Tag Archives: low muscle tone

Toilet Training? Your Child Needs the Right Shorts!

 

In my first e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, I wrote almost a full chapter just on clothing management.  If your child needs you to pull clothing on and off, they are NOT fully trained.  And if they have clothes that make it impossible for them to manage, you are holding them back from feeling like a real success.

Target has your back!

Yes, the same place you go for their swimsuits, toilet paper, and hand soap.  Target sells a cheap pair of shorts that children can easily pull down and back up again.  Their Cat and Jack line is pretty inexpensive, which is helpful when you know that you will be going through a few pair of shorts per day due to accidents.  They are soft to the touch for kids with sensory sensitivities, and they do have a drawstring waist if you have one of those kids whose shorts slide off their tush.  But remember that if you knot it, your kid won’t be able to slide their shorts off easily.  Better to buy a smaller size.

I would pair these with a T-shirt that ends close to their natural waist.  A longer top will get in the way during bathroom use.  You want to give your child every chance to have a positive experience, and peeing on your clothing by accident isn’t a positive!

Here is a link to a post on dressing skills: Low Muscle Tone and Dressing: Easy Solutions to Teach Independence

Want more help with your child?  

The Practical Guide….. is available on my website Tranquil Babies as a printable download, and on Amazon as a read-only download.  It is also available on Your Therapy Source individually and bundled with either my book on hypermobility in very young children The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today! or as a discounted super-bundle with my book on hypermobility in school-age children included A Practical Guide to Helping the Hypermobile School-Age Child Succeed

The Best Ride-On Toy For Younger (or Petite) Toddlers

 

61-g+QMVAYL._SL1000_.jpgAs an occupational therapist, I have always found it difficult to recommend a toddler ride-on toy for younger or smaller kids with low muscle tone and hypermobility.  Most of these toys have such a wide seat that children must propel themselves with their knees rotated out and pushing forward on their toes.  Exactly the pattern of movement we DON’T want to see.

And then I saw the Fly Bike.  This little fold-up bike has a seat that is about 9.5 inches high and has a very narrow seat.  This allows a child’s feet to be aligned with their hips, facilitating the development of hip and trunk control, not substituting bending forward and back to propel the toy.

The textured seat helps grip a child’s clothing for a little extra stability, and the small handlebars mean children aren’t draping their chest over the front of the toy; they are holding onto the handlebars with their hands.  Brilliant.  The rubber wheels are kind to indoor floors, but can handle pavement easily.

Are there children that don’t fit this toy?  Absolutely.  If your child is too tall for this toy, they shouldn’t use it.  If your child cannot maintain adequate sitting balance independently on this toy, they may need more support from another style of ride-on toy, perhaps with a larger seat and a backplate.

I finally have a great ride-on toy that I can recommend for smaller kids.  An early Xmas present to me and my little clients!

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Three Ways To Reduce W-Sitting (And Why It Matters)

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Children who sit on the floor with their thighs rolled inward and their calves rotated out to the sides are told that they are “W-sitting”.  Parents are told to reposition their kids immediately.  There are even garments like Hip Helpers that make it nearly impossible to sit in this manner.  Some therapists get practically apoplectic when they see kids sitting this way.  Not me; I prefer to be a stealth ninja therapist: create situations in which the child wants to reposition themselves.

I get asked about W-sitting no less than 3x/week, so I though I would post some information about w-sitting, and some simple ways to address this without aggravating your child or yourself:

  1. This is not an abnormal sitting pattern.  Using it all the time, and being unable to sit with stability and comfort in other positions…that’s the real problem.  Typically-developing kids actually sit like this from time to time.  When children use this position constantly, they are telling therapists something very important about how they use their bodies.  But abnormal?  Nah.
  2. Persistent W-sitting isn’t without consequence, just because it isn’t painful to your child.  As a child sits in this position day after day, some muscles and ligaments are becoming overstretched.  This creates points of weakness and instability, on top of any hypermobility that they may already display.  Other muscles and ligaments are becoming shorter and tighter.  This makes it harder for them to have a wide variety of movements and move smoothly from position to position.  Their options for rest and activity just decreased.  Oops.  And they don’t feel uncomfortable in that position.  If you aren’t hypermobile yourself, you might not believe me.  Here is an explanation:  Is Your Hypermobile Child Frequently In An Awkward Position? No, She Really DOESN’T Feel Any Pain From Sitting That Way.
  3. Sitting this way locks a child into a too-static, too-stable sitting position.  This appeals to the wobbly child, the weak child, and the fearful child, but it makes it harder for them to shift and change position.  Especially in early childhood, developing coordination is all about being able to move easily, quickly and with control.  There are better choices.
  4. A child who persistently W-sits is likely to get up and walk with an awkward gait pattern.   All that over-stretching and over-tightening isn’t going to go away once they are on their feet.  You will see the effects as they walk and run.  It is the (bad) gift that keeps on giving.

What can you do?

Well, good physical and occupational therapy can make a huge difference, but for today, start by reducing the amount of time they spend on the floor.  There are other positions that allow them to play and build motor control:

  • Encourage them to stand to play.  They can stand at a table, they can stand at the couch, they can stand on a balance disc.  Standing, even standing while gently leaning on a surface, could be helping them more than W-sitting.
  • Give them a good chair or bench to sit on.  I am a big fan of footstools for toddlers and preschoolers.  They are stable and often have non-skid surfaces that help them stay sitting.  They key is making sure their feet can be placed flat on the floor with their thighs at or close to level with the floor.  This should help them activate their trunk and hip musculature effectively.
  • Try prone.  AKA “tummy time”; it’s not just for babies.  This position stretches out tight hip flexors and helps kids build some trunk control.  To date, I haven’t met one child over 3 who wouldn’t play a short tablet game with me in this position.  And them we turn off the device and play with something else in the same position!
  • If your child still wants/ needs to sit on the floor, fix their leg position without risking damage to their hips and knees.  Read How To Correctly Reposition Your Child’s Legs When They “W-Sit” for more details.

