Tag Archives: low tone

Doing Preschool Camp at Home This Summer? This is the Water Table You Want!

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I just found this online after a parent asked me for recommendations for equipment.  She isn’t sending her two kids under 5 to camp this year, and needs some ideas to turn her backyard into a fun place to spend the summer.  This is the Little Tikes Magic Flower water table.

Why do I love this one?

Watch their video on Amazon and you will understand!  But before you do, here are my reasons, as an occupational therapist, for recommending this water table:

  • Multiple levels mean that children of different ages can both have fun.
  • Multiple ways to explore helps kids take turns without having to choose between “the fun thing” and the “barely OK things” on the water table.
  • The animal theme works for lots of kids.  Not everyone likes pirates.  Or even understands pirates.
  • It is big enough to have at least 2 kids playing at the same time, maybe 3.
  • They include 2 duckies (who doesn’t love duckies?), 2 frogs, 3 turtles, a fish, and three pouring choices.  I hate tables where you STILL have to go out and buy stuff to make it fun.  This table is “one-and-done”.
  •  All of my clients with low tone and hypermobility that can stand will be motivated to do so; there isn’t really any way to lean on this water table.  They can stabilize by holding an edge, but they cannot drape themselves over it.  They will be bending and reaching.  A lot.  That is a good thing.
  • Kids that use a wheelchair or need to sit while playing due to mobility issues will still be able to have fun with their friends and siblings that can stand and bend.  This water table is inclusive.

I really hate sand tables.  You would think that as an OTR, I would love them.

Nope.  Sand gets everywhere.  In clothes, in body folds, everywhere.  Kids get sand in their mouth and in their eyes.  It tracks into the house unless you shower your kid outside, and maybe it will be found inside even then.  Sand is a pain in the neck.

As long as you empty your water table and hit it regularly with some soap or a diluted bleach solution to keep it clean, it is much easier on everyone to have a water table rather than a sand table.  This one is going to be a lot of fun!

Need more ideas for fun this summer?  Read The Preschool Water Arcade Game You Need This Summer If Camp is Cancelled (and maybe even if it isn’t) and Doing OT Telehealth? Start Cooking (And Baking)!

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How To Pick A High Chair For Your Special Needs Child

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My first Early Intervention home visit always involves seeing the child sitting in their high chair.  I learn a few things.  I learn how the child is handled by the parent or caregiver, including whether they use the available strapping to secure them.  Many don’t, and don’t realize that it is part of the problem.  I learn how well the child fits into the chair, and how well the child can balance and reach in this chair.  And I hear about what problems the parent or caregiver is having with using this seating system.

This post is intended to share some of what therapists know about seating, and how to pick a better chair for kids that have challenges.

Every parent reading this post should know that their child’s therapists are their best source for getting the right high chair.  Never consult Dr. Google when you have licensed professionals available.  There is a reason for that license!  The folks you meet online cannot evaluate your child and provide safe recommendations for you.  This includes me; my comments are meant to educate, not prescribe.  That would be unethical and unsafe.

Typical children need a high chair when they can maintain their head balanced in the center and can start reaching and holding a bottle or finger food.  Before that, they use a feeding seat.  Feeding seats are slightly-to-moderately reclined and do the job of a parent cradling a child while feeding.  A child in a feeding seat usually isn’t expected to independently steady their head or hold a bottle. There are usually straps that stabilize a child’s chest and shoulders as well as a strap that stabilizes their pelvis.

Again, not every adult uses these straps correctly to give a young child the best support.  I will always do some education on methods to correctly position and adjust strapping.  The adult’ reaction (relief, curiosity, resistance, disinterest) tells me a great deal about what is coming down the pike.  Some special needs kids will use a feeding chair well past 12 months of age.  The commercially-made feeding chairs aren’t large, so some kids won’t fit  into one much past 18 months.  After that happens, we have to think about either a commercial high chair or adaptive seating.

Commercially-made high chairs in the US are gigantic.  They could hold a 4 year-old! This is always a problem for special needs kids.  Too much room to move in the wrong way isn’t helpful.   These chairs may or may not have chest/shoulder straps, and they may not have an abductor strap (the one between a child’s legs, that prevents them from sliding under the waist belt).  The best chairs have the waist belt low enough that it sits across a child’s lower hips like a car’s seat belt.  This is always preferable to sitting at the bellybutton level.  It provides more stability.

If a special needs child collapses their posture while sitting in a high chair, when I stabilize their hips in a way that doesn’t allow them to collapse, they might complain.  They were allowed to slouch so much that this new position, with appropriate core activation, feels wrong to them.  It can take a while for a child to learn that eating and playing in a chair requires them to use their core.  I allow them to gradually build up their abilities with short periods of eating and playing.  Not every parent is comfortable finding out that they were contributing to core weakness by allowing a collapsed posture.  I don’t add to that feeling; you know more, you do better.  Simple as that. No guilt.

Some providers insist that every child, at every age and stage, have a place to put their feet.  The strongest proponents of this idea are usually not therapists but educators or speech therapists who attended a positioning lecture or inservice.  Occupational therapists know that a child that doesn’t have the hip control and emerging knee and foot control to place weight into their feet will not be able to use their feet to steady their trunk.  They will, however, figure out how to use a footplate incorrectly.  Unless a child is older than 2 and requires lower leg stabilization to avoid tightening their hamstrings (which will derail their positioning) and sliding forward, or to prevent sensory-seeking or ataxic movements, I don’t strap a child’s feet onto a footplate, or even worry about providing a footplate.  A child that is in a feeding chair, or just beginning to use a high chair, isn’t going to use a footplate correctly, and is more likely to use one to ruin previously decent positioning.  A child that is able to bench-sit or is starting to take weight into their feet?  That child can use a footplate to build sitting control.  Here is a post to help you use one well: A Simple Strategy To Improve Your Child’s Posture In A Stokke Tripp Trapp or Special Tomato Chair

Special needs kids that have very limited head and trunk control will often need an adaptive seat that gives them more support.  It can transform them!  More support can allow more freedom, not less.  These chairs are able to be customized, are obtained through DME vendors and can be paid for by insurance or EI.  They are expensive, and considered medical equipment, not chairs.  Parents need instruction in their use to avoid harming a child by too intensive strapping and incorrect adjustments.  But when done right, they can transform a child’s abilities in ways that no commercially-available chair can accomplish.  Giving a child a seating system that frees them to reach and look and eat and communicate is a wonderful feeling.  Those of us that are trained in seating evaluation know that the right chair can build skills, not substitute for them!

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How Therapeutic Listening Enhances Motor Skills

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

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

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

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

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

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

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

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Potty Training in the COVID-19 Age

 

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Parents are staying home with their toddlers and preschoolers now.  All day.  While this can be a challenge, it can also be the right time to do potty training.

