead will fit on the string, I am assuring them that they could be successful.  More importantly, I am demonstrating the correct grasp pattern and stabilization method.  And finally, I am rebooting their motor plan and their frustration level.  Just handing the object over to me reduces their agitation.  When children aren’t so frustrated, they can think and create better motor patterns.’

All this from a little “wiggling”.

To read more about building confidence and coordination, read For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance and Why Telling Your Child “It’s OK” Doesn’t Calm Him Down (And What To Do Instead)