Category Archives: school-age children

Want Better Self-Regulation in Young Children? Help Them Manage Aggression

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You might think as a pediatric OTR, I would be writing a post about sensory-based treatment for self-regulation.  And I have in the past.  Not today.

But I have been an OTR for decades, and what I know about today’s children is that agitated and dysregulated kids often need help managing aggressive impulses and negative emotions first, in order for me to assess whether or not their behaviors have a sensory basis.

That’s right:  a young agitated child cannot be assumed to have sensory processing difficulties if they haven’t learned any self-management tools.  It is too easy to assign them a label, and I refuse to do that.  But I can and will use effective techniques to manage aggression before I jump in with all the bells and whistles from my sensory processing treatment bag.

What works for me?

I get a lot of mileage out of Dr. Harvey Karp’s Happiest Toddler on the Block strategies.  Once I learned these simple techniques, I applied them to every situation in which a young child was oppositional, aggressive, defiant, or threatening/delivering a tantrum.   That could be every session!  Toddlers aren’t known for their easy-going ways.

His Patience Stretching, Fast Food Rule, and Time-Ins are my three-legged stool that supports my therapy sessions.  Read Use The Fast Food Rule For Better Attunement With Your Child and Stretch Your Toddler’s Patience, Starting Today!  Kids aren’t born with the ability to handle frustration and manage impulses.  Adults teach them how to deal with their feelings.  When they aren’t taught what to do when they are disappointed, when they want attention, or when they are angry, things can get pretty unpleasant.  The good news is that learning can begin around their first birthday.

Job number one should never be unclear to anyone, but as time has gone on, fewer and fewer parents seem to communicate it clearly:  physical violence from anyone isn’t acceptable at any time.

Are parents committing violence against their child?  No.  It is the child that is biting, hitting, or damaging items.   “We don’t hurt people or animals in this house” isn’t always communicated clearly to a child.  I never hear a parent say that they like being smacked across the face by their child, but they also seem to struggle to clearly communicate that this behavior is unacceptable.  Resorting to responding with violence is not helpful.  Teaching how to manage aggression can be done without spanking a child or even raising their voice.  Changing their tone of voice and rapidly putting the child out of arm’s reach will make it clear to their child that they have crossed a line.  But so many parents seem hesitant to set limits, and some seem to worry that being firm will harm their child or hurt their feelings.  This is coming from,  remember, the same child that just smacked them in the face or bit them.  By not reacting clearly, parents are in fact communicating that aggression toward others isn’t a problem.

I try hard to teach parents that it is kind and loving to teach children that they can have their feelings but they cannot express them with aggression.  There are limits in the wider world, and if they act this way with people that don’t love them, the consequences aren’t going to be good.  Learning to hear “no” from someone that loves you is a lot easier.

Young children need to learn the vocabulary of negative emotions like anger, disappointment, frustration and sadness.  They need to practice waiting and need to be spoken to in a way that makes it clear that they are understood but may not get their way all the time.  Negotiation and appreciation go hand in hand.  Dr. Karp’s techniques really work for me, and they aren’t difficult to learn or use.  I wish every parent would try even one and see how easy they can be incorporated into daily life with young children!

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Doing OT Telehealth? Start Cooking (And Baking)!

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Parents are looking for ways to survive the lockdown without daycare and preschool.  Even the easiest child is starting to chafe under the oppression of the COVID quarantine.  As an OT, it is my job to help parents support growth and development, but I don’t have to make it feel like work.

Enter cooking and baking as OT activities!

The simplest recipe I know has two ingredients and cannot be ruined unless you step on it:  Chocolate rolls.

You need:

  • Baking sheet, preferably non-stick or lined with parchment paper.  This dough is sticky, and the melted chips are a pain to clean off a surface.
  • Work surface: possibly another baking sheet, non-stick foil, or parchment paper.  
  • One container of crescent rolls (8 to a package, usually) Keep it cold until you are going to use it.  When it gets warm it gets very goey.  Kids either love it and mash it about, or won’t touch it.
  • 1 to 1 1/2 cups chocolate chips, separated into two small bowls.  You will need only about 1 cup, but have extra since kids will taste a few.  Or a lot.  A mom only had a chocolate bar, and she broke it up into small pieces.  I think she needed to smash something that day!   COVID has made us adaptable….

DIRECTIONS:

Preheat the oven to 350 degrees F.

Unroll two triangles of dough, one for the adult, and one for the child.