Here’s how to make it work when you want to teach your toddler how to “make” in the potty:

  1. You don’t have to wait for readiness.  What you might get instead is a child that has lost the excitement of being praised by adults, and fears failure more than seeks praise or rewards.  If that sounds like your child,  quickly read Waiting for Toilet Training Readiness? Create It Instead!
  2. Have good equipment.  If you don’t have a potty seat that fits your child or a toilet insert and a footstool that is stable and safe, now is the time to go online shopping for one.  Without good equipment, you are already in trouble.  Children should be able to get on and off easily and not be fearful of falling off the toilet.  If you are training a preschooler and not a toddler, you really need good equipment.  They are bigger and move faster.  Safety and confidence go hand in hand.
  3. Have a plan for praise and rewards.  Not every child will want a tiny candy, but nobody should expect a new toy for every time they pee in the potty.  Know your kid and know what gets them to try a new skill.  Some children don’t do well with effusive praise Sensitive Child? Be Careful How You Deliver Praise , so don’t go over the top if this is your kid.
  4. Know how to set things up for success.  If your child is typically-developing, get Oh Crap Potty Training by Jamie Glowacki, because she is the best person to tell you how to help you be successful.  She even has a chapter just on poop!  If your child has hypotonia or hypermobility, consider my e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone.  It is inexpensive, available on Amazon and Your Therapy Source, and gives you checklists and explanations for why you need to think out-of-the-box to potty train these kids.  You don’t leave for vacation without a map.  Don’t wing this.  Just don’t.
  5. Build your ability to calm yourself first.  Exactly like on an airplane, (remember them?  We will get back on them eventually) you need to calm yourself down in the face of refusals, accidents and tantrums.  You are no good to anyone if you are upset.  Read Stress Relief in the Time of Coronavirus: Enter Quickshifts and Should the PARENTS of Kids With Sensory Issues Use Quickshifts? for some ideas.

Looking for more information on potty training?  I wrote an e-book for you!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone was my first e-book.  It is still my best seller.  There is a reason:  it helps parents and kids succeed.  This unique book explains why learning this skill is so tricky, and it gives parents and therapists detailed strategies to set kids (and parents) up for success!  Understanding that the sensory and social-emotional impacts of low muscle tone are contributing to potty training deals is crucial to making this skill easier to learn.  I include a readiness guide, strategies to pick the best equipment and clothes (yes, you can dress them so that they struggle more!), and how to move from the potty seat onto the adult toilet.

It is available on Amazon and on Your Therapy Source, a great site for materials for therapists as well as parents looking for homeschooling ideas.

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Why Injuries to Hypermobile Joints Hurt Twice

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My new e-book, The JointSmart Child: Living and Thriving With Hypermobility, Volume I, is just about ready to launch.  One of the book’s major themes is that safety awareness is something that parents need to actively teach hypermobile young children.  Of course, physical and occupational therapists need to educate their parents first.  And they shouldn’t wait until things go off the rails to do so.

Hypermobile kids end up falling, tripping, and dropping things so often that most therapists have the “safety talk” with their parents on a regular basis.  What they don’t speak about as often are the long-term physical, emotional and social impacts of those injuries.

Yes, injuries have more than immediate physical effects on hypermobile kids.  Here is how this plays out:

  • The loss of mobility or function after an injury creates more dependency in a little person who is either striving for freedom or unsure that they want to be independent.  Needing to be carried, dressed or assisted with toileting when they were previously independent can alter a child’s motivation to the point where they may lose their enthusiasm for autonomy.  A child can decide that they would rather use the stroller than walk around the zoo or the mall.  They may avoid activities where they were injured, or fear going to therapy sessions.
  • A parent’s fear of a repeated injury can be perceived by a child as a message that the world is not a safe place, or that they aren’t capable in the world.  Instilling anxiety in a young child accidentally is all too easy.  A fearful look or a gasp may be all it takes.  Children look to adults to tell them about the world, and they don’t always parse our responses.  There is a name for fear of movement, whether it is fear of falling, pain or injury: kineseophobia.  This is rarely discussed, but the real-life impact can be significant.
  • Repeated injuries produce cumulative damage.  Even without a genetic connective tissue disorder such as Ehlers-Danlos syndrome, the ligaments, tendons, skin and joint capsules of hypermobile children don’t bounce back perfectly from repeated damage.  In fact, a cascade of problems can result.  Greaster instability in one area can create spasm and more force on another region.  Increased use of one limb can produce an overuse injury in the originally non-injured limb.  The choice to move less or restrict a child’s activity level can produce unwanted sedentary behavior such as a demand for more screen time or overeating.
  • Being seen as “clumsy” or “careless” rather than hypermobile can affect a child’s self-image long after childhood is over.  Hypermobile kids grow up, but they don’t easily forget the names they were called or how they were described by others.  With or without a diagnosis, children are aware of how other people view them.  The exasperated look on a parent’s face when a child lands on the pavement isn’t ignored even if nothing is said.

Do you have a hyper mobile child under 6?  

I wrote an e-book for you!

The JointSmart Child:  Living and Thriving With Hypermobility  Volume One:  The Early Years is a totally unique book.  It is both a manual for finding the right equipment and using the right techniques as well as an educational book for parents who are trying to figure out why loose joints create so many difficulties in daily life.  It even has chapters on building relationships with babysitters, family members, teachers and medical professionals!

Visit Amazon to buy a read-only copy, or Your Therapy Source for a click-able and printable version.

 

In this new book, I provide parents with a roadmap for daily life that supports healthy movement and ADL independence while weaving in safety awareness.  Hypermobility has wide-reaching affects on young children, but it doesn’t have to be one major problem after another.  Practical strategies, combined with more understanding of the condition, regardless of the diagnosis, can make life joyful and full for every child!

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Hypermobility Or Low Tone? Three Solutions to Mealtime Problems

 

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Many young hypermobile kids, with and without low muscle tone, struggle at mealtimes. Even after they have received skilled feeding therapy and can chew and swallow safely, they may continue to slide off their chair, spill food on the table (and on their body!) and refuse to use utensils.

