I regularly field questions about this problem from the parents of children I treat. If your 8 to 24-month old is fussy during diaper changes and you know it isn’t from diaper rash, keep reading. I have some information and ideas for you.
Parents of kids with sensory processing issues or developmental delays often assume that this is the source of their child’s diaper drama. Parents who lack confidence or parents who spend a lot of time online with “Dr. Google” think that it could be sign of autism or of poor attachment.
At least, not usually.
If your young child is suddenly giving you the business, even though they really need a diaper change, there are a few things to think about before you run to a developmental pediatrician (or any pediatrician):
Your child may have been busy exploring, and they are unhappy that they were interrupted with a task they find boring. Getting a fresh diaper isn’t much fun after those first few months of face-gazing and smiles. Once a child can really play, they have better things to do. Parents can be surprised that their gurgling infant that loved diaper changes is now resisting, or even fighting, to get off the changing table.
If your child is one of the 15-20% of kids that Dr. Harvey Karp identifies as having a “spirited” temperament, then you are going to get a strong reaction to almost any action they didn’t initiate. Bedtimes, leaving to go to the park, leaving the park to go home, etc. Spirited kids are going to give you oversized reactions in both directions; super happy, super sad, super angry.
Kids with limited receptive language aren’t sure exactly what is going on when you pick them up. Receptive language means understanding the words another person is using. Your child doesn’t have to be delayed; they could simply not have enough language skills to understand what you are saying.
Your child has decided to use diapering as their “line in the sand” to express their independence and test your limits. Testing limits is normal, and I believe that nature intended this to start early. By the time parents are experiencing limit testing with a teen, they have been practicing for a while. Young children that feel that they are being controlled will test more and with more energy. This doesn’t mean that their parents are actually more controlling. Perception is reality, and if a child feels micro-managed, then they react whether or not they are indeed highly controlled. This could happen when they spend a lot of time with babysitters instead of parents, or if they have had many recent changes in caregivers, new sibling, new home, etc.
What works to reduce diaper drama?
Use routines to improve language comprehension and manage expectations. Kids that get a regular diaper check/change know what you are doing and where they are going.
Shorten your phrases and use the same words for the same events. See above.
Try not to over-react to an overreaction. Spirited kids don’t need more fuel for the fire, and neither do tired, sick, or hungry children.
Give your child more chances to control other situations in their life. Manufacture the situations if you have to. This means that they get to decide of the doll goes in the cradle or the car, or if the blue car goes down the ramp first, or if it is the red car that leads. Dr. Karp’s “give it in fantasy” strategies Give (Some of) Your Power Away To Your Defiant Toddler And Create Calmness and all of his positive “time-ins” are excellent ideas to build a child’s sense of fairness and autonomy.
Offer the 8-24 month old child something interesting to hold and look at during the diaper change. It could be a new soft toy, but it might be better to give them a tiny collapsible colander to examine. The novelty factor should buy you enough time to do the deed. Remember to change it up regularly. They need to learn to expect that this could be more fun than drama.
Older kids with the language skills to understand the negotiation could be asked “Do you want your diaper change NOW or in one minute?” It doesn’t have to be 60 seconds later. The idea is that you have given them a choice. You have to stick to the agreement. If they still balk after the minute is up, don’t use this again right away. You will be teaching them that their protests work to avoid following your directions. Oops.
The truth is that most children know that you are going to change their diaper regardless of their protests, and they can handle it if you help them a little bit.
Hypermobility is a symptom that affects almost every aspect of a family’s life. Unlike autism or cerebral palsy, online resources for parents are so limited and generic that it was obvious that what was needed was solid practical information using everyday language. Being empowered starts with knowledge and confidence.
The result? My new e-book: The JointSmart Child: Living and Thriving With Hypermobility. Volume One: The Early Years.
What makes this book unique?
This manual explains how and why joint instability creates challenges in the simplest tasks of everyday life.
The sensory and behavioral consequences of hypermobility aren’t ignored; they are fully examined, and strategies to manage them are discussed in detail.
Busy parents can quickly spot the chapter that answers their questions by reading the short summaries at the beginning and end of each chapter.
This book emphasizes practical solutions over theories and medical jargon.
Parents learn how to create greater safety at home and in the community.
The appendices are forms that parents can use to improve communication with babysitters, family, teachers and doctors.
Who should read this book?
Parents of hypermobile children ages 0-6, or children functioning in this developmental range.