Demonstrate how to gently push the chips into the dough, then roll up, starting at the wider end.  Assist your child to imitate you. Don’t over-fill with chips.   If it becomes a squishy mess when they roll it up, don’t panic.  This will bake off just fine.  I promise.

Repeat with all dough triangles.

Place both rolls on the baking sheet, and once filled, place the baking sheet on the center rack of the oven.

Bake for about 8-12 minutes or just until the bottom of the rolls turns light golden brown.  You will have to check them after 8 minutes, as they bake quickly.  They keep baking a bit after you take them out of the oven, and if you overbake, you will have 8 chocolate hockey pucks.

Cool and enjoy!

NOTES:

I ALWAYS make a recipe by myself first before baking with kids.  Why?  Two reasons:

  1. I need to know what can go wrong and how my oven responds.  Every minute counts in baking.  Kids take failure personally, so I want to make mistakes and fix them before I ask a child to try a recipe out.
  2. You have a finished product to show them.  Young children cannot look at dough and chips and imagine what it will be like when it is done.  Showing them the actual, real, tasty end product makes it understandable to them.

Is your child likely to snack on the supplies?  Use an “eating bowl”.  I often tell parents to assemble a small amount of chocolate chips in a separate bowl and designate this as an “eating bowl”.  Rather than criticize a child’s desire to sample, they can eat from this bowl without altering the amount needed for the recipe.  Even Julia Child liked to snack on her supplies!!

If you want to get fancy, you can place a few raspberries at the wide end of the dough.   Toddlers and preschoolers aren’t gourmets, and they can reject things that aren’t simple, so don’t insist that they copy you.  But this is a way to expand a child’s awareness of food variety as well as make your chocolate roll tastier.

 

 

 

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Gifted Child? Try “How Does Your Engine Run” For Sensory Processing

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

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

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

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

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

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

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

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

Looking for more information on helping your gifted child?  

I am writing an e-book on this topic, but you can also call me for a consult as well.  Visit my website Tranquil Babies  and use my contact information to set things up today!

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How Therapeutic Listening Enhances Motor Skills

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My readers know that I am a huge fan of Quickshifts in treatment.  I have had some amazing successes with Quickshifts for regulation and modulation.  Their focus on combining binaural beat technology with instrumentation, rhythm, melody and tone makes these albums effective, and it eliminates the challenges of modulated music for very young or fragile kids.  But many parents (and a few therapists!) think that if a child doesn’t have severe sensory processing issues, then therapeutic listening isn’t going to be helpful.

That indicates that they don’t understand the principles and the rationale for the use of therapeutic listening.

Since every movement pattern has rhythm and sequence, it is completely logical that enhancing brain function with an emphasis on a calm-alert state with music will affect movement quality.  (This includes speech.  Speech is a highly skilled series of very small movements in a precise sequence! )

I am currently treating a toddler who experienced encephalopathy in infancy.  A virus affected the functioning of his brain.  The residual low muscle tone and praxis issues are directly improved by using Gravitational Grape in sessions.  He is safer and shows more postural activation while listening.  Endurance while standing and walking is significantly improved.

Another client with low tone has Prader-Willi syndrome.  Her movements are so much more sequenced with the Bilateral Control album.  Her ability to shift her weight while moving is significantly better during and immediately after listening.

All of us are more skilled when we are in the calm-alert (alpha brainwave) state that Qucikshifts entrain.  For people without motor or sensory issues, alpha states can help us think clearly and organize our thought and movement for higher level performance.  For children with movement control issues, it can improve their safety and stability.  They move with greater ease.  Therapy sessions are more productive, and play or school functioning is less work.

Due to COVID-19, I have been forced to do telehealth and use therapeutic listening with more children, rather than rely on equipment or complex sensory processing activities.  The silver lining is that parents are more involved in my sessions and can see what benefits this treatment is having on their children.   When social distancing retreats, I hope that therapeutic listening will be seen for the powerful treatment it most definitely can be!

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CPSE or CSE Review Without a Re-Eval Because of COVID-19? Here’s What You Need To Ask For

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One of my private clients just called me for some backup.  Her son, who is on the autism spectrum, may lose some of his school OT sessions due to his increased handwriting ability (thank you; we have been very working hard on it!), but no further formal testing could be done before schools were shut down due to COVID-19.  His fine motor scores were in the average range. Everyone knows he is struggling with attention and behavior in class.  Everyone.