It doesn’t have to be such a challenge.  In my new e-book coming out this year, I will address mealtime struggles.  But before the book is out there, I want to share three general solutions that can make self-feeding a lot easier for everyone:

  1. Teach self-feeding skills early and with optimism.  Even the youngest child can be taught that their hands must be near the bottle or cup, even when an adult is doing most of the work of holding it.  Allowing your infant to look around, play with your hair, etc. is telling them “This isn’t something you need to pay attention to.  This is my job, not yours.”  If your child has developmental delays for any reason, then I can assure you that they need to be more involved, not less.  It is going to take more effort for them to learn feeding skills, and they need your help to become interested and involved.  Right now.  That doesn’t mean you expect too much from them.  It means that you expect them to be part of the experience.  With a lot of positivity and good training from your OT or SLP, you will feel confident that you are asking for the right amount of involvement. Read Teach Spoon Grip By Making It Fun And Sharing a Laugh With Your Child and Teach Utensil Grasp and Control…Without the Food! for some good strategies to get things going.
  2. Use excellent positioning.  Your child needs a balance of stability and mobility.  Too much restriction means not enough movement for reach and grasp.  Too much movement would be like eating a steak while sitting in the back seat of your car doing 90 mph.  This may mean that they need a special booster seat, but more likely it means that they need to be sitting better in whatever seat they are in.  Read Kids With Low Muscle Tone Can Sit For Dinner: A Multi-Course Strategy for more ideas on this subject.  Chairs with footplates are a big fave with therapists, but only if a child has enough stability to sit in one without sliding about and can actively use their lower legs and hips for stabilization.  Again, ask your therapist so that you know that you have the right seat for the right stage of development.
  3. Use good tableware and utensils.  If your child is well trained and well supported, but their plates are sliding and their cups and utensils slide out of their hands, you still have a problem.  Picking out the best table tools is important and can be easier than you think.  Items that increase surface texture and fill the child’s grasping hand well are easiest to hold.  Read The Not-So-Secret Solution for Your Child With Motor And Sensory Issues: Dycem and OXO for Kids: Great Tableware For Older Kids With Sensory and Motor Issues for some good sources.  Getting branded tableware can be appealing to young children, and even picking out their favorite color will improve their cooperation.  Finally, using these tools for food preparation can be very motivating.  Children over 18 months of age can get excited about tearing lettuce leaves and pouring cereal from a small plastic pitcher.  Be creative and have fun!

 

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The Not-So-Secret Solution for Your Child With Motor And Sensory Issues: Dycem

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Many different ways to use Dycem!

In adult rehab, occupational therapists are regularly providing patients who have incoordination, muscle weakness or joint instability with both skill-building activities and adaptive equipment such as Dycem.  In pediatrics, you see a predominance of skills training.  Adaptive equipment shows up primarily for the most globally and pervasively disabled children.  I think that should change. Why?  Because frustration is an impediment to learning, and adaptive equipment can be like training wheels; you can take them off as skills develop.  When kids aren’t constantly frustrated, they are excited to try harder and feel supported by adults, not aggravated.

 

What Dycem Can Do For Your Child

Dycem isn’t a new product, but you hardly ever see it suggested to kids with mild to moderate motor incoordination, low tone, sensory processing disorders, hypermobility, and dyspraxia.  We let these kids struggle as their cereal bowl spills and their crayons roll away from them.  Dycem matting is a great tool for these kids.  It is grippy on both sides, but it is easy to clean.  Place a terrific bowl or plate on it OXO for Kids: Great Tableware For Older Kids With Sensory and Motor Issues, and it won’t tip over with gentle pressure, and not even if the surface has a slight incline.  It lasts a long time, and can be cut into any shape needed for a booster seat tray or under the base of a toy like a dollhouse or a toy garage.  Placing a piece of Dycem under your child while they are sitting on a tripp trap chair or a cube chair A Simple Strategy To Improve Your Child’s Posture In A Stokke Tripp Trapp or Special Tomato ChairThe Cube Chair: Your Special Needs Toddler’s New Favorite Seat! will help them keep their pelvis stable while they eat and play.  The bright color contrasts with most objects, supporting kids with visual deficits and poor visual perceptual skills.  It catches their eye and their attention.  As you can see, Dycem has a lot to offer children and parents.

How To Use Dycem To Build Motor Skills

Will it prevent all spills or falls?  No.  But it will decrease the constant failures that cause children to give up and request your help, or cause them to refuse to continue trying.  Children are creating their self-image earlier than you realize, so helping them see themselves as competent is essential.  Will it teach kids not to use their non-dominant hand to stabilize objects?  Not if an adult uses it correctly.  Introducing Dycem at the appropriate stage in motor development and varying when and where it is used is the key.  Children need lots of different types of situations in order to develop bilateral control, and as long as they are given a wide variety of opportunities, offering them adaptive equipment during key activities isn’t going to slow them down.  It will show them that we are supporting them on their journey.  When kids are new to an activity or a skill and need repeated successes to keep trying, Dycem can help them persevere.  When children are moving to the next level of skill and see that they are struggling more, Dycem can support them until they master this new level.

Should you buy the pre-cut mats or the roll of Dycem?  It depends on your needs.  Be aware that Dycem doesn’t stay tacky forever, so the cheaper strategy is the roll.

The Cheap Hack:  Silicone Mats

I will often recommend the use of silicone baking mats instead of dycem.  These inexpensive mats often do the job at a lower cost, and can be easily replaced if lost at daycare or school.  Dycem is a specialty item that can be purchased online but not in most stores.  Silicone mats aren’t as grippy, but they are easily washed and dried.  Some families are averse to anything that looks like adaptive equipment, so I may introduce these mats first to build a parent’s confidence in my recommendations.

Looking for more information on helping your child build self-care and safety awareness?

I wrote 2 e-books for you!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone and The JointSmart Child: Living and Thriving With Hypermobility Volume One: The Early Years are unique books that both educate and empower you.

They are filled with understandable explanations for the challenges and all the confusion that comes up during ADL training.   When you aren’t provided with enough information on the motor, sensory and behavioral consequences of low tone and hypermobiilty, you can’t effectively help your child achieve the basic self-care and safety awareness skills that every child needs.  My books have checklists and forms that help you communicate with your babysitters, teachers, even your child’s doctors.

Both books are sold on Amazon.com  as read-only downloads, and on Your Therapy Source   as printable and click-able downloads.  Your Therapy Source also sells both books together as a discounted bundle, saving you money and giving you lots of information all at once!

 

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Is Your Hypermobile Child Frequently In An Awkward Position? No, She Really DOESN’T Feel Any Pain From Sitting That Way

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Hypermobile children end up in some impressively awkward positions.  It can feel uncomfortable just to look at the way their arms or legs are bent.   It can be an awkward position with any part of the body; shoulders that allow an arm to fold under the body and the child lies on top of the arm, crawling on the backs of the hands instead of the palms, standing on the sides of the feet, not the soles.

The mom of a child I currently treat told me that this topic is frequently appearing on her online parent’s group.  Mostly innocent questions of “Does your child do this too?”  and responses like “At least she is finally moving on her own”  When I met her child, she was rolling her head backward to such a degree that it was clearly a risk to her cervical (neck) spine.  We gradually decreased this behavior, and have almost eliminated it.  This child is using it to get attention when she is frustrated, not to explore movement or propel herself around the room.  Time to teach other ways to get an adult’s attention and express frustration.

Because of their extreme flexibility and the additional gradual stretching effects of these positions, most children will not register or report pain in these positions.  Those of us with typical levels of flexibility can’t quite imagine that they aren’t in pain.  Unfortunately, because of their decreased proprioception Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children and decreased sense of stability, many hypermobile kids will intentionally get into these awkward postures as they seek more sensory input.  It can actually feel good to them to feel something!