For more strategies for hypermobile kids, take a look at  Joint Protection And Hypermobility: Investing in Your Child’s Future and How Hypermobility Affects Self-Image, Behavior and Activity Levels in Children.

Looking for More Information on Hypermobility in Young Children?

I wrote an e-book for you!

The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years is my newest e-book, filled with strategies to help parents understand the complexities of hypermobility and find answers to their everyday problems.  Learning how to help a child sit for a meal, get dressed, bathe and hold a crayon isn’t intuitive. Trying to figure out how to teach your babysitter or mother-in-law how to hold and carry your hypermobile child or how to give them a bath safely?  Parenting manuals don’t cover this, and your child’s therapists might not know how to help you either.

This book gives parents the information they need to feel empowered and confident!  There are even chapters on how to improve communication with a child’s siblings and the extended family, with babysitters and teachers, and even how to speak with your doctors to get results.  My book contains many of the techniques I have learned in my 25 years as a pediatric OTR and great ideas that parents have taught ME!

This unique e-book gives parents helpful information to make everyday life better.  

It is available on Amazon as a read-only download, or on Your Therapy Source as a printable and click-able download.  Buy it today!

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For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance

 

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One of my most popular posts, Why “Hand-Over-Hand” Assistance Works Poorly With So Many Special Needs Children , explains how this common method of assisting children to hold and manipulate objects often results in rejection or even aversion.  This post tells you about my most successful strategy for kids with low muscle tone and limited sensory processing:  using graded resistance.

Why does making it harder to move work better?  Because if the child is actively trying to reach and grasp an object, you are providing more tactile, kinesthetic and proprioceptive information for their brain.  More information = better quality movement.  Your accurately graded resistance is doing what weighted/pressure vests, foot weights and SPIO suits do for the rest of their body.  Could you use a hand weight or weighted object?  Maybe, but little children have little hands with limited space to place a weight, and weights don’t distribute force evenly.  Did you take physics in school?  Then you know that gravity exerts a constant pressure in one direction.  Hands move in 3-D.  Oh, well.  So much for weighting things.

How do you know how much force to use?  Just enough to allow the child to move smoothly.  Its a dance in which you constantly monitor their effort and grade yours to allow movement to continue.

Where do you place the force?  That one is a little trickier.  It helps to have some knowledge of biomechanics, but I can tell you that it isn’t always on their hand.  Not because they won’t like it, but because it may not deliver the correct force. Often your force can be more proximal, meaning closer to the shoulder than the hand.  That would provide more information for the joints and muscles that stabilize the arm, steadying it so the hand can be guided accurately.   If a child has such a weak grasp that they cannot maintain a hold while pushing or pulling, you may be better off moving the object, not the hand,  while they hold the object, rather than holding their hand.

Still getting aversive responses from the child?  It may be because the child doesn’t want to engage in your activity, or they don’t realize that you are helping them.  They  may think that adults touch them to remove objects from their grasp or otherwise stop them from exploring.  Both can be true.  In that case, make sure that you are offering the child something that they want to do first.  Remember, we can’t force anyone to play.  The desire to engage has to come from them, or it isn’t play.  Its just adults making a kid do something that we think is good for them.

Want more information on how to help children build hand skills?  Read Using A Vertical Easel in Preschool? WHERE You Draw on it Matters! and Egg Crayons or Fingertip Crayons: When Good Marketing Slows Down Fine Motor Skill Development.

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One of the most amazing places I have ever seen:  Australia!

Hypermobile Toddlers: It’s What Not To Do That Matters Most

 

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Do you pick up your toddler and feel that shoulder or those wrist bones moving a lot under your touch?  Does your child do a “downward dog” and her elbows look like they are bending backward?  Does it seem that his ankles are rolling over toward the floor when he stands up?  That is hypermobility, or excessive joint movement.

Barring direct injury to a joint, ligament laxity and/or low muscle tone are the usual culprits that create hypermobility.  This can be noticed in one joint, a few, or in many joints throughout the body.  While some excessive flexibility is quite normal for kids, other children are very, very flexible.  This isn’t usually painful for the youngest children, and may never create pain for your child at any point in their lifetime.  That doesn’t mean that you should ignore it.  Hypermobility rarely goes away, even though it often decreases a bit with age in some children.  It can be managed effectively with good OT and PT treatment.   And what you avoid doing at this early stage can prevent accidental joint injury and teach good habits that last a lifetime.

  1. Avoid over-stretching joints, and I mean all of them.  This means that you pick a child up with your hands on their ribcage and under their hips, not by their arms or wrists.  Instruct your babysitter and your daycare providers, demonstrating clearly to illustrate the moves you’d prefer them to use. Don’t just tell them over the phone or in a text.  Your child’s perception of pain is not always accurate when joint sensory aren’t stimulated (how many times have they smacked into something hard and not cried at all?) so you will always want to use a lift that produces the least amount of force on the most vulnerable joints.  Yes, ribs can be dislocated too, but not nearly as easily as shoulders, elbows or wrists.  For all but the most vulnerable children, simply changing to this lift instead of pulling on a limb is a safe bet.  Read Have a Child With Low Tone or a Hypermobile Baby? Pay More Attention to How You Pick Your Little One Up
  2. Actively discourage sitting, lying or leaning on joints that bend backward.  This includes “W” sitting.   I have lost count of the number of toddlers I see who lean on the BACK  of their hands in sitting or lying on their stomach.  This is too much stretch for those ligaments.  Don’t sit idly by.  Teach them how to position their joints.  If they ask why, explaining that it will cause a “booboo” inside their wrist or arm should be enough.  If they persist, think of another position all together.  Sitting on a little bench instead of the floor, perhaps? Read   Three Ways To Reduce W-Sitting (And Why It Matters) for more information and ideas.
  3. Monitor and respect fatigue.  Once the muscles surrounding a loose joint have fatigued and don’t support it, that joint is more vulnerable to injury.  Ask your child to change her position or her activity before she is completely exhausted.  This doesn’t necessarily mean stopping the fun, just altering it.  But sometimes it does mean a full-on break.  If she balks, sweeten the deal and offer something desirable while you explain that her knees or her wrists need to take a rest.  They are tired.  They may not want to rest either, but it is their rest time.  Toddlers can relate.