My strategy?  I gave her the Sensory Profile for ages 3-10 (SP) to complete.  Almost all of his scores were in either the “probable difference” or “definite difference” categories.  This means that his behavior on most of over 125 different items is between one and two standard deviations from the mean.  Even without a statistics course, you can understand that this is likely to be impacting his behavior in the classroom!

Many of the modulation sections of the SP, including “modulation of visual input affecting emotional responses” and “modulation of movement affective activity level” directly relate to observed school behaviors.  Scores in “multi sensory processing” and “auditory processing” were equally low.  Think about how teaching is done in a group:  it is visual and verbal.  Kids have to sit to learn.  They have to tolerate being challenged.

This is why OT in the schools is more than how to hold a pencil.  We address the foundational skills that allow children to build executive functioning skills.  Without these skills, all the routines, prompts, reward systems and consequences aren’t going to be very effective.

School therapists cannot test your child accurately using a standardized instrument when schools are closed due to COVID-19.  But parents can respond to a questionnaire, and it can be sent and scored remotely.  The Sensory Processing Measure is another sensory processing questionnaire able to be completed remotely.  These scores will help your therapist and your district understand the importance of OT for your child.  When school does resume, related services are going to be essential services!

For more information on how to work on OT issues at home, read Using A Vertical Easel in Preschool? WHERE You Draw on it Matters! and Does Your Older Child Hate Writing? Try HWT’s Double-Lined Paper.

If your child is hypermobile, you will need my newest e-book, out on Amazon right now!

The JointSmart Child:  Living and Thriving With Hypermobility Volume Two:  The School Years, is designed to address the challenges and needs of the school-aged child 6-12.  It has plenty of add-ons in the appendix to help you at home and at school. Learn how to pick the right chair, the right spoon, the right desk and even the right bike!  It gives you ideas to build ADL skills like dressing and independent bathing, and ways to build your confidence when speaking to doctors and teachers!

My earlier book, The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years, is also available on Amazon and at  Your Therapy Source.  It addresses development from birth to age 5.  It provides parents with all the ADL strategies to build independence AND safety, plus ways to teach your family    and babysitters how to work with your child more effectively.  Parents start feeling empowered, not overwhelmed, right away!

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Is this recess in your house during the COVID crisis?

Using A Vertical Easel in Preschool? WHERE Your Child Draws on it Matters!

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There are a few equipment and toy recommendations that every home-based pediatric OTR makes to a child’s parents:  Play-Doh, puzzles, tunnels, …and a vertical easel.  Found in every preschool, children from 18 months on can build their reach and proximal (upper body) control while coloring and scribbling on a vertical surface, rather than a tabletop.

But WHERE a child is directed to aim their stroke matters.  Here is why:

  • Grasp and reach have a range of efficiency.  I tell adults to imagine that they are writing on a whiteboard for a work presentation.  Your boss is watching.  Where will your writing/drawing be the most controlled?  Everyone immediately knows.  It is between your upper ribs and your forehead, within the width of your body or a few inches to either side.  Beyond that range, you have less stability and control.  Its an anatomy thing.  If you are an OTR, you know why.  If you are a parent, ask your child’s OTR for a physiology and ergonomics lesson.
  • Visual acuity (clarity of focus) is best in the center of your visual field (the view looking directly forward with your head centered).  Looking at something placed in this range is called using your “central vision”.  Your eyes see more accurately in that location, children can see an adult’s demonstration more clearly,  and therefore they can copy models and movements more accurately.  Kids with ASD like to use their peripheral (side) vision because it is cloudy, and the distortion is interesting to them.  This is not good for accomplishing a visual-motor task or maintaining social eye contact, but they find this is a way to perform sensory self-stimulation and avoid the intensity of direct eye contact with others.
  • Young children have little self-awareness of how their environment impacts them.  Until they fail.  Then they think it is probably their fault.  The self-centeredness that is completely normal in children gets turned around, and a child can feel that they are the problem.  Telling children where to place their work on an easel gives them the chance to do their best work and feel great about it.
  • Children move on when a task is too hard, or when an adult doesn’t provide enough supportive strategies.  Telling a child to try again, or telling them that their results weren’t too bad” isn’t nearly as helpful as starting them off where they have the best chance of success.
  • Using the non-dominant hand to support the body while standing is an important part of vertical easel use.  For kids with low muscle tone or hypermobility, it is very important.  Standing to the side or draping the body on the surface to write are both poor choices that OTRs see a lot in kids with these issues.  Make the easel a piece of therapy equipment and teach a child to place their non-coloring/painting hand on the side of the easel in the “yes zone”.  Look at the picture of the older boy at the beginning of this post, then at the gentleman below.  Note each person’s posture and try to embody it.  Which posture provides  more ease, more control? 

