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Should Hypermobile Kids Sit On Therapy Balls For Schoolwork?

They are everywhere; colorful therapy balls have migrated from the clinic to the classroom.  You can buy a base or a whole chair with a ball attached.  But do kids with hypermobility benefit from using them, or will they create more problems than they solve?

Hypermobility in infants and very young children is common, and decreases over time in typical children.  And then there are the kids with low muscle tone or connective tissue disorders.  These kids do not commonly see a decrease in their loose joints over time.  They do become stronger, and they can become more stable and steady.  But they can still display considerable flexibility over time.

In fact, hypermobility can increase with each overstretched ligament or damaged joint.  It is as simple as basic construction principles:  when the foundation is shaky, the structures around the foundation receive some of the forces from action and movement that the foundation should have absorbed.  A child who has an unstable pelvis will experience more forces in their upper spine and in their knees as the muscles try to compensate for the extra movement at the pelvis.  Over-stretching, excessive tightening of the wrong structures, and damage to joint surfaces are the result of excessive force absorption.

In this situation, another symptom becomes more and more obvious:  fatigue.  Well-aligned joints are designed to decrease effort during movement, like a Swiss clock.  Damaged joints and joints that don’t glide correctly due to lax ligaments and weak muscles require more effort to do the same job.  Hence fatigue sets in just from the extra effort required.  This is true even if the connective tissue that creates muscles and ligaments is of good quality.  Some genetic connective tissue disorders are characterized by incomplete or faulty construction of connective tissue.  These children are starting out with a foundation that is unstable and weak before any forces have been applied.  They will become weak and tired more quickly than a child with the same level of instability but with stronger connective tissue.

While sitting on a therapy ball-chair, the expectation is that the dynamic movement of the ball will activate core musculature and provide a dynamic position that helps a child  achieve core stability.  Sounds great!  But…this assumes that the physical structures needed are capable of doing so, and that the child is also able to write or play, using his arms and hands effectively at the same time.  It also assumes that the child will notice when his alignment has decreased and will take action to prevent compensation.  I think that is a lot to ask of most kids, even most teens.  They just want to get their homework done and over.

Based on all of these concerns, I recommend that children with hypermobility be closely evaluated and monitored by a therapist before they use a therapy ball set-up as a chair for play or schoolwork.  The extra effort to sustain and achieve good alignment is likely to be difficult to manage as they concentrate on a task like handwriting.  The risk is that they fatigue the supporting musculature, recruit compensatory muscles for support, and place more strain on joints and ligaments without awareness.  Yes, I am saying that there is a chance that the use of these chairs with some kids can make things worse.

A better idea for kids with hypermobility?  A more supportive seating set-up.  Reduce the physical demands while your child is working, and leave exercising on a ball to therapy sessions and your therapy home program.  Therapists are skilled at designing programs that target specific muscles to develop balanced control around a joint while protecting it at the same time.  They are also great at assessing work stations and chairs to determine which designs will give your child support and dynamic positioning at the same time without excessive fatigue.  This is one of my favorite tasks as an OT.  I know that a well-designed seating set-up will provide a pay-off every time a child sits down for a meal, plays at a table, or does their homework.  Sometimes it means that joint protection and support have to be blanked with dynamic control, and my training helps families to parse it out for the best result possible for their child.

Looking for more ideas with your hypermobile child?  Check out Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior and Should Hypermobile Kids Use Backpacks? to start the school year.

I am working on a new e-book on hyper mobility, and welcome parents and therapists to suggest topics that are rarely discussed online or in the clinic.  My goal is to create a book that helps kids thrive!

 

 

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Halloween Fun When Kids Don’t or Can’t Trick-Or-Treat

 

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Kids big and little are anticipating Halloween, but this holiday isn’t always enjoyable for children with ASD, SPD, anxiety or motor issues.  Putting on a costume can be difficult for some kids to tolerate and nearly impossible for kids that have mobility issues.  Kids with endurance and mobility issues struggle to walk up to a front door and ring the bell, but they don’t want to be carried “like a baby”.  Even seeing other children in costume or decorations in their own home can be difficult for children that are very sensitive.