The fact that your child isn’t in pain at the moment doesn’t mean that there isn’t damage occurring as you watch them contort their bodies, but the underlying inflammation and injury may only be perceived later, and sometimes not for years.  Possibly not until tissue is seriously damaged, or a joint structure is injured.  Nobody wants that to happen. Read   Safety Awareness With Your Hypermobile Child? Its Not a Big Thing, Its the Biggest Thing.  If you think that there is a chance that your child is more than just loose-limbed, ask your therapist to read Could Your Pediatric Therapy Patient Have a Heritable Disorder of Connective Tissue? and get their opinion on whether to pursue more evaluations.  Some causes of hypermobility have effects on other parts of the body.  An informed parent is the best defense.

Here is what you can do about all those awkward postures:

  • Discuss this behavior with your OT or PT, or with both of them.  If they haven’t seen a particular behavior, take a photo or video on your phone.
  • Your professional team should be able to explain the risks, and help you come up with a plan.  For the child I mentioned above, we placed her on a cushion in a position where she could not initiate this extreme cervical hyperextension.  Then we used Dr. Harvey Karp’s “kind ignoring” strategy.  We turned away from her for a few seconds, and as soon as she stopped fussing, we offered a smile and a fun activity.  After a few tries, she got the message and the fussing was only seconds.  And it happens very infrequently now, not multiple times per day.
  • Inform everyone that cares for your child about your plan to respond to these behaviors, to ensure consistency.  Even nonverbal children learn routines and read body language.  Just one adult who ignores the behavior will make getting rid of a behavior much, much harder.
  • Find out as much as you can about safe positioning and movement.  Your therapists are experts in this area.  Their ideas may not be complicated, and they will have practical suggestions for you.  I will admit that not all therapists will approach you on this subject.  You may have to initiate this discussion and request their help.  There are posts on this blog that could help you start a conversation.  Read Three Ways To Reduce W-Sitting (And Why It Matters) and Kids With Low Muscle Tone: The Hidden Problems With Strollers  and How To Reposition Your Child’s Legs When They “W-Sit”.  Educate yourself so that you know how to respond when your child develops a new movement pattern that creates a new risk.  Kids are creative, but proactive parents can respond effectively!!

Looking for more information on hypermobility?

I wrote 2 e-books for you!

My first, The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years is your guide to helping your child develop independence and safety from birth through age 5.  Filled with practical strategies to help parents understand the complexities of hypermobility, it empowers parents every step of the way.  In addition to addressing all the basic self-care skills kids need to learn, it covers selecting chairs, trikes, even pajamas!  There are checklists for potty training and forms that parents can use to help communicate with teachers, therapists, family members…even doctors!

“Dr. Google” isn’t helping parents figure out how to help their kiss with PWS, SPD, ASD, Down syndrome, and all the other diagnoses that result in significant joint hypermobility.  This is the book that provides real answers in everyday language, not medical jargon.

Read more about this book, and get a peek at part of chapter 3 on positioning for success by reading The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today!

This unique e-book is available on Amazon as a read-only download or on Your Therapy Source as a printable and click-able download.  Feel more empowered and confident as a parent…today!

Is Your Hypermobile Child Older Than 5?  This is the E-book for You!

The jointSmart Child:  Living and Thriving With Hypermobility Volume Two: The School Years is a larger, more comprehensive book that helps the parents and therapists of older children ages 6-12 navigate school needs, build full ADL independence, and increase safety in all areas of life, including sports participation.  Need to know how to pick the right chair, desk, sport, even musical instrument?  Got it.  Want to feel empowered, not aggravated, at medical appointments?  Got that too!  There are forms and checklists that parents can use to improve school meetings and therapists can use for home programs and professional presentations.  Read more about it here: Parents and Therapists of Hypermobile School-Age Kids Finally Have a Practical Guidebook!

Get my newest book today on  Amazon .  Don’t have a Kindle?  Don’t worry:  Amazon has an easy method to load it onto your iPhone or iPad!

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Picking The Best Bikes, Scooters, Etc. For Kids With Low Tone and Hypermobility

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Welcome to the world of faster (and faster) movement!  After mastering walking and possibly running, kids are often eager to jump on a ride-on toy and get moving.  If a child has had motor delays and has had to wait to develop the strength and balance needed to use a bike, they may be a bit afraid, or they may throw caution to the wind and try it all as soon as possible!

Selecting the best equipment for kids that have low tone or hypermobility doesn’t end with picking a color or a branded character ( Thanks, Frozen, for bringing up my Disney stock in 2013 almost single-handedly!).  In order to find the right choice for your child, here are some simple guidelines that could make things both easier and safer:

  1. Fit matters. A lot.  Hypermobile children are by definition more flexible than their peers.  They stretch.  This doesn’t mean that they should be encouraged to use pedals so far away from their bodies that their legs are fully extended, or use handlebars that reach their chins.  In general, muscles have their greatest strength and joints have their greatest stability and control in mid-range.  Fit the device to the child, not the other way ’round. Choose equipment that fits them well now,  while they are learning, and ideally it can be adjusted as they grow.  For the youngest or smallest kids, read The Best Ride-On Toy For Younger (or Petite) Toddlers and check out this great ride-on toy!
  2. Seats, pedals and handlebars that have some texture and even some padding give your child more sensory information for control and safety.  These features provide more tactile and proprioceptive information about grip, body positions and body movements.  You may be able to find equipment with these features, or you can go the aftermarket route and do it yourself.  A quick hack would be using electrical tape for some extra texture and to secure padding.  Some equipment can handle mix-and-match additions as well.  Explore your local shops for expert advice (and shop local to support your local merchants in town!)
  3. Maintain your child’s equipment, and replace it when it no longer fits them or works well.  Although it is more affordable to receive second-hand items or pass things down through the family, hypermobile kids often find that when ball bearings or wheels wear down, the extra effort required to use a device makes it harder to have fun.  The additional effort can create fatigue, disinterest in using the equipment, or awkward/asymmetrical patterns of movement that aren’t ergonomically sound.  Repair or replace either than force your child to work harder or move poorly.

Looking for more information about low tone and hypermobility?  

I wrote two e-books for you!

The JointSmart Child:  Living and Thriving With Hypermobility  Volume One:  The Early Years  and Volume Two:  The School Years are here!  Both have useful information to make caring for your hypermobile child easier, safer, and both build their independence throughout the day.  This is essential reading for parents of children with PWS, EDS, many forms of SPD, and Down syndrome.  These books cover how to teach your family  members, babysitters and teachers the best ways to work with your child, making life easier for BOTH of you!  They teach parents and therapists how to communicate with families, professionals and community members such as coaches and educators.  There are helpful checklists and forms that make picking the right chairs, clothes, even plates and utensils that make life easier for hypermobile kids.

Understanding that hypermobility creates more than unstable joints is key. Hypermobility creates emotional, social and sensory processing issues that affect a child’s development.  When parents have knowledge, they are empowered and can act as advocates rather than react to situations.  When therapists have a solid treatment plan, they can be amazing clinicians and help a child blossom!