Although we as therapists will be big players in your child’s development, parents are and always will be the single greatest force in shaping a child’s behavior and outlook.  It is possible to raise a hypermobile child that is active, happy, and aware of their body in a nonjudgmental way.    It starts with parents understanding these simple concepts and acting on them in daily activities.

 

Wondering about your stroller or how to help your child sit for meals or play?  Read Kids With Low Muscle Tone: The Hidden Problems With StrollersThe Cube Chair: Your Special Needs Toddler’s New Favorite Seat!,  Kids With Low Muscle Tone: The Hidden Problems With Strollers and Picking The Best Trikes, Scooters, Etc. For Kids With Low Tone and Hypermobility for practical ideas that help your child today!

Wondering about your child’s speech and feeding development?  Take a look at Can Hypermobility Cause Speech Problems? to learn more about the effects of hypermobility on communication and oral motor skills.

Looking for information on toilet training, or for more general strategies for your child with Ehlers Danlos syndrome, generalized ligament laxity, or low muscle tone?  

I wrote 2 e-books for you!

My first e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, gives you detailed strategies for success, not philosophy or blanket statements.  I include readiness checklists, discuss issues that derail training such as constipation, and explain the sensory, motor, and social/emotional components of training children that struggle to gain the awareness and stability needed to get the job done.  You will start making progress right away!

This e-book is available on my website tranquil babies, at Amazon, and at Your Therapy Source.

My second e-book, The JointSmart Child:  Living and Thriving with Hypermobility Volume One:  The Early Years, is a more comprehensive guide to managing hyoermobility in the child birth -5 years of age.  Filled with information regarding ADLs, safety awareness at home and at preschool or daycare, it is designed to empower parents, not just provide information.  Parents learn how to pick the right high chair, booster seat, even the right clothing to improve their child’s independence and reduce accidental injuries.  There are even forms to share with babysitters, family  members, even a form to make doctor’s visits more productive!

Find this book on Amazon as a read-only download, or buy it on Your Therapy Source  as a printable and click-able download.  Don’t have a Kindle?  Don’t worry!  Amazon makes it easy to read on your hone or iPad.

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Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children

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When most parents think of sensory processing issues, they think of the children who hate clothing tags and gag on textured foods.   Joint hypermobility, regardless of the reason (prematurity, Ehlers-Danlos syndrome, head injury, etc) can result in kids who stumble when they move and wobble when they rest.  They are seen by orthopedists and physical therapists, and told to build up those weak muscles.  Well, hypermobile kids have sensory processing issues too!   And they deserve more effective treatment for these issues than they typically receive.

Lack of joint integrity, especially decreased joint stability, results in a decrease in proprioception and kinesthesia.  These two under-appreciated (and poorly explained) senses tell a child about her body’s positions and movements without the use of vision. The literature out there is sparse.

If you are hoping that a lot of research on this topic exists, and you think your pediatrician understands why your child can’t grasp a pencil but can squeeze the @@#$% out of Play-Doh, good luck.  

Who will believe AND understand you?  Your OT!

Most of the scientific research into proprioception and hypermobility has been done by PTs, and is focused on proprioception in the leg. They are interested in how it affects mobility.

The problems with poor proprioception and kinesthesia go far beyond walking.  Essentially no research has been done on hand function or the practical application of research to living skills of any kind when it comes to hypermobility syndromes and proprioception. But OTs can teach you and your child’s classroom staff about the connections between sensory processing and motor performance.  They can help your child improve skills based on their knowledge of neurology and function.

Here is a simple explanation of how proprioception and kinesthesia affect function.  Consider the process for touch-typing.  Your awareness of your hand’s position while at rest on the home row is proprioception.  You know where your movement starting and end points are via proprioception without looking.  Your awareness of the degree of movement in a joint while you are actively typing is kinesthesia.  Kinesthesia tells you that you just typed a “w” instead of an “e” without having to look at the screen or at your fingers.Your brain “knows”, through learned feedback loops, that your finger movement was too far to the left to type the letter “w”, but far enough to have been a “e”.  Teachers and others call this “muscle memory”, but that is a misnomer.  Muscles have no memory; brains do.  And brains that aren’t getting the right information send out the wrong instructions to muscles.  Oops!

You are able to grade the amount of force on each key because your skin, joint and muscle sensors transmit information about the resistance you meet while pressing down each key.   Your brain compares it previous typing success and the results on the screen, and makes adjustments in fractions of a second. This is sensory processing at work.

Why do children with hypermobility have proprioceptive and kinesthetic processing problems?  Because information from your body is transmitted is through receptors embedded in the tissue within and surrounding the joints.   These receptors respond to muscle and tendon stretch, muscle contraction, and pressure within the joint.   Joint hypermobility creates less stimulation (and thus less accurate information) to these sensory receptors.  Like the game at the carnival, the ball isn’t hit hard enough to ring the bell at the top of the post.  The sensory information coming into the brain is either insufficient or delayed (or both), and therefore the brain’s output of directions to achieve postural stability or dynamic movement is correspondingly poor.

This shows up as a collapsed posture, difficulty quickly changing positions to catch a ball or leap over an obstacle, a heavy-footed gait, and a whole lot of other difficulties.  One of the most common issues are the awkward or extreme positions these kids get into, and sometimes strongly prefer.  They look like they should be in pain, but they aren’t.  Read more about what to do when your child insists on sitting in a position that could harm them in Is Your Hypermobile Child Frequently In An Awkward Position? No, She Really DOESN’T Feel Any Pain From Sitting That Way

What should parents be looking for when they wonder if proprioception is affecting their child’s functional performance?

Can children with hypermobility improve their sensory processing and thereby improve the quality of their movements in daily life?  Absolutely.