Therapists looking for new ideas for treatment or home programs.
New therapists, or therapists who are entering pediatrics from another area of practice.
Special educators, and educators that have hypermobile children mainstreamed into their classroom.
Looking for a preview? Here is a sample from Chapter Three: Positioning and Seating:
Some Basic Principles of Positioning:
Therapists learn the basics of positioning in school, and take advanced certification courses to be able to evaluate and prescribe equipment for their clients. Parents can learn the basics too, and I feel strongly that it is essential to impart at least some of this information to every caregiver I meet. A child’s therapists can help parents learn to use the equipment they have and help them select new equipment for their home. The following principle are the easiest and most important principles of positioning for parents to learn:
The simplest rule I teach is “If it looks bad, it probably IS bad.” Even without knowing the principles of positioning, or knowing what to do to fix things, parents can see that their child looks awkward or unsteady. Once they recognize that their child isn’t in a stable or aligned position, they can try to improve the situation. If they don’t know what to do, they can ask their child’s therapist for their professional advice.
The visual target is to achieve symmetrical alignment: a position in which a straight line is drawn through the center of a child”s face, down thorough the center of their chest and through the center of their pelvis. Another visual target is to see that the natural curves of the spine (based on age) are supported. Children will move out of alignment of course, but they should start form this symmetrical position. Good movements occurs around this centered position.
Good positioning allows a child a balance of support and mobility. Adults need to provide enough support, but also want to allow as much independent movement as possible.
The beginning of positioning is to achieve a stable pelvis. Without a stable pelvis, stability at the feet, shoulders and head will be more difficult to achieve. This can be accomplished by a combination of a waist or seatbelt, a cushion, and placing a child’s feet flat on a stable surface.
Anticipate the effects of activity and fatigue on positioning. A child’s posture will shift as they move around in a chair, and this will make it harder for them to maintain a stable position.
Once a child is positioned as well as possible, monitor and adjust their position as needed. Children aren’t crockpots; it isn’t possible to “set it and forget it.” A child that is leaning too far to the side or too far forward, or whose hips have slid forward toward the front of the seat, isn’t necessarily tired. They may simple need repositioning.
Equipment needs can change over time, even if a child is in a therapeutic seating system. Children row physically and develop new skills that create new positioning needs. If a child is unable to achieve a reasonable level of postural stability, they may need adjustments or new equipment. This isn’t a failure; positioning hypermobile children is a fluid experience.
The JointSmart Child: Living and Thriving With Hypermobility Volume One: The Early Years is now available on Amazon.com.
Already bought the book? Please share your comments and suggestions for the next two books! Volume Two will address the challenges of raising the school-aged child, and Volume Three focuses on the tween, teen, and young adult with hypermobility!
My new e-book, The JointSmart Child: Living and Thriving With Hypermobility, Volume I, is just about ready to launch. One of the book’s major themes is that safety awareness is something that parents need to actively teach hypermobile young children. Of course, physical and occupational therapists need to educate their parents first. And they shouldn’t wait until things go off the rails to do so.
Hypermobile kids end up falling, tripping, and dropping things so often that most therapists have the “safety talk” with their parents on a regular basis. What they don’t speak about as often are the long-term physical, emotional and social impacts of those injuries.
Yes, injuries have more than immediate physical effects on hypermobile kids. Here is how this plays out:
The loss of mobility or function after an injury creates more dependency in a little person who is either striving for freedom or unsure that they want to be independent. Needing to be carried, dressed or assisted with toileting when they were previously independent can alter a child’s motivation to the point where they may lose their enthusiasm for autonomy. A child can decide that they would rather use the stroller than walk around the zoo or the mall. They may avoid activities where they were injured, or fear going to therapy sessions.
A parent’s fear of a repeated injury can be perceived by a child as a message that the world is not a safe place, or that they aren’t capable in the world. Instilling anxiety in a young child accidentally is all too easy. A fearful look or a gasp may be all it takes. Children look to adults to tell them about the world, and they don’t always parse our responses. There is a name for fear of movement, whether it is fear of falling, pain or injury: kineseophobia. This is rarely discussed, but the real-life impact can be significant.
Repeated injuries produce cumulative damage. Even without a genetic connective tissue disorder such as Ehlers-Danlos syndrome, the ligaments, tendons, skin and joint capsules of hypermobile children don’t bounce back perfectly from repeated damage. In fact, a cascade of problems can result. Greaster instability in one area can create spasm and more force on another region. Increased use of one limb can produce an overuse injury in the originally non-injured limb. The choice to move less or restrict a child’s activity level can produce unwanted sedentary behavior such as a demand for more screen time or overeating.