Pick them up as a read-only download on Amazon or as a printable and click-able download on Your Therapy Source today!

Want more posts on hypermobility?  Read The Hypermobile Hand: More Than A Strength Problem , Is Your Hypermobile Child Frequently In An Awkward Position? No, She Really DOESN’T Feel Any Pain From Sitting That Way and How Hypermobility Affects Self-Image, Behavior and Activity Levels in Children.

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Should Your Hypermobile Child Play Sports?

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This is one of the most difficult questions I field from parents of children over 5.  Every parent wants their child to receive the social, emotional and physical benefits from participating in sports.  They also know that there are greater risks for hypermobile kids.

Kids with hypermobility fall on a very wide spectrum.  Some are strong and flexible, allowing them to compete in gymnastics and dance with ease or even excellence.  Some kids are prone to injury; they spend more time on the sidelines than on the field.  And some need to have P.E. classes adapted for them or substituted with physical therapy.

Wherever your child lands on this spectrum of ability, it is likely that they want to be able to participate in sports, and you want them to be able to do so as well.  Engaging in sports delivers a lot of positives:  conditioning, ability to work in a group, ability to achieve goals and handle failure/loss, etc.  Most therapists and doctors will say that being as physically active as possible enhances a child’s overall wellness and can be protective. But every child is different, and therefore every solution has to be tailored to the individual.

Here are a few questions to guide your assessment as a parent (and involve your child the decision, if appropriate):

  1. Is this activity a high or low-risk choice?  High-risks would include heavy physical contact, such as football.  Tennis requires hitting a ball with force and rapid shifts of position with lots of rotation of the trunk and limbs.  I am going out on a limb, and say that ballet on-pointe is a high-risk choice for kids with lower-body weakness and instability.  The question of risk in any activity has to be combined with what is risky for each child.  Your doctor, PT, OT or other specialist can help you identify what the risks are for your child.
  2. Will endurance be an issue, or will there be flexible breaks?  Activities that require a lot of continuous running, such as soccer and lacrosse, may be harder than dance classes.  Swimming is often suggested as an easier sport, but think about  the strokes.  Competitive swimming is a lot of resistance work against the water with repetitive motions of the shoulders.  Some strokes are more difficult than others, so examine each stroke as well as the frequency, duration and intensity your child intends to pursue.
  3. Are there ways to support performance, such as braces, kineseotaping or equipment modifications?  A great pair of skis or shoes can help tremendously in sports.  So can targeted exercises from a physical therapist or a well-trained coach that understands the needs of the hypermobile athlete.  Your child may not be able to be on a travel team due to the intense demands and greater risk of injury due to fatigue/strain, but they will be very satisfied being on a local team.  For the smallest kids, even changing your trike can make a difference Picking The Best Trikes, Scooters, Etc. For Kids With Low Tone and Hypermobility.  To remain safe in a sport, many hypermobile kids need to keep working with a PT.  Do you have the insurance or the cash to pay for this expense?
  4. Will your child report pain or injury and ask for assistance?  Will your child accept limitations on their activity level? Some kids are very proactive, and others will try to hide injuries to stay in the game or on the team.  Without this ability to communicate lived experience,  coaches and parents find it harder to make the right/safe choices.  Sometimes it’s an age thing, where young children aren’t good communicators or teens are defending their independence at the cost of their health.  If you think that your child will hide injuries or push themselves past what is safe for their joints, you will have to think long and hard about the consequences of specific activities.  Read For Kids With Hypermobility, “Listen To Your Body” Doesn’t Teach Them To Pace Themselves. Here’s What Really Helps. and    Joint Protection And Hypermobility: Investing in Your Child’s Future for more information about teaching your child to handle fatigue and pain better.
  5. Within a specific sport, are there positions or types of participation that are well-suited for your child’s skills and issues?  Skiing wide green (easy) slopes and doing half-pipe snowboard tricks are at distinct ends of the spectrum, but a hypermobile child may be quite happy to be out there in any fashion as long a they are without pain or injury.  Goalies are standing for longer periods but running/skating less.  Endurance running and sprinting have very different training and participation requirements.  There may be no options for a child that insists on running cross-country when their body cannot handle it.
  6. Sadly, hypermobility can progressively reduce or alter safe participation in sports.  Not for all kids, and not even for kids with current issues.  Children can actually be less hypermobile at 12 than they were at 3.  They build muscle strength as well as they grow.   It can happen.  Therapy and other strategies like nutrition and orthotics can make huge improvements for hypermobile kids who want to play sports.  But too often, the child who is pain-free in dance class at 7 isn’t pain-free at 14.  This doesn’t have to be a tragedy.  Kids can be taught to adjust and adapt so that they are playing and working at their current maximal level.  Your child may find that changing sports is easier than struggling or suffering in a sport that is now difficult for them.  Good physical or occupational therapists can help you figure out how to make athletic activities fun and safe!
  7. Are you sad that they are losing their passion?  Try to separate your sadness from their sadness.  It is OK to feel your feelings.  If your child has a heritable condition such as EDS, and you didn’t know you had it yourself until your child was diagnosed, you may be feeling a great deal of (unfounded) guilt.  Even if you knew the you could pass on a HDCT, the truth is that you probably also are their greatest fan and supporter.  Your child has someone in their life who really knows what they are going through.  That is helpful, even though you might not see it right now.  Think about how you felt as a child when you didn’t understand why you were dropping things or not as skilled as other kids.  Your child knows that you know how they feel.  Working through those feelings will help you see things clearly with your own child.  Avoiding your feelings will keep you mired in them.  Only after you come to terms with how you feel will you be able to help your child see that their passions are evolving and they can create new passions in many areas.  The bigger issue is handling the feeling of vulnerability that come with chronic disorders and an uncertain future.
  8. Get your professionals to support your decisions and let them take some of the pressure off of you.  Kids are often really good at blaming parents, and parents can be vulnerable to the guilt trips kids send out.  If their doctors or therapists are telling them about the risks they face, you won’t seem like the only person that is trying to rob them of fun.  The truth is that children, including teens, cannot imagine that the damage they do today could shorten their professional career in 20 years, or contribute to surgeries in 30 years.  This is the sad truth of hypermobility:  damage is often cumulative and what is only a small discomfort today can grow into a serious loss of ability later.  No one will be able to predict your child’s future, but it is possible to identify a range of potential risks.  When you understand the risks, you are able to make decisions with more confidence.

Does your hypermobile child play a musical instrument?  Then read Hypermobility and Music Lessons: Is Your Child Paying Too High a Price for Culture? for some insights into the ways that parents can make playing less of a physical risk and increase the wonderful benefits of musical instruction.

For more information regarding hypermobility, please read Hypermobile Kids, Sleep, And The Hidden Problem With Blankets ,  Can You K-Tape Kids With Connective Tissue Disorders?  and Should Hypermobile Kids Use Backpacks?