Because sensory processing is a complex skill, addressing each component of functional performance will give the hypermobile child more skills.  Building muscular strength within a safe range of joint movement is only one aspect of treatment.  If your child is experiencing difficulty in music lessons or when playing sports, please read Should Your Hypermobile Child Play Sports? and  Hypermobility and Music Lessons: How to Reduce the Pain of Playing for some useful ways to think about what you say to your child.  Positioning a child to give them more sensory feedback while in action is essential.  Increasing overall sensory processing by using other sensory input modalities is often ignored but very helpful.  And don’t forget joint protection.  They have to last as long as possible.  Read Why Joint Protection Solutions for Hypermobility Aren’t Your Granny’s Joint Protection Strategies to understand more about this topic.

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I’ll bet that you didn’t think of toileting as a proprioceptive issue.  When thinking about toileting the hypermobile child, the biggest problem is often an interoceptive issue; the kind of proprioception that involves internal organs.  This can make it difficult for hypermobile kids to feel when they need to “go” in time to get to the bathroom, but it can also create retention.  The urge isn’t very powerful for them. Read For Kids Who Don’t Know They Need to “Go”? Tell Them to Stand Up and Teach Kids With EDS Or Low Tone: Don’t Hold It In!.  And of course, you might want an e- book that will help you with toilet training.  I wrote it for youThe Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

I believe that vestibular input is one of the most powerful but rarely used modalities that can improve the sensory-motor performance of hypermobile children.  They don’t have to demonstrate vestibular processing deficits to benefit from a vestibular program.  The lack of effective sensory processing due to poor proprioceptive registration and discrimination creates problems with balance, and targeted vestibular input is designed to fine-tune the brain’s balance center.  I could link you to scholarly articles on this concept, but you would fall asleep before finishing them.  Trust me, vestibular input can make a difference.  This program can be done without stressing fragile joints, which is often a limitation for the programs that focus too much on muscular strengthening and stabilization activities.

 

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My favorite sensory processing strategy for hypermobile kids?  The use of rhythmic music during movement.

Therapeutic music programs that use the powerful effects of sound on the brain are effective treatments for hypermobile children.  Using sound to improve vestibular processing increases the quality and the speed of response to a loss of balance.  Muscle tone increases in children while they are listening through stimulation of  midbrain centers, and this combo of improved tone and improved vestibular processing helps children improve their safety while moving and even while sitting still. For all of you with kids who fall off chairs while doing nothing, you know what I mean!  I have been trained in the use of Therapeutic Listening through Vital Sounds, and I really like to ease of using Quickshifts.  These short pieces of music that entrains both sides of the brain for activation and attention can really make a change in hypermobile kids.  There are other programs that work well too.  I prefer Vital Links’ Quickshifts for greater options and ease of use in a daily schedule Quickshifts: A Simple, Successful, and Easy to Use Treatment For Processing, Attention and Postural Activation.  You download their free app and buy the music for your phone!  The most significant benefit to adding a listening program to a home program for any child or adult is that there is no stress on connective tissue, even for kids that are in a lot of pain and have very limited mobility.  For kids that have POTS as well as hypermobility, this can be a real advantage.  The middle ear is connected intimately to the vagus nerve, which impacts the autonomic nervous system.  Treatment of the vestibular system can directly improve the ability of the autonomic nervous system, without the risks associated with many activities.

Another technique to enhance sensory processing is the Wilbarger Protocol.  Although not created for children with hypermobility, I believe that it can be altered to address poor proprioceptive discrimination in specific conditions such as EDS.  Read Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome? for a look at how I adapt the protocol with safety in mind.

Kineseotape can be helpful to provide some of the missing proprioceptive information.  When your child has a connective tissue disorder, or is under the age of 3, skin issues complicate taping.  Read Can You K-Tape Kids With Ehlers-Danlos and Other Connective Tissue Disorders? for some suggestions to make this treatment more effective and less risky.

It is difficult to explain to insurers and sometimes even neurologists ( don’t get me started on how hard it is for orthopedists to follow this),  but if you understand the complex processes that support sensory processing, you will be changing the background music in your clinic or your home in order to capitalize on this effect!  I recommend the Vital Links Therapeutic Listening programs for their ease of use and child-friendly music.

Children with hypermobility can benefit from occupational therapy sessions that provide more than a pencil grip and a seat cushion.  All it takes is an appreciation for the sensory effects of hypermobility on function.

Looking for a manual that empowers you and your hypermobile child?

I wrote 2 e-books just for you; one for the smaller kids, and one for the school-age child!

The JointSmart Child:  Living and Thriving With Hypermobility Volume One: The Early Years is my e-book for the parents and therapists of young children, packed with strategies that make life easier and build a toddler’s and preschooler’s skills!

It is available as a read-only download on Amazon and as a printable and clickable download at Your Therapy Source    YTS has it bundled with my book on toilet training for a complete set at a discounted price.

Read how my new e-book can help you today:  Parents of Young Hypermobile Children (and Their Therapists) Finally Get Their Empowerment Manual!

Need a book for older kids?  Here you go!

The JointSmart Child:  Living and Thriving with Hypermobility Volume Two:  The School Years is my newest book, filled with even more information for kids ages 6-12.  There are strategies to help them write and play sports with less risk of injury, plus methods to communicate with teachers and doctors to get the services your child needs.  Learn how to pick the best chairs, bikes, even the right clothes to make your child safer and more independent.  Read more about it here:  Parents and Therapists of Hypermobile School-Age Kids Finally Have a Practical Guidebook!  It is available on Amazon as a read-only download and as a printable e-book on Your Therapy Source!

Does your hypermobile child also have toileting issues?  

My e-book, The Practical Guide To Toilet Training Your Child With Low Muscle Tone, could help you make progress today!  

The Practical Guide is available on my website, tranquil babies and on Amazon as well as at your therapy source, a great place for therapists and parents to find exercise programs and activities for children.  Read more about it, and hear what parents have to say about this unique e-book:The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

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Does An Atypical Pencil Grasp Damage Joints or Support Function In Kids With Hypermobility?

