Many children resist doing their homework, but most kids say “Its so BORING!” not “My hand hurts too much”. If a child is complaining of pain, and they don’t have a joint disease such as JRA, the first thought is hypermobility. The good news is that there are a few fast fixes that can decrease or even eliminate hand pain.
It is rare that hypermobility in the hand is directly addressed at the preschool level unless it is generalized throughout the body or severely reduces pencil grasp. Many children have atypical grasp patterns when they cannot achieve the required stability for a standard pencil grasp. Children with mild instability and no other developmental issues may still be able to write legibly and even fast enough to complete assignments in the early grades. It is when the volume of work increases or the joint stability decreases that therapists get a request for service.
Here are a few strategies that can support hypermobile kids to write with less pain:
Use a tabletop easel. These can be foldable or static. They support not just the wrist and forearm, but also the shoulder and trunk. The angle of an easel both supports correct wrist positioning and decreases strain on the wrist and hand. Some easels come with clips that hold the paper, but they should be placed on an angle to mirror the natural arm position. This will require more table space, so be aware that the size of the easel could be an issue. Simple hack: use a three-ring binder as an easel.
Enlarge the width of the pencil shaft. My favorite pencils for grades 1+ (see photo above) have a standard #2 lead, but a wider shaft. Joint protection principles tell us that avoiding a closed joint position should lead to less strain on joints and supporting ligament structures. You could use some of the adaptive pens available, but I find kids reject these as looking strange. Of course, if you enlarge the shaft oo much you will find that it is more awkward, not less. Think of those novelty pencils you buy in gift stores on vacation. Cute but useless. Nobody really writes with anything that thick. Match the child’s hand size to the pencil.
Increase the texture of the pencil shaft for easier grip, less pain, and more endurance. Everyone has seen the rubbery grips you slip onto a pencil. You can slide 3-4 onto the entire shaft, or add some tape to create a non-slip surface. I have been adding kineseotape or Dycem to handles this year, with good results. You are battling grasp stability, but also fatigue. A hand that is tired is a hand that experiences more pain. Adding texture reduces the amount of force needed for proprioceptive registration (a fancy way of saying that kids need to squeeze to fully feel what is in their hand). Reducing force reduces pain and fatigue.
Teach pacing. Kids think that the faster they write, the faster they will be out of pain. Breaking up the work can have better results, but it isn’t natural for children to pace themselves. In fact, I have never seen a young child do so. You have to teach this to kids who likely will have joint instability throughout their school years. A schedule, a timer, organizing assignments and breaking them down into heavy writing choices and light writing choices all help.
Splinting can be a real option. Not a heavy plastic or metal splint (usually). A neoprene splint can be a lightweight supportive choice. These splints are comfortable and washable. These are affordable without insurance for most families, and your OT can help you decide if this is a worthwhile pursuit. They are durable but easily lost by younger children, so not all families send one to school. But the support is real, and kids that have been told for years to “fix your fingers” can feel relieved that they can now focus on writing and composing on the paper.
Looking for more assistance with hypermobility? My new e-book is coming out this summer, and it will address the issues of the early years (0-5). The series will continue with school age kids and teens. But you don’t have to wait; visit my website tranquil babies and request a consultation to discuss your child’s treatment plan and make a better plan that works for everyone…today!
I ran across a comment piece online that recommended parents teach their hypermobile children to “listen to your body” to pace activities in an effort to avoid fatigue, pain or injury. My reaction was fairly strong and immediate. The sensory-based effects of hypermobility (HM) reduce interoception (internal body awareness) and proprioception/kinesthesia (position and movement sense, respectively). These are the main methods of “listening” we use to know how we are feeling and moving. For children with HM, telling them to listen to their body’s messages is like telling them to put on their heavy boots and then go outside to see how cold the snow is!
Relying primarily on felt senses when you have difficulty receiving adequate sensory feedback doesn’t make…..sense. What often happens is that kids find themselves quickly out of energy, suddenly sore or tripping/falling due to fatigue, and they had very little indication of this approaching until they “hit a wall”. They might not even see it as a problem. Some kids are draped over the computer or stumbling around but tell you that they feel just fine. And they aren’t lying. This is the nature of the beast.
I am all for therapy that helps kids develop greater sensory processing (as an OTR, I would have to be!), but expecting HM kids to intuitively develop finely tuned body awareness? That is simply unfair. Kids blame themselves all too easily when they struggle. What begins as a well-meaning suggestion from a person with typical sensory processing can turn into just another frustrating experience for a child with HM.
What could really help kids learn to pace themselves to prevent extreme fatigue, an increase in pain and even injury due to overdoing things?
Age-appropriate education regarding the effects of HM. Very young children need to follow an adult’s instructions (“time to rest, darling!”), but giving older kids and teens a medical explanation of how HM contributes to fatigue, pain, injuries, etc. teaches them to think. Understanding the common causes of their issues makes things less scary and empowers them. If you aren’t sure how to explain why your child could have difficulty perceiving how hard they are working or whether they are sitting in an ergonomic position, read Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children for some useful information. You could ask your child’s OT or PT for help. They should be able to give you specific examples of how your child responds to challenges and even a simple script to use in a discussion. Explaining the “why” will help children understand how to anticipate and prepare for the effects of HM.
Consider finding a pediatric occupational therapist to teach your child postural, movement and interoceptive awareness, adapt your child’s learning and living environments for maximal ease and endurance, and teach your child joint protection techniques. Occupational therapists are often thought of as the people that hand out finger splints and pencil grips. We are so much more useful to your child than that narrow view! For example, I have adapted desks for optimal postural endurance and decreased muscle tension. This has immediate effects on a child’s use of compensations like leaning their chin on their hand to look at a screen. OT isn’t just for babies or handwriting!
Pacing starts with identifying priorities. If you don’t have boundless energy, attention, strength and endurance, then you have to choose where to spend your physical “currency”. Help your child identify what is most important to them in their day, their week, and so on. Think about what gives them satisfaction and what they both love to do and need to do. This type of analysis is not easy for most kids. Even college students struggle to prioritize and plan their days and weeks. Take it slow, but make it clear that their goals are your goals. For many children with HM, being able to set goals and identify priorities means that they will need to bank some of their energy in a day or a week so that they are in better shape for important events. They may divide up tasks into short components, adapt activities for ease, or toss out low-level goals in favor of really meaningful experiences. Can this be difficult or even disappointing? Almost certainly! The alternative is to be stuck at an event in pain, become exhausted before a job is completed, or end up doing something that places them at higher risk for injury.
Help your child identify and practice using their best strategies for generating energy, building stamina and achieving pain-free movement. Some kids with HM need to get more rest than their peers. Others need to be mindful of diet, use relaxation techniques, wear orthotics regularly, adapt their home or school environment, or engage in a home exercise program. Learning stress-reduction techniques can be very empowering and helps kids think through situations calmly. Sports can be an issue or they can be a wonderful way to build endurance and body awareness. Read Should Your Hypermobile Child Play Sports? for some ideas on managing pain, endurance and coordination. Creating a plan together and discussing the wins and failures models behaviors like optimism and resourcefulness. Children depend on adults to show them that self-pacing is a process, not an endpoint.