Looking for even more practical strategies to raise your hypermobile child?

 I just wrote two e-books for you! 

The JointSmart Child:  Living and Thriving With Hypermobility  Volume One:  The Early Years  and the companion Volume Two:  The School Years are filled with practical strategies to help you feel empowered and in control.

Volume One focuses on the basics with children 0-5: utensil use, potty training (I wrote a separate book on that subject!) picking out the right high chairs and bikes, teaching your child how to move safely, and even how to communicate with your teachers and doctors.  It is available as a read-only e-book on Amazon or as a clickable and printable download on Your Therapy Source.

Volume Two reviews all the principles of managing hypermobility in Volume One so you don’t have to buy both books, and takes things into the classroom, the sports field or court, and out into the wider world.  There are strategies for kids 6-12 to build handwriting and keyboarding, pick the right musical instrument, and manage the comments and expectations of family and friends.

The appendix in Volume Two is much larger.  It has forms and checklists that parents and therapists can use with teachers, babysitters, coaches, and even doctors.  There is a form for your district meeting to get more of what you need at school, and even recipes to build motor skills while having fun!  It is available as a read-only e-book on Amazon and very soon on Your Therapy Source!

 

Is your child even older?

One issue for tweens and teens with hypermobility is looking at the future clearly in terms of school, jobs, and careers.  Take a look at  Career Planning for Teens with JRA, EDS, and Other Chronic Health Issues  and Teens With Chronic Illness Or Disability Need A Good Guide: Read “Easy For You To Say” for some strategies to help your child think clearly but positively about their future.

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How To Teach Your Child 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.  Most children don’t have more than one BM per day, but they urinate many times per day.  For an overview on wiping, even if your child doesn’t have low tone, read Low Tone and Toilet Training: Teaching Toddlers to Wipe

Constipation or just the discomfort of normal bowel 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 only 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.  The people that invented the Kandoo line of wipes have an amusing way to practice posted on their site:  spread peanut or sunflower butter on a smooth plate, and give your child some wipes or TP.  Tell him to clean the plate completely.  This is a visual and motor experience that teaches how much work it is to clean his tush well.  After this practice, your child will make a real effort, not just wave the paper around.  Brilliant!
  3. Will you have to reward your child for practicing? 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.
  6. Teach them how to know when they are done wiping.  It’s kinda simple;  you wipe until the toilet paper is clean when you wipe.  This usually means little kids have to do at least two separate wipes, but they get the idea quicker.  Little hands are not that skilled, but dirty versus clean is something they can grasp.

 

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 on 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!

Teach Kids With Ehlers-Danlos Syndrome Or Low Tone: Don’t Hold It In!

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People who have read my blog are aware that I wrote a book on toilet training, The Practical Guide to Toilet Training Your Child With Low Muscle Tone. The issue of kids who “hold it in” didn’t make it into the book, but perhaps it should have. Children that have problems with muscle tone or connective tissue integrity (or both) risk current and future issues with incontinence and UITs if they overstretch their bladder or bowel too far. We teach little girls to wipe front-to-back to prevent UTIs. We need to teach all children to avoid “holding it in” in the same manner that we discourage them from w-sitting.

I am specifically speaking here about kids with Ehlers Danlos Syndrome, Down Syndrome and all the other conditions that create pelvic weakness and muscle control issues. But even if your child has idiopathic low tone (meaning that there is no identified cause) this can still become a problem.

The effects of low tone and poor tissue integrity on toilet training are legion. Many of them are sensory-based, a situation that gets very little acknowledgment from pediatricians. These children simply don’t feel the pressure of their full bladder or even a full rectum with the same intensity or discomfort that other children experience. This is known as poor interoception, a sensory-based issue that is rarely discussed, even by parents and occupational therapists that are well versed in other sensory processing issues.  For more on how sensory problems affect toilet training, see Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!).   Kids that don’t accurately perceive fullness can be “camels” sometimes, holding it in with no urge to go, and have to be reminded to void. It can be more convenient for the busy child to keep playing rather than go to the bathroom, or it can save a shy child from the embarrassment of public bathrooms; she prefers to wait until she returns home to “go”.

This is not a good idea at all! The bladder is a muscle that can be overstretched in the same way the hip muscles loosen in children who “W-sit”. Don’t overstretch muscles and then expect them to work well. In addition, the ligaments that support the bladder are subject to the same sensory-based issues that affect other ligaments in the body: once stretched, they don’t bounce back. Holding urine instead of eliminating just stretches vulnerable ligaments out.  A weak pelvic floor is nothing to ignore. Ask older women who have had a few pregnancies how that is working out for them.  Read Is Your Constipated Toddler Also Having Bladder Accidents? Here Are Three Possible Reasons Why to learn why you should be connecting both types of incontinence and taking action sooner rather than later.

For children with connective tissue disorders such as Ehlers-Danlos syndrome, another comorbidity (commonly occurring disorder) is interstitial cystitis (IC).  What does that feel like? The pain of a bad urinary tract infection without any bacterial infection.  Anything that irritates the walls of the bladder adds stress to tissue.  Regular elimination cannot prevent IC, but good bladder care could minimize problems.  Not holding it in is part of good bladder care.

The stretch receptors in both the abdominal wall and in the bladder wall that should be telling a child with low tone that it is time to tinkle just don’t get enough stretch stimulation to do so when they have been extended too far.

When should you teach a child not to hold it in?  Right from the start.  The time to prevent problems is when a child is developing toileting habits, not when problems have developed.  One way to encourage children to use the bathroom is to make it optimally accessible.  Read Should You Install a Child-Sized Potty for Your Special Needs Child? and see if this affordable potty will help your child feel confident and independent right away!

So….an essential part of toileting education for children is when to head to the bathroom. If your child has low muscle tone or a connective tissue disorder that creates less sensory-based information for them, the easiest solution is a routine or a schedule. They use the bathroom whether they feel they need to or not. The older ones can notice how much they are voiding, and that tells them that they really did need to “go”.   The little ones can be rewarded for good listening.

Understanding that the kidneys will fill up a child’s bladder after a large drink in about 35-45 minutes is helpful. But it can always be the right time to hit the bathroom shortly after a meal, before leaving the house, or when returning home. As long as it is routine and relatively frequent, it may not matter how a toileting schedule is created. Just make sure that as they grow up, they are told why this is important. A continent child may not believe that this is preventing accidents, but a child who has a history of embarrassing accidents in public may be your best student.

Many kids with hypermobility have bedwetting issues long after most kids are continent at night.  It helps to explain to them why this may be an issue for them.  Without that discussion, kids often assume that there is something inherently wrong with them as people.  Don’t let your child’s self-esteem drop because they don’t understand why this is such a hard thing to accomplish.  Understanding also makes them more willing to follow a toileting schedule or to focus on developing interoceptive awareness.  If you are wondering if your child’s hypermobility has emotional and behavioral impact, read How Hypermobility Affects Self-Image, Behavior and Regulation in Children and Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior .