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As a pediatric OTR, I am often asked to assess and teach proper pencil grasp.  Once you start looking, you see a lot of interesting patterns out there.  When a child clearly has low muscle tone and/or hypermobile joints, the question of what to do about an atypical pencil grasp used to puzzle me.  I could spend weeks, or even months, teaching positioning and developing hand strength in a child, only to find that they simply couldn’t alter their grasp while writing.

Now I triage grasp issues by determining if it is a problem for the child now or in the future.  An atypical pencil grasp can be an acceptable functional compensation or it can be a contributor to later joint damage.  What’s the difference?  You have to know a bit about hand anatomy and function, how to adapt activities, and how to assess the ergonomics of writing.

Children aren’t aware of most of the problems that low tone and/or hypermobility create when they hold a pencil.  They just want to write or draw.  Teachers and parents don’t know what is causing issues either.  The effects of their unique physiology often results in grasp patterns that cause parents pain just to observe; fingers twisted around the shaft of the pencil, thumb joints bent backward, etc.  The kids aren’t usually complaining; their lack of sensory receptor firing at the joints and muscles gives them no clues to the strain they are inducing.  None.  Occasionally children will complain of muscular fatigue or pain after writing a few paragraphs or completing an art project.  For the most part, they are unconcerned and unaware of what is really going on.  For a more detailed explanation, please check out Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children,

Do these funny grasp patterns reduce legibility?  Only sometimes.  There are atypical grasp patterns that are good choices for children with hypermobility.  One is to place the shaft of the pencil directly between the index and third finger, and allow the thumb to support the side of the pencil.  The knuckle joints of those fingers provide more stability than the standard tripod grasp.  This grasp pattern is illustrated at the beginning of this post.

I allow preschoolers who need to keep more than 3 fingers on the shaft of the pencil to do so, and wait to see what happens as they develop more overall hand control.  This is especially beneficial for the child with sensory discrimination issues or joint hypermobility.  Forcing a tripod grip isn’t always in their best interest now or for the future.

What can be done?  My favorite method to help children with low tone or hypermobility is to look at the problem with both a wide-angle lens and with targeted analysis.  I think about changing overall posture, altering any and all equipment, and examine the mechanics of movement.

Does handwriting instruction matter?  I think so.  The best writing program teaches children quickly, so that they don’t have to write 100 “A”s to learn how to write.   The only program I use is Handwriting Without Tears.  The high-quality materials and the developmental progression make learning easier and faster.  Read KickStart Kindergarten: Get Your Child Ready for Kindergarten Writing The Easy Way! to see some sample pages and understand how this particular book can work for ages 4-8.

Wondering if there are issues beyond writing that your OT can address?  Check out   Hypermobility and Music Lessons: Is Your Child Paying Too High a Price for Culture?Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children and Three Ways To Reduce W-Sitting (And Why It Matters) for more information.

Atypical pencil grasp can be a problem, but it can also be a solution to a child who is struggling to write and draw in school.  If you have concerns, ask your OT to evaluate and explore the issue this week!

Looking for more information on raising (or treating) a hypermobile child? 

I wrote 2 e-books to help you!

The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years

is filled with practical strategies to help parents of children 0-5 build safety, skills, and independence.  Written in easy-to-understand language and designed with chapter summaries that help busy parents find the answers they need, this book is unique in the world of special needs resources!  Therapists will find easy ways to boost ADL skills, safety awareness, and early fine motor skills with an awareness of the sensory processing needs of the hyper mobile client.

My e-book is available as a read-only download on Amazon and as a clickable and printable download on Your Therapy Source.  Worried that you don’t have a Kindle?  No problem:  Amazon’s downloads are totally supported on iPads and iPhones.

The JointSmart Child:  Living and Thriving With Hypermobility Volume Two:  The School Years

is my newest e-book for parents and therapists of kids 6-12.  Older children may still need to build their ADL independence and safety, but they also need to write and keyboard, and they play sports and musical instruments.  This book is larger and more comprehensive than Volume One, filled with forms and checklists to find the right chair, desk, bike, even the best way to arrange a bedroom for sleep.  Parents and therapists will have forms and handouts they can use in CPSE and CSE meetings with the school district and information on how to become an empowered consumer in doctor’s appointments.

It is available as a read-only download on Amazon  and as a printable download on Your Therapy Source ,and just like Volume One, Amazon doesn’t require you to have a Kindle to download my book.  They make it easy!

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Hypermobility in Young Children: When Flexibility Isn’t Functional

Your grandma would have called it being ” double jointed”.   Your mom might mention that she was the most flexible person in every yoga class she attended.  But when extra joint motion reduces your child’s performance or creates pain, parents get concerned.  Sometimes pediatricians and orthopedists do not.

Why would that happen?  A measure of flexibility is considered medically within the norm for children and teens.  Doctors often have no experience with rehab professionals, so they can’t share other resources with parents.  This can mask some significant issues with mild to moderate hypermobility in children.  Parents leave the doctor’s office without a diagnosis or advice, even in the face of their child’s discomfort or their struggles with handwriting or recurrent sports injuries.  Who takes hypermobility seriously?  Your child’s OT and PT.

Therapists are the specialists who analyze functional performance and create effective strategies to improve stability and independence.  I will give a shout-out to orthotists, physiatrists and osteopaths for solutions such as splints and prolotherapy.  Their role is essential but limited, especially with younger children. Nobody is going to issue a hand splint or inject the ligaments of a child under 5 unless a child’s condition is becoming very poor very quickly.  Adaptations, movement education and physical treatments are better tolerated and result in more functional gains for most middle and moderately involved hypermobile children.  Take a look at Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children to understand more about what an OT can do to help your child.

Low tech doesn’t mean low quality or low results.  I have done short consults with children that involve only adaptations to sitting and pencil choice for handwriting, with a little ergonomic advice and education of healthy pacing of tasks thrown in.  All together, we manage to extend the amount of time a child can write without pain.  Going full-tilt paperless is possible when pain is extreme, but it involves getting the teachers and the district involved.  Not only is that time-consuming and difficult to coordinate, it is overkill for those mildly involved kids who don’t want to stand out.  Almost nothing is worse in middle school than appearing “different”.  A good OT and a good PT can help a child prevent future problems, make current ones evaporate, or minimize a child’s dependence and pain.