What begins as a celebration and an adventure becomes a minefield.  And yet, your child may be invited to participate in many Halloween events.  You may want to have a party in your own home.  Your child may even beg to be involved in things you know they will end up hating, not realizing the challenges ahead.  Inclusion is a murky pond for some kids.

Perhaps it doesn’t have to be so difficult.  Here are a few ideas that could make this holiday less stressful and more inclusive:

  • Costumes can be anything you want them to be.  Purchased costumes can be adapted or altered for comfort and tolerance.  If you have a child with tactile sensitivity, choosing the fabric that is less irritating is worth a trip to a brick-and-mortar store, or ordering multiple sets online with easy returns.  Instead of an eye patch for a pirate, you can use makeup to create one.  Princess skirts and Batman pants can be shortened to prevent tripping.  They can be bought larger and altered to allow for braces and for sitting in a wheelchair.  Hats and headpieces are optional, and can also be switched out for more wearable choices.  They can be purchased separately or by combining two costumes.  A comfortable costume is fun; an awkward costume will cost you in time, pain and struggle much more than you can imagine.
  • Trick-or-treat is over-rated.  Choose people your child knows, a neighborhood that has flat, accessible front steps, or even an apartment building with an elevator.  The experience of trick-or-treat doesn’t have to be a marathon to be fun: in fact, “fun” is the opposite of dragging stressed children around from house to house.  Remember that children with sensory modulation issues will start out excited and happy and become overwhelmed quickly.  Monitoring and planning for this helps both of you have fun that doesn’t end badly.
  • Many children with sensitivities need to practice wearing their costume until it becomes familiar.  They may protest and initially refuse, but some practice can really help them.  Make the run-through more fun by pairing it with something like watching a halloween movie at home or putting up decorations.  The child that refuses to wear a costume can become the child who doesn’t want to take it off!
  • Choose your home decorations with your child’s tolerance in mind.  It isn’t always about whether they are scary or not, it can be the brightness, the amount of movement or the sounds that overwhelm children.  You won’t always know what will be too much, so prepare yourself and the rest of the family that you may have to substitute/remove/repurpose things that don’t work out.
  • Do fun events that your child can handle.  Bake cookies, including the buy-and-bake-off cookies that don’t require a lot of effort or time.  The end product can be given to friends and family proudly.  Decorate a Halloween cookie house.  Put up cling-on decorations in windows and storm doors that are easy to remove if they become an issue.  Watch a fun movie at home and invite friends to dress up and come over for the show.

Holidays for kids with special needs take more thought, but they don’t have to be less fun, just a bit different.  The important concept is to consider your child’s needs and aim for the essential feelings of the holiday:  fun, and sharing the fun with others!

When Your Gifted Child Is A Perfectionist

 

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Do you know a child who is always trying to get to “perfect”?  Being called a perfectionist is almost universally a criticism in our society.  It doesn’t have to be.  Some kids that are reaching for the ultimate aren’t unnecessarily stressing them selves out.  They may gifted.

The gifted child is capable of seeing what others do not.  They envision a wider and deeper experience, a more complete artistic expression, a better-turned phrase.  And they demand a chance to achieve it.  In this way, perfecting their performance or product isn’t psychological struggle, it is accomplishing what they can imagine.

A gifted child may not beat himself up for not immediately achieving his vision, but he may not leave well enough alone.  He may not have to.  Given the chance, he may work happily on his project for hours or days or even months, not really minding the process that requires failures and one-offs.  This should give you a clue to the source of your child’s persistence;  the gifted enjoy the process as much as the product.  This is very different from the child who tears up a picture in frustration.  There are no tears from a gifted child, but there may not be any negotiation.  They cannot leave their work in it’s current state, knowing that a better outcome is right around the corner.

What if the picture or term paper is due on Tuesday?

Give your gifted child the gift of understanding and teach them that deadlines also have value.  Living in our society requires the gifted child to bend to fit, but not break.  They can continue to work on their project when it is returned to them, or they can accept that reaching the perfect state the they see is something that doesn’t happen with every endeavor.

Let them enjoy the creative process, as this is the true joy for them.  Gifted children need your help to learn how to navigate the wider world, where often their modest efforts are celebrated.  They know that they can do more, but if they can shift off of a demand for perfection in some things, they can reach the heights of their abilities in other experiences.