For little girls who are at a higher risk of UTIs, I tell parents to teach wiping after urination as a “pat-pat” rather than the standard recommendation of front-to-back wiping.  Why?  Because children aren’t really good at remember that awkward movement, and even if you are standing right their reminding her, she may just wipe back-to-front because that is easier and more natural.  “Pat-pat” is an easy movement and reduces her risk of fecal contamination.  I cannot tell you I have done hard research on this strategy reducing infections, but then, I have common sense.  This is the smarter way for her to wipe.  Want more info on wiping?  Check out How To Teach Your Toddler To Wipe “Back There”

Maybe you have the opposite problem; a child who doesn’t know that they need to head to the bathroom until the last moment.  Read For Kids Who Don’t Know They Need to “Go”? Tell Them to Stand Up for a simple strategy to increase sensory awareness and help them connect the dots in time to make it to the potty!

The good news in all of this? Perceiving sensory feedback can be improved. There are higher-tech solutions like biofeedback, but children can also become more aware without tech. There are physical therapists that work on pelvic and core control, but some children will also do well with junior Kegel practice and education and building awareness of the internal sensations of fullness and urgency.  Many occupational therapists use the Wilbarger Protocol for general proprioceptive awareness.  If your child has Ehlers-Danlos Syndrome, please read Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome? for information on how to use this treatment technique wisely.

Looking for more toilet training information?

My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, has readiness checklists that help you decide what skills to work on right away, and detailed strategies for every stage of training.  I want children to become independent and confident, and for parents to feel good about their role in guiding kids to develop this important life skill.

If you are interested in purchasing The Practical Guide to Toilet Training Your Child With Low Muscle Tone, please visit my website, tranquil babies and click on “e-book” at the top ribbon. You can also buy it on Amazon and your therapy source

Need more than toilet training help?

The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years and Volume Two:  The School Years are finally available!  These e-books help parents with all the self-care challenges, helps them figure out the right chairs, bikes, sports and even pencils, and learn the easiest way to teach their child to get dressed and stay safe on the playground.  Both books are packed with strategies that help kids and therapists as well, plus checklists to improve communication within the family, with teachers, and even with a child’s doctors.  Both books are unique resources that empower parents and inform therapists!  Read more about Volume One here: The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today! and Volume Two here: Parents and Therapists of Hypermobile School-Age Kids Finally Have a Practical Guidebook!  .

You can find the digital downloads on Amazon.com and don’t worry if you don’t have a Kindle; Amazon has a simple way to load them onto your iPhone or iPad!

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

photo-1445800363697-51e91a1edc73  Toilet Training Help Has Arrived!             

My most popular post,  Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!) inspired me to write a manual to help parents with potty training.  There was nothing in books or online that really helped families, just a few lines about being patient and not pushing children….which is no help at all! Families deserve good strategies and an explanation for all the frustration they experience.

What makes this book so unique?  Media specialists say that you have to be able to explain your product in the time it takes for the average elevator ride.  OK, here is my elevator speech on The Practical Guide to Toilet Training Your Child With Low Muscle Tone:

My book provides a complete explanation of the motor, sensory, and social/emotional effects that low muscle tone has on toilet training.  It does so without being preachy or clinical.  Parents understand whether their child is ready to train, and how to start creating readiness immediately.  They learn how to pick the right potty seat, the right clothes, and how to decide between the “boot camp” or gradual method of training.  A child’s speech delays, defiance or disinterest in potty training are addressed in ways that support families instead of criticizing them.

  • Each readiness quiz helps parents figure out what issues need to be addressed for successful training and reminds them of their child’s strengths.
  • Chapter summaries give a quick review of each section.  Parents decide which chapter they need to read next to get more information.
  • Clinical information is explained in layman’s terminology, so parents don’t have to Google “interoception” to understand the neurology that causes a child not to recognize that they have a full bladder.

Here’s what parents are saying about The Practical Guide”:

The Practical Guide has truly been heaven sent!  Although my globally delayed 5-year old daughter understood the idea of toileting, this skill was certainly not mastered.  Our consultations with Cathy and her guide on how to toilet train have given me the knowledge I’ve needed to understand low tone as a symptom that can be tackled.  Morgan has made visible advances, and I am so encouraged and empowered because I know what piece we need to work on next.  Thank you, Cathy, for writing this book!”      Trish C, mother of Morgan, 5 years old

“I would often say to myself “Cathy has to put all of her accumulated wisdom down into a book”.  I am happy to say-here it is!  You will find no one with more creative and practical  solutions.  Her insights and ideas get the job done!”     Laura D. H., mother of M., 4 years old 

Cathy has been a “go-to’ in every area imaginable, from professional referrals to toilet training.  I can’t say enough positive things about her.  She has been so insightful and helpful on this journey.”  Colleen S. mother of two special needs children

Want a bit of a preview?  Here is a small section from Chapter One: Are You Ready For Toilet Training?  Is Your Child?

Parents decide to start toilet training for three primary reasons.  Some families train in anticipation of an outside event, such as enrolling their toddler in a preschool that doesn’t change diapers.  Another example would be the impeding birth of a sibling  Parents who want to train their older child hope that they can avoid having two children in diapers, They do not expect to have the time and attention for training after their new baby arrives.

The second common reason to begin training is when their child achieves a skill that parents believe to be a precursor to successful toileting.  For example, when children learn a word or a sign for urination, adults may thing that they may finally be able to train them.  The final reason is when school staff or their pediatrician recommends that they start training.  whatever your reason, you are reading this book because you are wondering if you and/or your child could be ready for toilet training.

These are the eight types of toileting readiness: 

  1. Financial
  2. Physiological
  3. Communication 
  4. Cognitive 
  5. Social/emotional 
  6. Clothing Management
  7. Time and Attention
  8. Appropriate Equipment

How can you find my book?

Three ways:  Visit my website  tranquil babies and click on “e-book” at the top of the homepage, buy it on Amazon, or visit  Your Therapy Source, a wonderful site for parents and therapists.  Just search for The Practical Guide to Toilet Training Your Child With Low Muscle Tone!

 

Need more than toilet training strategies?

 My new e-book, The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years is for you!  Like The Practical Guide, it has solutions to everyday problems, but this book also gives you strategies to make your child and your home safer, have mealtime and dressing successes, and even learn how to communicate better with your family, babysitter, teacher and doctor!  Find it on Amazon.com.  It is also available as a printable download on Your Therapy Source.

HELP HAS ARRIVED!

Low Tone In The Summer: Why The Heat Affects Your Child’s Safety

 

rawpixel-653771-unsplashIf you have a child with low muscle tone, you may have seen them wilt like flowers in the sun.  Even if they are well-hydrated, even if they are having fun, they just can’t run as fast or sit as steadily when they are warm.  Add a SPIO vest or other compression garment, and the tripping and falling seems to happen more often.  What gives?