Being seen as “clumsy” or “careless” rather than hypermobile can affect a child’s self-image long after childhood is over. Hypermobile kids grow up, but they don’t easily forget the names they were called or how they were described by others. With or without a diagnosis, children are aware of how other people view them. The exasperated look on a parent’s face when a child lands on the pavement isn’t ignored even if nothing is said.
In my new book, I provide parents with a roadmap for daily life that supports healthy movement and ADL independence while weaving in safety awareness. Hypermobility has wide-reaching affects on young children, but it doesn’t have to be one major problem after another. Practical strategies, combined with more understanding of the condition, regardless of the diagnosis, can make life joyful and full for every child!
After writing my first e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived! ,I continue to think of additional issues that can complicate (but not derail) training. One of these issues is a receptive language delay. This is when a child’s ability to comprehend language is not age appropriate. It may be accompanied by a delay in expressive language as well. I don’t think it is a hard stop to training, but there are some strategies that improve the experience. Not all of them are obvious.
When a child is unable to easily and quickly understand what you are saying during toilet training, you will need to do a few things differently:
Expect to need established routines to support your verbal instruction. This can include very regular trips to the potty rather than happening randomly. Routines are essential for all children, but these kids really need them to shore up the language you are using. Think about buying something in another language. The routine or presenting the item, finding out the fee, offering payment and leaving with your item helps you get over the fact that you have forgotten most of your high school level French. When they always sit on the potty right before a specific show, they know why and what you are saying more easily because they know the context.
Use clear and consistent gestures and facial expressions as additional messaging while teaching and encouraging performance. Gestures and facial expressions clarify your words and help kids respond quickly. If they have too many accidents because they were confused, they could decide to stop cooperating.
Monitor your language complexity, and consider simplifying it for ease of comprehension under stress. As in the Fast Food Rule’s use of Toddler-ese, shorten phrases and emphasize important words. This is not the time to lengthen your statements. Repeat if necessary, but don’t elaborate. Read Taming Toddler Tantrums Using Sympathetic Reframing for more details on TFFR.
Assume that you will need to be more enthusiastic, more positive, and spend more time on training in general. Your child is probably already someone with a short fuse. Struggling to understand what people are saying makes that easy. Now you are trying to teach a new skill, possibly one that they aren’t 100% excited to learn. That doesn’t mean never teach it. It means have a good plan, with lots of optimism and patience on your part.
There are so many families out there that need great equipment for their sensory kids. Pillowfort materials are on sale at Target, one of my favorite big box stores. The items are affordable and stylish. But are they what you really need? In order to get the products that serve your child’s needs, you may want to think beyond color and style. The key to good equipment is having a big picture plan. The wrong item for the wrong kid is worse than not hitting “send”.
Some good examples are their crash pad and their chair. If you have a sensory-seeking kid, you know what abuse your couch and bed can take. Kids tend to dive bomb them and little by little, destroy them. Pillowfort will sell you a nice crash pad, and they use a smiling child lying prone on one of their pads in their display on Target.com.
You might want to look at the dimensions. In my professional experience, most of my clients are looking for way more square footage to crash into. And when they are dysregulated, which is often, they aren’t going to be able to land squarely on such a small pad. Therapists use pad the size of a thick full mattress for a reason. We are all safety, all the time. And we know what works.
The rocking desk chair is another nice chair that will serve a small number of kids. It looks pretty sturdy, but the big sensory seekers can wear out hinges really easily. A chair that rocks is a chair that can become tippy with the right (or wrong) user. Choose this chair only if you have a child that isn’t one of THOSE kids.
Not a week goes by that a parent or nanny asks me how to get a young child, usually under 3, to share. I get it; it is embarrassing when a toddler rips a toy away from another child, or has a death grip on a toy car while growling at their playdate friend.
Sharing isn’t something that comes naturally to most kids. The rare child that hands over a toy when asked isn’t the average child. You have to teach this behavior, and you have a couple of choices. Only one is going to give you any peace:
Threats: Telling your child that if he doesn’t share that he will lose his valued toy. This may work in the short run, but like spanking, you teach a child that violence or the threat of violence is the way to power. We have too much of that already.