Go Back To School With Target’s Sensory-Friendly Clothing Line

 

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A boy’s tee from the Cat and Jack collection at Target

Here in the US, kids are getting ready to start the school year.  A mom mentioned to me that Target is now carrying sensory-friendly clothing by Cat and Jack; attractive and functional clothes for kids who find tags, seams and textured clothing uncomfortable.  I went to check them out online.  Here is what I learned:

The selection is limited but sufficient for kids who don’t have to wear a uniform for school.  It includes clothes for toddlers up through grade school.  I saw leggings and tees, both long and short-sleeved.  There aren’t any tags and the seams are sewn flat.  The garments have been pre-washed for softness, which saves parents some work.  I know that there are kids who insist their new clothing be repeatedly laundered to get out the stiffening agents that have been applied to fabrics.

I know that this limited line doesn’t solve the problem of getting your child into formal clothing for a big wedding, and it may not have every color under the sun, but it is nice to see affordable clothing options for kids who struggle with this issue.

In my experience as a pediatric OT, children could still have issues with tolerating sleeves and pant legs.  Some kids find the movement of fabric on skin irritating, regardless of the level of softness.  I suggest that you ask your OT about desensitization techniques that can help you and your child have better experiences when dressing, regardless of the type of garment.

Happy Back-To-School shopping!

 

 

Address A Child’s Defiance Without Crushing Their Spirit

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Kids that defy adult instructions, even instructions that are ultimately for their benefit, often get begged or threatened into compliance.  Pleading with your child to pick up their mess, or threatening your child that those toys on the floor will be given to a charity shop isn’t always going to work.

Why? Probably because your child is waiting you out.  Children are wise observers of what works and what doesn’t, so they know you will eventually clean things up and they are fully aware that toys never disappear after a threat.

If you are tired of pleading and threatening, I have a strategy that could make you less aggravated and even ultimately boost your child’s self-esteem.  It works best with children that have at least a 30-month cognitive and language level.  This means that if you have an older developmentally delayed child that is unable to comprehend a request with a reward attached (“If you give me the shoe, I will get your milk”) then you should try a less complex strategy until they can understand this concept.

The idea is simple:  you make a request and if no response is elicited, you explain that they have a choice.  Not complying will result in a consequence they can see.  After the consequence is imposed, you offer the child another chance to make things right by following a slightly different direction or offering a “re-do”.  There is no “1-2-3” counting, because if you are certain that your child has understood your initial request and the explanation of the consequence, those were already the “one” and the two” of the countdown.  Your execution of the consequence is the “three”.  Good enough for me!

The trickiest parts of this strategy are the maintenance of a warm tone while your beloved child is defying you, and your quick thinking to identify a later task that allows them to save face while complying with your second request.  Do not think I haven’t had to act warm and friendly when inviting a difficult child to give participation another try.  I remind myself that I am the adult in the situation, and my job is to model calmness and teach skills, not get the upper hand on a 4 year-old.

I have also made up some pointless tasks such as rearranging boxes on a shelf, just to have an easy and successful task to offer them after the first consequence is delivered.  The younger the child, the less they will realize that Job #2 was only a chance for them to know that I am not rejecting them in any way.   I could say it, but actions speak louder than words.

Here is what this strategy looks like with a young child:

Adult:  “Please pick up all the cars, and then we can go have our yummy lunch.”

Child:   Looks at you, shakes her head and runs to the fridge. 

Adult:  ” Here is your choice:  pick up your cars and put them in the bin, or they will sit in their bin on top of the fridge until after dinner.”  Adult points to the fridge and/or taps the top to clarify what that means.

Child:   Gets a spoon from a drawer and stands by the fridge, no acknowledgment of your  directions.

Adult:  Uses The Happiest Toddler Kind Ignoring strategy and turns away from the child and waits next to the car pile for about 15 seconds for a positive response.  If the child doesn’t return, the adult puts the cars into the bin without more discussion, and places the bin on top of the fridge.

Child:  Cries, recognizing that a consequence has been delivered.