Hypermobile kids are often bright and resourceful, and once they learn basic principles of ergonomics and joint protection, the older children can solve some of their own problems.  For every child that is determined to force their body to comply with their will to compete without adaptation, I meet many kids that understand that well-planned movements are smarter and give them less pain with more capability.  But they have to have the knowledge in order to use it.  Therapists give them that power.

Parents:  please feel free to comment and share all your great solutions for your child with hypermobility, so that we all can learn from YOU!

Is your hypermobile child also struggling with toilet training or incontinence?  Check out Low Tone and Toilet Training: Learning to Hold It In Long Enough to Make It to The Potty  to gain an understanding of how motor and sensory issues contribute to this problem, and how you can help your child today!

Low Tone and Constipation: Why This Issue Delays Toilet Training Progress

Kids with low tone and sensory processing disorders are not the only children who struggle with constipation, but it is more common for them.  The reasons are many:  low abdominal and oral tone, less use of available musculature because they use compensatory sitting and standing (the schlump, the lean, the swayback) patterns, and even food choices that have less fiber.  If you struggle to chew and swallow, you probably aren’t drinking enough and eating those fruits and veggies that have fiber.  Sucking applesauce packets may get you Vitamin C, but it has pulverized all that fiber.  Now add discomfort with the sensory experience: the smells, feelings, sounds of bathrooms and using the potty.  It can all be too much!

Without fluids, fiber and intra-abdominal pressure to support peristalsis (the automatic contraction of the intestines), children with low tone are at a huge risk for constipation.  And constipation makes pooping harder and even painful.  Sensory overload makes kids agitated, distracted, and sometimes even aggressive.  Not good for learning or letting it go into the toilet.  Hence, resistance and even fear of pooping, and therefore more stress and withholding of stool.  A really big problem, one that you may have to get your pediatrician’s assistance to solve.

It can change.  Here is your secret weapon: your child’s occupational therapist.  If you haven’t been involved in your child’s therapy before, this might be the time.  Research has shown that sensory-based issues can contribute to toileting problems, and OTs are capable of evaluating all the sensory and motor-based contributors.  While  your pediatrician gives you recommendations on diet, laxatives and more, your OT can help your child stay in the alert-but-calm zone where digestion is relaxed, get better core stability to help push that poop along, and adapt the toileting experience for minimal sensory aversion and maximal sensory perception.  Take a look at Low Tone and Toilet Training: How Your Child’s Therapists Can Help You and Low Tone and Toilet Training: The Importance of Dry Runs (Pun Totally Intended).

Update:  Many of my clients have been successful with a creative combo approach:  they use stool softeners, they limit refined carbs (sorry, Goldfish crackers are cheese plus refined carbs!), ensure lots of fluids and then add some tasty fiber.  Prunes covered with chocolate have been popular, but beware the results of too much of a good thing!  They use abdominal massage and make sure that their physical and occupational therapists are working those core stabilizers.

There are medications that improve gastric motility, but they aren’t always tolerated or even prescribed for small children.  Pediatricians are very hesitant to be aggressive with a small child that could dehydrate in a few hours of diarrhea.  Find a doctor that listens to you and is creative.  My suggestion?  Think outside the box and consider an osteopath.  They are “real” doctors, but they have more training in alternative and manual treatment approaches.

Think constipation is only going to affect pooping?  Wrong!  Read Is Your Constipated Toddler Also Having Bladder Accidents? Here Are Three Possible Reasons Why to understand more about how this problem can contribute to other toilet training struggles.

Good news!

My book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, is done and available at  Your Therapy Source ( a terrific site for parents and therapists!), on Amazon as well as on my website, tranquil babies !!  Just click on the “e-book” section, and start making progress with your child today!

I include detailed readiness checklists and a full explanation of how to train your child in all aspects of toilet training.  You will know how to get the right equipment, what clothes to use so that dressing doesn’t derail your child’s best efforts, and how to deal with defiance and distress.  And yes, constipation is addressed in more detail than in this blog post.  It may turn out to be only one of the issues that you have to confront.  Don’t worry, help has arrived!

If you want a hard copy, contact me through my site and request a mailing address for your payment.

            As I say in my book:  be prepared, be consistent, expect to practice, and be positive that you and your child can do this!

 

 

 

 

Low Tone and Toilet Training: How Your Child’s Therapists Can Help You

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Over the years as an occupational therapist, I have been giving parents hints here and there.  Writing my e-book  this fall, and preparing an e-course (coming soon) to support families makes me realize that some clients did not ask me very many questions while they were toilet training their child.

So….Are there aspects of therapy that can help you with toilet training?  Yes indeed!  Does getting more therapy mean that your child will automatically be trained earlier and more easily?  Unfortunately, not really.

When it comes to potty training, you can bring a child to the potty, but you can’t make him “make”.  Toilet training is a complex skill, and even the best therapy will still only prepare all of you and develop important skills needed for this skill.  Bringing it all together is still the job of the parent or the full-time caregiver that creates and executes the plan. Waiting for readiness?  Read Waiting for Toilet Training Readiness? Create It Instead!  to understand what you can do today to inspire interest and build skills. Thinking that it’s too soon?   How Early Can You Start Toilet Training?  will shad some light on what is really important when you are wondering if your child is old enough.  If you are wondering if your child’s diagnosis is part of the issue, take a look at Why Do Some Kids With ASD and SPD Refuse Toilet Training?  And finally, if you are eager to move into night-time training, read Why is Staying Dry at Night So Challenging For Some Children? for support at the finish line of toilet training.

Here is a list of what therapy can do to support you and your child for toilet training.  If you haven’t heard your therapists discussing these treatment goals/approaches, you might want to share this post with them.  They may be more focused on other very important skills right now, but always keep your discussions open and inform them that you are planning on training.  Most therapists are very eager to support families whenever they can with whatever goals the family has.

