Category Archives: preschoolers

Help Your Child Develop Self-Regulation With Happiest Toddler On The Block

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Children start learning self-regulation early.  Most kids eventually become reasonably skilled at it, given some help from loving adults.  The problem is they don’t learn it quickly.  Self-regulation takes a long time to become established in the slowly-developing brain of a young child.  While you are scooping up the puddle of Jell-O that used to be your toddler before she dropped her ice cream cone, think about how you can use this moment to build her ability to come back to a calm state:

  1.   Reflect her emotions without denying them or taking them on.  After all, you know that it isn’t the end of the world.  But at that moment, she can’t see it.  She is sad and maybe even angry.  Use the Fast Food Rule Use The Fast Food Rule For Better Attunement With Your Child to state what happened and how you think she feels.  Remember to use lots of gestures and alter your vocal tone to convey empathy.  Don’t be placid; after all, she needs to know that you get how unhappy this has made her.  Kids tune into your expressions much more than your words at this age.  You may think you should be soothingly quiet, but she is thinking ” You don’t see my pain!!”
  2. Make sure she knows that you care about what happened, and use this moment to identify what she is feeling.  Even if you intend to get her another cone, allowed her to be upset for a very brief period, and let her know that we call that feeling “sad”.  Kids depend on us to explain what happened to the dinosaurs, how to eat with a fork, and also how to identify and manage emotions.  Take that moment to explain that there is a name for what she is feeling, and that it is normal and understandable, even if you intend to fix it with another ice cream.
  3. Ask her if she wants another ice cream cone, but not too soon.  Sometimes children aren’t ready for our solutions, even if they do want them, and presenting one too early gives a message that we never intended:  I can’t handle your pain, you can’t either, and I need to fix it right away.  Look for that shift in body language, eye contact or verbal connection that tells you she is starting to pull herself together before you jump in with a solution.

 

If you find yourself more upset than your child, their pain ripping through you, take a moment to look inside and see what experiences in your past are contributing to this feeling.  You may have been taught the same lesson early in your own childhood.  If you received the message that pain is unbearable and should be avoided at all costs, you are not alone.  Well, I am going to tell you that an important part of your life, and a part of your child’s life is all about learning to feel feelings without fear and come back to a good place after a difficult experience.

Bad things happen to us all, and the most important lesson you can teach your child at this moment is that she can handle this feeling and come through it.  With your support, and with the support of other people who love her, she will get through the loss of her ice cream and other losses in life as well.

And it can start with how to handle the loss of an ice cream cone….!

 

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Improving Daily Life Tasks for Kids With Special Needs

 

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

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

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

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

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The view north from West Point.  Welcome spring!

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

 

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

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

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

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

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How Hypermobility Affects Self-Image, Behavior and Activity Levels in Children

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Loose joints affect emotions and behavior too!

As rehab therapists, OTs and PTs are focused on skill building and reaching functional goals with our clients.  In this post, I would like to address the many ways that hypermobility can create social and emotional issues for children.  Without awareness of these experiences, we cannot be the best therapists for these kids, or help parents be the best advocates for their children.

Because hypermobility varies so widely in it’s severity, it’s presentation (generalized, primarily proximal, or primarily distal) and it’s progression (decreasing with age or increasing with repeated injuries and overstretching of tissues), the psychological impact on a child will also vary tremendously.  The child who has had significant and global hypermobility from birth will have a very different presentation than the young teen who is only recently experiencing functional issues with instability or pain after years of sports-related injuries.