Adult:  Uses a disappointed but calm tone :  “I am sad too, because now we have to wait to play cars.” Adult’s body language and tone brightens. “Would you like to try listening again?  Please give me the blocks and I will stack them.”  Adult begins to stack very slowly to allow the child to consider her choice, and warmly welcomes the child’s help.

Child:   Begins to hand blocks to the adult.

Adult:  “You did a great job helping me!  Thank you!  Let’s go have our lunch!”

This can go south with strong-willed children, tired children and even some hungry children. I don’t recommend letting kids get super-tired or starving and then setting them up to lose.   Some kids are feeling great, but they draw a line in the sand and decide that they aren’t budging.  They won’t back down.  I express my disappointment in the outcome (no car play) but not in the child.  I don’t tell them I am disappointed in their behavior, because for a young child, they may not always be able to distinguish themselves from their behavior.  They will always be able to see the result: no cars.

I keep calm and impose consequences unless things go from defiance to aggression.  Then I consider a time-out strategy.  Aggression should never be ignored, because that is as good as approving of aggression.  In this age of zero-tolerance in schools, no one is doing any favors to a child by inadvertently teaching them that aggressive behavior is inconsequential.  They will find out soon enough that other people feel very differently about it.

Young kids will defy you.  I guarantee it.  Responding to defiance with limit setting doesn’t have to damage them or your connection with them.   Addressing defiance in this way can build a more positive relationship while making it very clear that there are consequences to not listening to you.

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Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior

 

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There is nothing worse than using a scientific study that correlates two variables and assuming causation. Translation:  If behaviors typical of disorder “A” are seen in a lot of people with problem “B”, we cannot assume that “A” is the cause of their behavior.   But we do it all the time.  People who love coffee adore studies that say coffee drinkers seem to live longer.  People who hate to exercise are validated by reports that find the number of heart attacks after exercise “is increasing”.

When it comes to labeling children’s behavior, we should take a couple of big steps back with our erroneous reasoning.  And when the label is ADHD, take three more.  Not because ADHD isn’t a big issue for families.  The struggles of kids, parents and educators shouldn’t be minimized.  We should be cautious with labels when two situations occur:  very young ages and multiple diagnoses that are determined largely by clinical observation, not testing.  Seeing ADHD in a child with hypermobility is one of those situations.

Hypermobility without functional problems is very common in young children.  Super-bendy kids that walk, run, hit a ball and write well aren’t struggling.  But if you have a child that cannot meet developmental milestones or has pain and poor endurance, that is  a problem with real-life consequences.  Many of them are behavioral consequences.

Yes, I said it.  Hypermobility is a motor problem that has a behavioral component.  I don’t know why so little has been written on this subject, but here it is:  hypermobile kids are more likely to fidget while sitting, more likely to get up out of their chairs, but also more likely to stay slumped on a couch.  They are more likely to jump from activity to activity, and more likely to refuse to engage in activities than their peers.  They drape themselves on furniture and people at times.

Why?  Hypermobility reduces a child’s ability to perceive body position and degree of movement, AKA proprioception and kinesthesia.  It also causes muscles to work harder to stabilize joints around a muscle, including postural muscles.  These muscles are working even when kids are asleep, so don’t think that a good rest restores these kids the same way another child gets a charge from a sit-down.

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When a hypermobile child starts to move, the brain receives more sensory input from the body, including joints, skin and muscles.  This charges up a sensory system that was virtually starving for information.  Movement from fidgeting and movement by running around the house are solutions to a child’s sense that they need something to boost their system.  But fatigue can set in very quickly, taking a moving child right back to the couch more quickly than her peers.  It looks to adults like she couldn’t possibly be tired so soon.  If you had to contract more muscles harder and longer to achieve movement, you’d be tired too!  Kids  develop a sense of self and rigid habits just like adults, so these “solutions” get woven into their sense of who they are.  And this happens at earlier ages than you might think.

Then there is pain.  Some hypermobile kids experience pain from small and large injuries.  They are more likely to be bruised,  more likely to fall and bump into things, and more likely to report what pediatricians may call “growing pains”.  Sometimes the pain is the pull on weak ligaments and tight muscles as bones grow, but sometimes it isn’t.  Soreness and pain lead some kids right to the couch.  After a while, a child may not even complain, especially if the discomfort doesn’t end.  Imagine having a lingering headache for days.  You just go on with life.  These kids are often called lazy, when in truth they are sore and exhausted after activities that don’t even register as tiring for other children their age.