  1. Core stability for balance, abdominal strength and safety on the toilet.  Most kids with low tone do not have great core stability, and this is where the rubber meets the road.  A weak core will put a child at greater risk of falling or feeling like he will fall.  It is harder to relax and pee/poop if you are afraid you will land on the floor.
  2. Clothing management and hand washing.  No child is really independent in using the toilet if someone else has to pull clothing up and down.  Washing hands is a hygiene essential.  Time to learn.
  3.   Good abdominal tone.  See #1.  Helps with intestinal motility as well.  That is the contraction of smooth muscle that moves the poop through the colon and on out.  My favorite hack is the use of kineseotape in the classic abdominal facilitation pattern.  All but one of my clients have had a nice big bowel movement the next day after taping; no pain, no fuss.  Regular taping along with strengthening can improve proprioceptive awareness internally (interoception, for those of you who need a new word for the week!)
  4. Transfers and equipment assessment/recommendations.  Therapists can teach your child how to get on/off, up and down safely from a toilet or potty seat.  They can teach you what to say and do to practice transfers and how to guard them while they practice.  They can also take a look at what you already own and what you might need to obtain.  Children with significant motor issues may need an adaptive toileting seat, but most mildly to moderately low-toned kids do not need that level of support.  What they do need is safe and correctly-sized equipment.
  5. Proprioceptive awareness for balance and stability.  Some therapists use balance discs or boards, some use other equipment.  Swings, climbing, jumping, etc.  More body awareness= more independence.
  6. Sensory tolerance for the feeling of clothing, using wipes/TP, the smells and the small enclosure of a bathroom.  If your child has sensory sensitivity issues in daily life, you have to know that they are going to be issues with toilet training.
  7. Effective vestibular processing.  Children that have to turn around, bend and look down then behind their bodies to get TP or pull up their pants need efficient vestibular systems.  Vestibular processing isn’t just for walking and sitting at a table for school.
  8. Practicing working as a team and following directions.  Your child needs to be responsive to either your praise, your rewards or both.  Therapists that support independence (all of us!) and develop in your child the sense that the she is a part of the therapy plan will make it easier for your child to work with you on toileting!

Want more information on potty training?  Read my first book or call me for a consult!

 My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone is now available at Amazon.com as well as Your Therapy Source ( a terrific site for parents and therapists)  and on my website,  tranquil babies .  Families are telling me that they have made progress in potty training right away after reading my book!

Read The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Help Has Arrived!  to learn how my book will help you and your child move forward today!

Want 30 minutes of my time to problem-solve things?  Visit my website  Tranquil Babies and buy a Happiest Toddler on the Block session.  We don’t have to do HTOTB; we talk about whatever you need!  I can’t do OT with you, but I can give you potty training advice an behavior strategies that really work!

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Kids with low tone benefit significantly from supportive seating for eating, playing, and yes, toileting.  Picking the right training potty can make all the difference for them, and their parents. My new favorites for smaller children (smaller than the average 3-4 year-old) are the Little Colorado Potty Chair and the Fisher Price Custom Comfort Potty seat.  For older or larger children, I suggest that you take a look at my post on using the adult toilet for equipment ideas. Equipment matters, it really does. Why? Let me give you a short review of what potty seats need to provide for children, and why.

Low muscle tone makes children less stable, and when they are using a toilet, they are not sitting/standing passively. For little boys, you also have to consider standing to urinate. Although it can be easier to start teaching a boy to urinate in sitting, it seems to me that it quickly becomes natural and physically easier for all but the most unstable boys to shift to standing. This means that they may need to hold onto the raised seat for stability or hold onto the edge of the vanity cabinet or even a handrail.

Selecting a potty seat is seating them for action!  They need to be able to sit straight, get on and off independently and safely, and feel stable enough to let go.  The right seat will let them be slightly flexed forward with knees up above their hips a tiny bit.  This allows them to use their abdominal muscles more effectively to perform a gentle Valsalva Maneuver.

This position is the way traditional cultures “make”; they squat and bend forward, increasing the intra-abdominal pressure to help empty their bowels without straining or holding their breath.  Children with low tone almost always have weak abdominal musculature, and can even have poor smooth muscle contraction of the lower intestine.  That slows the timely movement of feces, contributing to constipation and straining.  Have you ever had the indignity and frustration of trying to have a bowel movement in a bedpan?  Enough said.

Learning a new skill, a skill that is not visible and involves both motor, sensory and cognitive abilities, is best done with equipment that fully supports skill development.  Children often have fears, including fears of falling in.  They get frustrated and don’t want to bother to sit when they could be playing.  The list goes on.  Pick well and a child can learn faster and become more independent.  Pick poorly and learning can be slower, more uncomfortable or embarrassing, or convince both of you to just give up for now.  Want your OT or PT to help you decide?  Read Low Tone and Toilet Training: How Can Your Child’s Therapists Help You ?  and see all the things that therapists can do to help you train your child.

And of course, my e-book, The Practical Guide to Toilet Training Your Child With /Low Muscle Tone will help you will all aspects of potty training.  Read more about this unique book, available on Amazon and Your Therapy Source here:

The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

Here is a short review of what my favorite seats have to offer:

Fisher Price Custom Comfort Potty Seat

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Pros:

  • This seat delivers a lot of support, with both a high back and armrests.  A child can feel very supported and safe.
  • Kids can use the armrests to re-position themselves independently and get on/off with less or without help.
  • Small size helps the younger or smaller child get their feet flat and have a better sense of their body position.  Even with the ability to raise the seat an inch or two, it is pretty short.
  • All-plastic construction is easy to clean.
  • A splash guard is molded into the bucket for those little boys who need some redirection.
  • Compact size is easier for travel.  Not if you have a Mini Cooper perhaps, but if you have larger car, you will be able to take your child’s comfortable potty with you on trips.  Nothing ruins a good time like accidents or constipation because a child is too anxious or unstable to “go”.

Cons:

  •  this is not one size fits all; the older and wider child could feel cramped or have their knees way too high for good posture or even comfort.  A shallow seat makes it harder for larger boys to aim accurately when peeing, and doesn’t give taller children of both genders enough input through their thighs for postural control.  Imagine sitting on a tiny little seat; you have to work extra hard to stabilize your body.
  • The short curved armrests may be angled too much to help with standing/sitting if a child really needs support.  They are not independent if they need help to get on and off the potty.