Here are some major points to consider:

  1. Hypermobility and it’s accompanying effect of stability and proprioceptive processing contribute to both sensory seeking and sedentary behavior, sometimes in the same child.  Add in pain and fatigue, and perhaps even POTS or dysautonomia, and you have a kid that is both active and inactive, both attentive and unfocused on tasks at different times of the day.  Self-regulation appears to be very unstable.  If a child’s entire physical condition isn’t taken into assessment, a referral for an ADHD diagnosis could result.
  2. Difficulties with mobility and stability make active play and engagement in sports more difficult.  This has social as well as physical effects on children at all ages.  For some kids, they can play but get injured at a more frequent rate.  Other children aren’t able to keep up with their peers on the playground and seek more sedentary or independent activities.  And for some other kids, they experience the pain of being the last kid picked for group play or being bullied for the awkward way they move.  The child that was more mobile and athletic when younger, and is now experiencing a loss of skill or an increase in pain, is also at risk for feelings of depression and fear of movement.  That fear is a real problem, with a name: kineseophobia.   This isn’t the same as gravitational insecurity, but it may look like it without the therapist’s awareness of a child’s history or current problems.
  3. Kids with hypermobility can have problems with falling and staying asleep, which affect daytime alertness and energy.  It is well-documented that a lack of good-quality sleep results in childhood behavioral changes.  Pain, lack of daytime activity levels high enough to trigger sleep, bladder control leading to nighttime awakening or bedwetting…the list of sleep issues for kids with hypermobility can be long.  Evaluating a child’s behavior without knowing about these issues is going to lead to incorrect assumptions about the source of reactions and interactions.
  4. Hypermobile kids can have issues with feeding that contribute to patterns of behavior that extend beyond the dinner table.  Difficulty with eating, chewing, and even constipation can result in behavioral changes.  Especially with younger kids, learning social interaction skills at the table can be lost in a parent’s need to alter food choice or their concerns over nutrition.  Hypermobile kids don’t always have issues that restrict them from eating; some kids don’t get enough exercise or find eating to be a pleasurable activity that doesn’t take too much energy or skill.  Used along with media use or gaming, snacking is something that they enjoy.
  5.  Children develop social and emotional skills in engagement with others.  The child who attends therapy instead of playdates, the tween that doesn’t have the stamina to go on a ski trip, the child who can’t sit still during a long play or movie.  All of these kids are having difficulties that reduce their social interactions to some degree.  Encourage the families of the children you treat to be mindful of a child’s whole life experiences and weave interventions into life, not life into interventions.

As therapists, we owe it to our clients to ask questions that help us understand the daily challenges of life and create treatment plans that support a child’s social and emotional development.  Waiting for mental health professionals to ask those questions isn’t enough.  And remember, if there is a counselor or therapist involved, share what you know about the impact of hypermobility on behavior.  Without awareness of the physiological and sensory basis of behavior, professionals may make an incomplete assessment that will not result in progress!

 

Looking for more information on treating kids with hypermobility?  Take a look at Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome? and Hypermobile Kids, Sleep, And The Hidden Problem With Blankets .

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Parenting Experts: Check Your Privilege

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Another day, another piece about how important it is to chat with your young child.  Zero-To-Three just ran this summary on their Facebook page MIT language study and I felt so sad.  For everyone.  For the umpteenth time in the past few years, I am in the awkward position of agreeing with “experts” that kids learn language skills best with face-to-face interaction that expands language, but I also appreciate why some cultures don’t interact with children like MIT researchers want them to.  My concern is that the  researchers can’t seem to see beyond their (boojie) bubble.

Because I have the good fortune to treat children in their homes, and have family and friends that span every economic group from barely-getting-by to (almost) Richie Rich, I have seen a lot of parenting styles.  A lot.  Here is what I see:

Parents teach children to behave so that they will succeed in the culture their parents exist in and the world they hope their children will access.  How parents interact with their children is also affected by how stressed they are.  No parent thinks about this consciously.  But there are huge differences, right from the start.

What I think the MIT folks haven’t realized is what goes on for those parents who come home after working two jobs, who worry about which bills to pay now and if they will have a job this time next month. These good, hardworking folks don’t have the extra bandwidth to chat with their children in the same way that a less stressed parent does.  Maybe the researchers haven’t thought to ask, maybe they assume that what they see in an interview tells the whole story.  But they haven’t seen these family’s homes and their lives.