How can you tell the difference between behaviors from ADHD and those related to hypermobiilty?  I think I may have an idea.

When a hypermobile child is given effective and consistent postural support, is allowed to rest before becoming exhausted (even if they say they are fine), and any pain issues are fully addressed, only then can you assess for attentional problems.  Occupational therapists with both physical medicine and sensory processing training are skilled at developing programs for postural control and energy conservation, as well as adapting activities for improved functioning.  They are capable of discussing pain symptoms with pediatricians and other health professionals.

I think that many children are being criticized for being lazy or unmotivated, and diagnosed as lacking attentional skills when the real cause of their behaviors is right under our noses.  It is time to give these kids a chance to escape a label they may not have.

How To Teach Your Toddler To Wipe “Back There”

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Potty training is a process.  For most kids, the final frontier is managing bowel movements.  Compared to learning to pee into the toilet, little kids are often more stressed by bowel movements and have less opportunities to practice.  Constipation or just the discomfort of normal elimination can make them wary, sometimes enough to convince some children that this is a process better done in a diaper.  In comparison, urination isn’t an uncomfortable experience for healthy children.  Bowel movements sometimes happen only a few times a week, instead of the multiple times a child needs to urinate per day.  Less practice and fewer opportunities for rewards (even if your reward is warm praise) make bowel training harder.

So when they finally make the leap and manage to do #2 in the toilet, a lot of parents decide to delay teaching their child how to wipe themselves.  After all, wiping can be messy and it has to be done well enough for good hygiene.  Here are my top suggestions to make “making” a complete success:

  1. Teaching should still be part of your narrative while you are the one doing the wiping.  In my book, The Practical Guide To Toilet Training Your Child With Low Tone, I teach parents how to transform daily diapering into pre-teaching.  While you are wiping, and even while you are waiting for them to finish on the toilet, your positive narrative about learning this skill doesn’t end.  You are telling your child how it’s done, in detail, as you are doing it. You convey with your words, your tone and your body language that this is a learn-able skill.
  2. Don’t forget the power of the “dry run”.  Practice with your child when he is in the bathroom, whether it is before bath time, before dressing, or during a special trip to the bathroom to practice.  Dry runs take away the mess but teach your child’s brain the motor planning needed to lean back, reach back and move that hand in the correct pattern.
  3. Will you have to reward him for this practice? Possibly.  It doesn’t have to be food or toys.  It could be the ability to choose tonight’s dessert for the family, or reading an extra two books at bedtime.  You decide on the reward based on your values and your child’s desires.
  4. Use good tools.  The adult-sized wet wipe is your friend.  The extra sensory information of a wet wipe versus a wad of dry paper is helpful when vision isn’t an option.  They are less likely to be dropped accidentally when clean, but having a good hold is especially important after it has been used. “Yucky”stuff  makes kids not want to hold on!  Wet wipes are more likely to wipe that little tush cleanly.  Don’t cut corners.  Allow your child to use more than one.
  5. Take turns.  Who wipes first and who bats “clean-up” (couldn’t resist that one!) is your decision.  Some children want you to make sure they are clean before they try, and some are insistent that they go first with anything.  This can change depending on mood and even time of day.  Be flexible, but don’t stand there like a foreman, ordering work but not willing to help out.  One of my favorite strategies is to always offer help, but be rather slow and inefficient.  This gives children the chance to rise to the occasion but still feel like you are always willing to support them.

 

Looking for more information on toilet training?  Take a look at my e-book, The Practical Guide To Toilet Training Your child With Low Muscle Tone to get a clear understanding of how to prepare for and execute your plan without tears on both sides.  Will it help you even if your child doesn’t have low muscle tone?  Of course!  Most of my techniques simply speed up the learning process for typically-developing children.  And who doesn’t want to make potty independence happen faster?

This e-book is available on my website tranquil babies, at Your Therapy Source (a great site for parents and therapists), and at Amazon.  Read more about my book with Amazon’s “look inside” section, or by reading The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!