Shame: Telling a child that they are not nice people because they don’t want to share isn’t any better. It doesn’t make it much kinder to say “You aren’t being nice right now” because you still haven’t acknowledged the child’s feelings. Don’t we all carry around more shame than we can handle? I know no one thinks they are shaming their child by saying this. Stop now. Make a better choice.
Empathy followed by reality: Using the Fast Food Rule, you tell the child what you think they are thinking “You don’t want to share; you want that car only for you” or an even simpler version “You say NO SHARE”. When the child nods or in some physical or verbal way indicates that they understand you and agree that this is their opinion, you add sympathy to your voice and say something like “I am SO sorry, but it is XXX’s turn now. You will get another turn later”. Many times the child will hand over the car. Sometimes you will have to take it, but they might not flip out. Your empathy and their intelligence (if they are over 18 months old, they have had experience with sharing) will help them accept the reality. Read Stop The Whining With The Fast Food Rule for more details on Dr. Harvey Karp’s excellent strategy.
Of course, if your child is exhausted, hungry, ill, or going through a change in routine, home, caregivers, new sibling, etc. all bets are off. They are living on the edge, and thing could fall apart. What do you do then? You feed, give a nap, a hug, and remember that asking a stressed child to share isn’t going to go very well. But you also use all Dr. Karp’s positive strategies, the ones he calls Time-Ins. Things like Patience Stretching Stretch Your Toddler’s Patience, Starting Today! and Gossiping Let Your Toddler Hear You Gossiping (About Him!).
The altruism that gives birth to sharing should not be expected in children under 2. We ask them to follow our sharing rules, and have to help them grow to an age and a place in which they can comprehend what sharing is really about. You may have to wait until 4 or 5 to see your child really understand how the other child is feeling and why sharing with them works better than being selfish. At a very young age, it is enough that they know we understand where they are coming from and we will help them follow this important social rule.
Many young hypermobile kids, with and without low muscle tone, struggle at mealtimes. Even after they have received skilled feeding therapy and can chew and swallow safely, they may continue to slide off their chair, spill food on the table (and on their body!) and refuse to use utensils.
It doesn’t have to be such a challenge. In my new e-book coming out this year, I will address mealtime struggles. But before the book is out there, I want to share three general solutions that can make self-feeding a lot easier for everyone:
Teach self-feeding skills early and with optimism. Even the youngest child can be taught that their hands must be near the bottle or cup, even when an adult is doing most of the work of holding it. Allowing your infant to look around, play with your hair, etc. is telling them “This isn’t something you need to pay attention to. This is my job, not yours.” If your child has developmental delays for any reason, then I can assure you that they need to be more involved, not less. It is going to take more effort for them to learn feeding skills, and they need your help to become interested and involved. Right now. That doesn’t mean you expect too much from them. It means that you expect them to be part of the experience. With a lot of positivity and good training from your OT or SLP, you will feel confident that you are asking for the right amount of involvement. Read Teach Spoon Grip By Making It Fun And Sharing a Laugh With Your Child and Teach Utensil Grasp and Control…Without the Food! for some good strategies to get things going.
Use excellent positioning. Your child needs a balance of stability and mobility. Too much restriction means not enough movement for reach and grasp. Too much movement would be like eating a steak while sitting in the back seat of your car doing 90 mph. This may mean that they need a special booster seat, but more likely it means that they need to be sitting better in whatever seat they are in. Read Kids With Low Muscle Tone Can Sit For Dinner: A Multi-Course Strategy for more ideas on this subject. Chairs with footplates are a big fave with therapists, but only if a child has enough stability to sit in one without sliding about and can actively use their lower legs and hips for stabilization. Again, ask your therapist so that you know that you have the right seat for the right stage of development.
Use good tableware and utensils. If your child is well trained and well supported, but their plates are sliding and their cups and utensils slide out of their hands, you still have a problem. Picking out the best table tools is important and can be easier than you think. Items that increase surface texture and fill the child’s grasping hand well are easiest to hold. Read The Not-So-Secret Solution for Your Child With Motor And Sensory Issues: Dycem and OXO for Kids: Great Tableware For Older Kids With Sensory and Motor Issues for some good sources. Getting branded tableware can be appealing to young children, and even picking out their favorite color will improve their cooperation. Finally, using these tools for food preparation can be very motivating. Children over 18 months of age can get excited about tearing lettuce leaves and pouring cereal from a small plastic pitcher. Be creative and have fun!