Category Archives: self-care skills

How To Stop All The Diapering Drama

 

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does this look familiar? read on!

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.

Nope.

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):

  1. 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.
  2. 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.
  3. 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.
  4. 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.

 

 

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Parents of Young Hypermobile Children Need A Guide To Navigate Everyday Life

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My first e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, was a wonderful experience to write and share.  The number of daily hits on one of my most popular blog posts  Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children helped me figure out what my next e-book topic should be.

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?

  1. Parents of hypermobile children ages 0-6, or children functioning in this developmental range.
  2. Therapists looking for new ideas for treatment or home programs.
  3. New therapists, or therapists who are entering pediatrics from another area of practice.
  4. 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!

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Why Injuries to Hypermobile Joints Hurt Twice

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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!

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Targeted Toilet Training Strategies to Help The Child With A Receptive Language Delay

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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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.

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Hypermobility Or Low Tone? Three Solutions to Mealtime Problems

 

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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:

  1. 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.
  2. 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.
  3. 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!

 

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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.  The parents may be experiencing their own PTSD Can Your Pediatric Patient’s Parents Have PTSD? so be aware that their reactions may be coming from a place of untreated trauma as well.
  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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Afraid to Toilet Train? Prepare Your Child… and Prepare Yourself

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I spend an extra 30 minutes at the end of a session this week helping a mom build her courage and confidence so that she felt ready to start toilet training soon.  Her child is over 3, has sensory and motor issues, but shows tons of signs for readiness:  dry diapers for increasingly long periods, tells adults when he needs to “go”, able to manage clothing, etc.  He also has no confidence in his abilities, rarely likes change or challenge, and is super-sensitive to altering routines and using new environments.  This isn’t going to be seamless.

It isn’t clear who is the more prepared individual, but I think it could be the child.

This mom read my favorite marketplace book on training “Oh Crap”, and she needs to re-read it with an eye to the many ways in which her child fits the picture of a child that could NEVER be fully ready to train.  This species is so averse to novelty and challenge that no treat or toy is a great enough reward.  Nothing is more frightening to them than failure, and you simply cannot miss the diaper.  It is familiar, fail-proof, and allows children to never have to monitor their body signals or stop watching Paw Patrol to go to the potty.  Ever.

This child is likely to be experiencing the normal sensations of fullness and pressure (as the bladder and rectum fill) as uncomfortable and a little scary.  This interoceptive input can be one that children are sensitive to in the same way that the find seams on clothes or lying down for a diaper change unpleasant.  He requires a lot of support to tolerate and process tactile input and vestibular input, so it isn’t exactly surprising that he would find interoceptive sensation difficult to handle.  Adding a new routine for dealing with elimination, placing it in a room he rarely uses (the bathroom) and being old enough to know that he could “fail” and old enough to absorb outside comments about being “dirty” is more than enough to make this harder than it should be.

My suggestions to this mom included:

  • Adding more vocabulary to her discussions about toilet training.  Speaking about the feelings of pressure and fullness, the actions of pushing the poop out gently, and cleaning/wiping with clear messaging that this is a learning experience that nobody does perfectly.  Hearing that his parents had “accidents” when they were little, and that every child will have accidents, well, this could really help both of them.
  • Dressing him lightly, or choosing to go naked or just underpants (I like two layers of training pants if they still fit his tiny heine!) so that there are fewer barriers to making it to the potty means she may need to shop for training garments.
  • Planning the environment if she is going to let him go naked.  All living events except sleeping need to happen in places where accidents can be cleaned up easily.  She isn’t averse to staining the carpet, but I assured her that her child knows not to spill things on that carpet.  He is too old not to interpret soiling it as a failure.  When she runs to clean it up, he will feel badly.  If she doesn’t have to rush and shows no stress, he will relax about the almost inevitable accident.  He NEEDS  the confidence to move forward.
  • Consider more media about toileting and the arc of learning.  Most children don’t like to talk about things that distress them.  But they LOVE to read about others who are going through the same things.  I suggested that she weave in some new books about characters who are learning to use the toilet, and add comments about their feelings as they learn.  This would include how excited and proud the character is.  Proud can be a new word in his vocabulary!

 

Training a child that has low tone?  I wrote an e-book for you!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone is filled with preparation ideas, strategies to address the common issues of sensory processing limitations and the behavioral effects of low tone, and even includes a guide to building readiness instead of waiting for it to arrive!  You can find it on my website Tranquil Babies,  on Amazon  , and on a terrific site for occupational therapy materials, Your Therapy Source

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