Little Colorado Potty Chair

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This natural wood chair looks like what it is: a traditional commode-style potty.  You can get it in a painted version, and I would opt for that, since the extra layers of finish should be the easiest to clean.

Pros:

  • You can get some add-ons that have benefits: a toilet paper holder and a book rack that attach on either side. The TP roll holder gives a child some independence with wiping (as long as they don’t think that rolling it out to the end is a fun game) .  I would think twice about the book rack for a child that struggles to perceive sensation from the bowel or bladder.  Lots of kids like to look at books while waiting, but for some kids any distractions hinder the ability to accurately perceive bladder/bowel information.  Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!)
  • This chair has a wide, straight back and straight armrests for extra stability and support.
  • This chair is higher, wider and deeper than the FP chair above.  For bigger kids or older children who are being trained later due to developmental delays, this is a big help.  It is hundreds of dollars less than the adapted toilet chairs that kids with more severe or multiple delays really need.  Most children with low tone are not going to need that level of stabilization, and getting more support than you need is not helpful, it slows down independence.

Cons:

  • The bucket insert doesn’t have a splash guard.  That means that little boys especially must be positioned well.  Kids with low tone often shift around more than the average toddler, so keep and eye on the position of everything while using this seat.
  • This chair is not travel-friendly, unless you drive an Escalade or a Tahoe.  It is affordable, so if you have a summer home or if you visit relatives regularly, you can pick up a pair and leave one there.

Neither chair plays music when you pee, has characters all over it, or does anything else but let your child sit there in peace, stable and ready to do the deal.  If you truly need those other things, I guess you could sing a potty song and find some stickers.  Hopefully your child will be able to train quickly and then advance to the next level:  using the adult toilet.

If you have a tall toddler, or your child is over 3.5 years of age, you may not have much choice.  The best system for very unsteady kids is shown in this post Low Tone and Toilet Training: Transition to Using The Adult Toilet , and I have also seen people use something call the Squatty Potty footstool for a bit higher support than the Baby Bjorn stool that I love. The area for foot placement is relatively small, so kids that pay no attention to where their feet are might not be ready for this one.  The squatty folks make a foldaway one with a tote bag that you could take when you go out and use discreetly in public toilets.  Genius.  And then there is the child-height toilet.  It isn’t difficult to find online, and even the big box stores like Home Depot and Lowe’s carry them online.  It can mean the difference between fear and confidence, so check out Should You Install a Child-Sized Potty for Your Special Needs Child?.

Want more information about toilet training the child with low tone?  I wrote a book for you!  Visit my website tranquil babies and click on the e-book section in the top ribbon. It is also available on Amazon.com and Your Therapy Source.  This book gives you extensive readiness checklists that help you make a plan, it teaches you how to navigate problems like refusals and fears, and explains why low tone is such an issue with toilet training!

Looking for seating that isn’t a potty seat?  Check out The Cube Chair: Your Special Needs Toddler’s New Favorite Seat! ,  Kids With Low Muscle Tone Can Sit For Dinner: A Multi-Course Strategy and A Simple Strategy To Improve Your Child’s Posture In A Stokke Tripp Trapp or Special Tomato Chair.

Is Low Muscle Tone A Sensory Processing Issue?

Only if you think that sensing your body’s position and being able to perceive the degree/quality of your movement is sensory-based.  I’m being silly; of course low tone creates sensory processing issues.

It isn’t the same sensory profile as the child who can’t pay attention when long sleeves brush his skin, nor the child who cannot tolerate the bright lights and noise at his brother’s basketball games.  Having difficulty perceiving your foot position on a step, or not knowing how much force you are using on a pencil can make life a challenge.  Sensory processing issues mean that the brain isn’t interpreting the sensory information it receives, or that the information it receives is inadequate.

That is the situation with low muscle tone.  Low tone reduces the amount of joint and muscle receptor firing because these receptors need either pressure or stretch to activate.  If it is not in a sufficient quantity, the receptors will not fire in time or in large enough numbers to alert the brain that a change has occurred. Therefore, the brain cannot create an appropriate response to the situation.   What does this look like?  Your child slowly sliding off the side of a chair but not noticing it, or your child grinding her crayon into the paper until it rips, then crying because she has ruined another Rapunzel picture.

Muscle tone is a tricky thing to change, since it is mediated by the lower parts of the brain.  That means it is not under conscious control.  You cannot meditate your way to normal tone, and you can’t strengthen your way there either.  Strength and tone are entirely different.  Getting and keeping strength around joints is a very important goal for anyone with low tone, and protecting ligaments from injury is too.  Stronger muscles will provide more active contraction and therefore pressure, but when at rest, they are not going to respond any differently.

Therapists have some strategies to improve tone for functional activities, but they have not been proven to alter the essential cause of low muscle tone.  Even vestibular activities, the big guns of the sensory gym, can only alter the level of tone for a short period during and after their use.   The concept of a sensory diet is an appropriate image, as it feeds the brain with some of the information that doesn’t get transmitted from joints and muscles.    Sensory diets require some effort and thought, just like food diets.  Just bouncing on a therapy ball and jumping up and down probably will not do very much for any specific child.  Think of a sensory diet like a diabetic diet. It doesn’t make the pancreas start producing insulin, but it helps the system regulate blood glucose more effectively.

Managing low muscle tone for better movement, safety and function is complicated.  Step one is to understand that it is more than a child’s rounded back when sitting, or a preschooler that chews his shirtsleeve.  Step two is to make a multifocal plan to improve daily life.

For more information on life hacks for toilet training, dressing and play with children that have low muscle tone, please look in the archives section of my blog for targeted ideas! My post and are new posts that go into more details regarding life with kids that have sensory processing issues.

For personalized recommendations on equipment and methods to improve a child’s functional skills, visit my website and buy a 30-minute consult.  We can chat, do FaceTime, and you get the personal connection you need to make your decisions for your family!