When that proud, super-stressed, working-class parent thinks about their child’s future, they want to see a job with benefits, a job that can’t be outsourced, a job that has automatic raises.  Many of the jobs they dream about for their children are government or union jobs.  These jobs require obedience to rules and to supervisors.  In these positions, telling your boss that he or she is wrong could cost you your job.  Staying out of controversy and following the rules gets you to the next rung on the ladder.

When their child questions a request, they aren’t going to have a heart-to-heart about why they don’t want to unload the dishwasher.  A parent wants it done because they need to do three loads of laundry immediately and won’t be done with it until 2 am tonight.  Everyone in their family has to help to make tomorrow a possibility.  And they want their child to know that refusal to follow a supervisor’s order could mean that they could be out of a job and maybe out of a home.

Someday there will be someone at MIT that learns more about these families, is brave enough to say what they think, and maybe even publish a study.  That will be something that I can’t wait to post on my blog!

Should Your Hypermobile Child Play Sports?

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Kids with hypermobility fall on a very wide spectrum.  Some are strong and flexible, allowing them to compete in gymnastics and dance with ease or even excellence.  Some kids are prone to injury; they spend more time on the sidelines than on the field.  And some need to have P.E. classes adapted for them or substituted with physical therapy.

Wherever your child lands on this spectrum of ability, it is likely that they want to be able to participate in sports, and you want them to be able to do so as well.  Engaging in sports delivers a lot of positives:  conditioning, ability to work in a group, ability to achieve goals and handle failure/loss, etc.  Most therapists and doctors will say that being as physically active as possible enhances a child’s overall wellness and can be protective. But every child is different, and therefore every solution has to be tailored to the individual.

Here are a few questions to guide your assessment  (and involve your child the  decision, if they are old enough to be reflective instead of reactive to questions):

  1. Is this activity a high or low-risk choice?  High-risks would include heavy physical contact, such as football.  Tennis requires hitting a ball with force and rapid shifts of position with lots of rotation of the trunk and limbs.  I am going out on a limb, and say that ballet on-pointe is a high-risk choice for kids with lower-body weakness and instability.  The question of risk in any activity has to be combined with what is risky for each child.
  2. Will endurance be an issue, or will there be flexible breaks?  Activities that require a lot of running, such as soccer and lacrosse, may be harder than dance classes.
  3. Are there ways to support performance, such as braces, kineseotaping or equipment modifications?  A great pair of skis or shoes can help tremendously in sports.  So can targeted exercises from a physical therapist or a well-trained coach that understands the needs of the hypermobile athlete.  Your child may not be able to be on a travel team due to the intense demands and greater risk of injury due to fatigue/strain, but be very satisfied being on a local team.
  4. Will your child report pain or injury and ask for assistance?  Some kids are very proactive, and some will try to hide injuries to stay in the game or on the team.  Without this knowledge, no coach or parent is able to make the right/safe choices.  Sometimes it’s an age thing, where young children aren’t good communicators or teens are defending their independence at the cost of their health.  If you think that your child will hide injuries or push themselves past what is safe for their joints, you will have to think long and hard about the consequences of specific activities.
  5. Within a specific sport, are there positions or types of participation that are well-suited for your child’s skills and issues?  Skiing wide green (easy) slopes and doing half-pipe snowboard tricks are at distinct ends of the spectrum, but a hypermobile child may be quite happy to be out there in any fashion without pain or injury.  Goalies are standing for longer periods but running/skating less.  Endurance running and sprinting have very different training and participation requirements.
  6. Sadly, hypermobility can progressively reduce participation in sports.  Not for all kids, and not even for kids with current issues.  Children can actually be less hypermobile at 12 than they were at 3.  They build muscle strength as well.   It happens.  Therapy and other strategies like nutrition and orthotics can make huge improvements for hypermobile kids who want to play sports.  But too often, the child who is pain-free in dance class at 7 isn’t pain-free at 14.  This doesn’t have to be a tragedy.  Kids can be supported to adjust and adapt so that they are playing and working at their current maximal level.  Good physical or occupational therapists can help you figure out how to make athletic activities fun and safe!