 

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Here is a graph of where an adult should place their demonstration on a page or board for optimal vision and motor control, and where adults should encourage a child to draw.  “NO” and “YES” refer to the child’s optimal location for drawing or writing.

The exception is for height.  A very tall child will need to draw higher on the chart, and a smaller child will only reach the lowest third of the easel.  This should still allow them to use their central vision and optimal reach.  If the easel doesn’t fit the child, place paper on a wall at the correct height.

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Need a Desk Chair for Your Hypermobile School-Age Child? Check out the Giantex Chair

 

71ASiKXBSJL._AC_SL1200_.jpgOne of my colleagues with a hypermobile third-grader told me this chair has been a great chair at school for her child.  It hits a lot of my targets for a chair recommendation, so here it is:  The Giantex chair.

Why do I like it so much?

  • It is a bit adaptable and sized for kids.  No chair fits every child, but the more you can adjust a chair, the more likely you are to provide good supportive seating.  This chair is a good balance of adaptability and affordability.  My readers know I am not a fan of therapy balls as seating for homework.  Here’s why: Should Hypermobile Kids Sit On Therapy Balls For Schoolwork?
  • It isn’t institutional.  Teachers, parents, and especially kids, get turned off by chairs that look like medical equipment.  This looks like a regular chair, but when adjusted correctly, it IS medical equipment, IMPO.
  • It’s affordable.  The child I described got it paid for by her school district to use in her classroom, but this chair is within the budget of some families.  They can have one at home for homework or meals.  Most kids aren’t too eager to use a Tripp Trapp chair after 6 or 7.  It’s untraditional looks bother them.  This chair isn’t going to turn them off as easily.
  • This chair looks like it would last through some growth.  I tell every parent that they only thing I can promise you is that your child will grow.  Even the kids with genetic disorders that affect growth will grow larger eventually.  This chair should fit kids from 8-12 years of age in most cases.  The really small ones or the really tall ones?  Maybe not, but the small ones will grow into it, and the tall kids probably fit into a smaller adult chair now or in the near future.

For more helpful posts on hypermobile kids, read Joint Protection And Hypermobility: Investing in Your Child’s FutureHow To Correctly Reposition Your Child’s Legs When They “W-Sit” and When Writing Hurts: The Hypermobile Hand.

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Want more information to help your child and make life easier?  My newest book has finally arrived!

The JointSmart Child:  Living and Thriving With Hypermobility  Volume Two: The School Years is now available as a read-only download on Amazon and a printable download on Your Therapy Source .  It is filled with the practical information that parents and therapists need to make kids’ lives easier, safer, and more independent.

There are extensive forms and checklists for school and home, and strategies that make immediate improvements in a child’s life.  Learn how to buy and fill a backpack that doesn’t damage a child’s joints, how blankets can create more pain and sleep problems,  and how to help a child write and keyboard with greater control.  Read more about it here: Parents and Therapists of Hypermobile School-Age Kids Finally Have a Practical Guidebook!

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Joint Protection And Hypermobility: Investing in Your Child’s Future

 

allen-taylor-dAMvcGb8Vog-unsplash.jpgParents of hypermobile kids are taught early on not to pull on limbs while dressing them or picking them up.  It is less common to teach children how to protect their own joints.

In fact, parents may be encouraged by their child’s doctors to let them be “as active as they want to be, in order to build their strength”.  Without adding in education about  good joint protection, this is not good advice.  This post is an attempt to fill in the space between “don’t pull on their limbs” and “get them to be more active”.

Why?  Because hypermobile joints are more vulnerable to immediate injury and also to progressive damage over time.  Once joint surfaces are damaged, and tendons and ligaments are overstretched, there are very few treatments that can repair those situations.  Since young children often do not experience pain with poor joint stability, teaching good habits early is essential.  It is always preferable to prevent damage and injuries rather than have to repair damage.  Always.  And it is not as complicated as it sounds.

The basic principles of joint protection are simple.  It is the application that can become complex.  The more joints involved in a movement or that have pre-existing pain or damage, the more complex the solution.  That is why some children need to be seen by an occupational or physical therapist for guidance.  We are trained in the assessment and prescription of strategies based on clinical information, not after taking a weekend course or after reading a book.  I am thinking of writing an e-book on this subject, since there really is nothing much out there for hypermobile people at any age….