For more information regarding hypermobility, please read Hypermobile Kids, Sleep, And The Hidden Problem With Blankets ,  Can You K-Tape Kids With Connective Tissue Disorders?  and Should Hypermobile Kids Sit On Therapy Balls For Schoolwork?.

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Why Telling Your Child “It’s OK” Doesn’t Work (And What To Do Instead)

 

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In a few months I will be doing another lecture on managing difficult toddler behaviors, and I can’t wait.  I love teaching parents, therapists and caregivers how to help young children manage their most difficult behaviors.   The responses that most therapists dread (crying, whining, tantrums, etc.) are the ones I hope will happen in a session with a parent.  Why?  So I can demonstrate and explain how to handle these tricky moments.  How you respond to your child can do more than help you get them into the car and back home.  It can teach them how to deal with their feelings and how to communicate them to other people.

When faced with a crying child, telling them “It’s O.K.” right away seems to be the most natural response in the world.  For one thing, it is usually the truth; you can clean up the broken cookie and get another, their bump is a minor scratch, and they have another blue crayon to replace the one that rolled under the couch.  And we want to help them feel better; comforting an upset child is what we do as caring adults.

But for many kids, telling them “It’s OK”  elicits more crying, if not some wailing and even physical responses like throwing things or hitting.  You go over to console them, and they might even push you away.  The baby that used to melt into your arms is now a toddler, rejecting your best efforts at comfort!

Why?  Very likely because your response did not show them that you understand the gravity of the situation and the pain they are experiencing.  I know, pain from a broken cookie? Really? Well, when you are 18 months old, you can’t always comprehend that there could be more cookies in the cupboard.  The horror of seeing your favorite treat destroyed in front of you is just too great.  And the feelings inside of you really do hurt.  Young children need two things to recover:  someone to say that they know what your problem is and for that person to say that they are aware that you feel this way.

Note that I did not say that the other person has to agree that it is the end of your toddler world.  The adult is only agreeing that something has happened and that you feel badly about it.  As adults, we don’t always remember a toddler’s perspective, and we invalidate it more than we think we do.  This is why telling your child “It’s OK” is heard as “Your complain is without merit, sir, and you have no right to feel angry or sad about it”.

You would never intend to say that to your child, and yet that is the message many children get when you rush in too soon with this response.  

What could you say instead?  I first use Dr. Harvey Karp’s Fast Food Rule combined with his Toddler-Use communication style to respond to an upset child.  It is fairly simple:  State what you believe your child is thinking in simple phrases that match their comprehension level when upset (which is always less than when they are calm) and matches their emotional tone by 1/3.  So if your child is screaming  “COOKIE, COOKIE, COOKIE!!!” and you know that her cookie fell on the sidewalk into the mud, your response has to be similarly short and heartfelt.  Something like “COOKIE BROKEN!  You want cookie!” tells the sad story of what has happened to her snack.

This can be enough validation to calm her down a bit, as seen by a decrease in the volume of her screaming, more eye contact with you, and even a sad nod.  NOW it is time for consolation, and perhaps the offer of an alternate snack.  You have shown that you know her problem and her pain.  She has felt understood and her feelings accepted, and may now be ready for a resolution to this crisis.  If she continues to scream, repeat your statement once or twice while further shortening your words and slightly increasing the emotion in your voice/the emphasis of your gestures.  Sometimes it takes the toddler brain a moment to process.  Give her that time.

Good luck trying out this approach with the next upset toddler or preschooler you encounter.  I promise you, communicating your empathy and modeling acceptance of feelings delivers more than a calmer child.  It teaches important emotional skills and deepens the connection between you.

And it all started with a broken cookie….

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