Some of the basics of joint protection are:

  • Joints should be positioned in anatomical alignment while at rest and as much as possible, while in use.  Knowing the correct alignment doesn’t always require a therapist.  Bending a foot on it’s side isn’t correct alignment.  Placing a wrist in a straight versus an angled position is.
  • Larger joints should execute forceful movements whenever possible.  That means that pushing a heavy door open with an arm or the side of your body is better joint protection than flattening your hand on it.  The exception is if there is damage to those larger structures.  See below.
  • Placing a joint in mid-range while moving protects joint structures.  As an example, therapists often pad and thicken handles to place finger joints in a less clenched position and allow force to dissipate through the padding.  We discourage carrying heavy loads with arms held straight down or with one arm/hand.

Remember:  once joints are damaged, if joints are painful, or the muscles are too weak to execute a movement, activity adaptations have to be considered.  There is no benefit to straining a weak or damaged joint structure.

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Hypermobility and Music Lessons: How to Reduce the Pain of Playing

 

kelly-sikkema-jrFNMM6K0VI-unsplash.jpgMost kids want to learn how to play an instrument in grade school.  Most parents encourage some form of musical training for the benefits of musical training: social, coordination, attention and focus, even the suggested connection between math skills and musical ability.  Hypermobile kids can struggle with the physical demands of playing an instrument sooner and more severely than a typically developing child.

There are ways to make it easier and less painful, right from the start.

  • Steer them into the right instrument for their physical abilities.  Heavy instruments are a questionable choice for kids that have back and shoulder issues, as they will be moving their instrument around a lot.  Children with very hypermobile wrists could find the hand positions for violin or guitar much more challenging than the positions for piano or clarinet.  There will still be a lot of fingering, but it occurs in a different plane of movement.  Read Joint Protection And Hypermobility: Investing in Your Child’s Future for some details.
  • Understand that as hypermobility changes, so may the type of instrument that best fits your child.  This is a tough thing for kids to accept, but if they are experiencing repeated strains and injuries, or an increasing amount of pain, they may have to switch to an instrument that is less risky.  Remember:  hypermobility syndromes don’t disappear, and most hypermobile children will not become professional musicians.  This isn’t life-or-death, no matter what they say about their passion.  Injuries that affect the ability to attend school and eventually affect working…THAT is something to avoid.  Cumulative trauma can result in surgeries or even ending up needing disability payments.  Don’t contribute to a less-bright future by permitting a child with recurrent overuse injuries to continue to injure their body in the present.
  • Positioning matters.  Just as with sitting at a desk or a table, hypermobile kids need to use the best possible postural control with the least amount of effort.  Children playing the piano may need a chair with low back support rather than a piano bench.  Seats for all kids may need to have cushions that give more support, and any seat should definitely provide solid foot placement on the floor at all times.  Some kids may need the support of a brace or braces.  Back, shoulder, wrist, and even finger splints aren’t slowing them down; they are supporting performance.  The biggest problem will be resistance from the musician.  Children rarely want to wear these devices, and if they aren’t well designed and fitted, you will hear about it.  Ask their OT or PT for direct assistance or find one that can do a consultation.  Ask their instructor to explain why wearing a well-chosen brace makes playing easier and better.  And don’t wait until an injury happens.  Get in front of this one.
  • Musical skills require practice, but hypermobile kids may need to break up their practice or do targeted practice to shorten the total amount of time spent and reduce the physical strain.  Targeted practice requires that their instructor knows which types of practice are the most likely to build skills, rather than just adding minutes to a practice session.  Breaks are important, and most kids don’t have the ability to know when and how to take them.  They need to be taught, and the little ones need to be supervised on breaks.

 

Looking for more information on raising a child with hypermobility?

My latest e-book, The JointSmart Child:  Living and Thriving With Hypermobility  Volume Two:  The School Years is now available on Amazon as a read-only download and on Your Therapy Source as a clickable and printable download!  It has practical information about improving independence and safety for kids 6-12, including sports and the hypermobile child, improving communication with your child’s teachers and coaches, and how to address handwriting and keyboarding problems.  It has more forms and checklists than the first book (Volume One: The Early Years), but still covers all the important self-care issues like toileting and how to make your home safer for your child while keeping it comfortable and attractive.

 

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