Just like a warm bath relaxes your tight shoulders after a long day, heat relaxes muscles.  It doesn’t matter if the heat is environmental or neutral warmth, the kind that is generated by your child’s own body and is held in by the SPIO or her clothes.  It is still heat.  And some kids with low tone don’t sweat efficiently, using the body’s natural method of heat reduction.  This isn’t a minor concern if you have a child that is pretty unsteady on a cool day.  Kids with low tone that are out and about in the heat can become so floppy that they stumble and get injured.  That is a problem.

What can you do?  Well, you may not be able to wear that SPIO in the heat.  Try kineseotaping instead.  (ask your OT or PT if they have been trained in it’s use).  Alternate time in air conditioning and time outside.  Offer cold drinks and ice pops if they can lick and swallow an ice pop safely.  Dress lightly and choose clothes with fabrics that evaporate body heat.  Choose shoes that offer more support, not Crocs or sandals.  This is not the time to pick the least-supportive footwear.

Most importantly, monitor them for safety and be aware that children really cannot judge whether or not they should come in and cool off.  They are counting on you to keep them safe!

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Low Tone and Toilet Training: What You Can Learn From Elimination Communication Theory

Yes, those folks who hold a 6 month-old over the toilet and let her defecate directly into the potty, not into a Pamper.  Elimination Communication (EC) has committed fans, as well as people who think it is both useless and even punishing to kids.  I am not taking sides here, but there is one thing that should get even the skeptics thinking:  a large portion of the developing world deals with babies and elimination this way.  It is very hard to buy a disposable diaper in Nepal, and it is a problem finding water to wash cloth diapers in the Sahara.  I know there are a bunch of parents who roll their eyes whenever EC comes up, but some aspects of the process could help you train your child to use the toilet.  Why not consider what you could learn from EC that will help your child?

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First, parents who practice EC become very very good at anticipating when their kids are going to need the toilet.  Signs such as grunting, flexing the trunk forward, even facial expressions are quickly noted.  If you spend a lot of time watching your child then you probably know some of the signs.  This makes it easier to tell them to sit on the potty when their attempts will actually be successful.  You can also help them connect the physical feelings they are reacting to with language.  Telling them that when they get that feeling in their belly, they need to go use the toilet sounds so obvious to us.  But if you are little, you need help connecting the dots.  If you are little and have learning issues, you need to hear it more often and stated clearly.

Secondly, EC counts on knowing that reflexive intestinal movement happens about 30 minutes after food enters the stomach, and kidneys dump urine into the bladder about 30-45 minutes after a big drink.  Unless your child has digestive issues, this is a good start to create your initial potty schedule plan.  Kids with constipation or slow stomach emptying may take longer, but you already know that you have to work on those issues as well to be successful in toilet training.  Remember, if your child is roaming the house with a sippy cup, it is going to be a lot harder to time a pee break so that they have a full bladder (remember the issue with poor proprioception of pressure in low tone?).  If not, check out  Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!)  Toilet training is a good time to limit drinking to larger amounts at meals and snacks.  This will work for preschool preparation as well.  Most programs would not allow your child to wander with a cup for hygiene reasons, and you are helping them get off the “sippy cup syndrome”, in which children trade bottle chewing for sippy cup slurping.

Think that embracing EC fully will fast-track your kid?  Not necessarily.  In fact, some EC kids struggle to become more separated from a parent as they are not cradled any longer while “making”.  Taking responsibility for their own hygiene and awareness can be harder for some very attached children than if they were using diapers and used them independently.  But EC concepts are something to think about carefully when you are making your plan to help your child with low muscle tone.

 

 

Low Tone and Toilet Training: Parents And Children Need To Work Together

This one is simple to explain, but not so easy to achieve with some kids.  Children whose interactional pattern is defiance or whining are going to be much harder to train, regardless of whether or not they have significant issues with low muscle tone.  In fact,  I would rather coach a very physically unstable but cooperative child than a toddler with mildly low tone but a firm commitment to resist any adult request.   If both parties aren’t able to work together, things may not go well.  At all.

Toddlers and preschoolers are known for their tendency to love the word “no”.  Did you know that, developmentally, the high-water mark for hysteria and the reflexive “no” is between 18 and 24 months?  Yup, that’s when language skills haven’t emerged to support expressing feelings and comprehending adult reasons. It is when emotional fuses are neurologically short, as in that forebrain is still sooo immature.   They really can’t handle their emotions at all on a brain level.  They have just left that sweet-baby phase where they want to please you more than anything, and they can’t be quite as easily distracted from bad behavior now.  This is a generalization, and there are some parents reading this that are thinking “We never got that lovely baby phase.  He went from crabby infant to bossy toddler!”  Well, I sympathize,  and I still invite you to read on.  All is not lost.  As language, emotional and reasoning skills slowly grow, a child who still falls apart easily and rages constantly isn’t always at the mercy of neurology as much as not having some basic coping skills.  It’s time to work on them before you jump into potty training.

Toddlerhood is long, all the way up to 5 years-old, and I won’t minimize the tantrums and agitation that can emerge.  This extended path to greater maturity is why I bought, devoured and constantly use The Happiest Toddler on the Block, Dr. Harvey Karp’s great book on building toddler coping skills. Half of the benefit is learning to both listen to and talk to toddlers in a way that calms things down.  I could not do my work as a pediatric occupational therapist with as much joy and enthusiasm as I have without these strategies.  Thanks, Dr. Karp!

For parents of children with language, communication or cognitive issues that result in developmental delays, your child may be 4 years-old but their other skills that are closer to 18 months old.  You can still toilet train.  Has your child been diagnosed on the autistic spectrum?  You can still train them.  Really.  The process may take longer and you may have to be both very creative and very consistent, but it can be done.  Job #1 is still the same: building a cooperative and warm relationship.

If your days are defined by defiance and whining, you need to learn all of the Happiest Toddler techniques that reduce frustration, including Patience Stretching and the Fast Food Rule.  Stretch Your Toddler’s Patience, Starting Today! You need to use “time-ins” for shared fun and warmth without a goal in mind.  You could try some of the more language-based techniques such as Give It In Fantasy and Gossiping.  And of course, you need to look at your approach to setting limits. All that love is great, but if your child knows that there are no consequences to breaking family rules or aggression,  your plan is in trouble.  Dr. Karp’s techniques aren’t intended to be a toilet training plan, but they set the stage for learning and independence.  Those are the ultimate goals of toilet training!

If you would like a more detailed or more personal level of support, visit my website tranquil babies  and purchase a consultation (in the NY metro area) or a phone/video consult!

 

Low Tone and Toilet Training: Kids Need To See How It’s Done

Low muscle tone creates more challenges for toilet training, but that means parents need to focus on getting all the parts of teaching and practicing down right.  If your child is unfocused or inattentive when you speak about potty training, you can try books and videos. Sometimes the use of media will spark interest and generate excitement.   If you don’t see an immediate boost in interest and cooperation, then your child might need a front row seat for a live demo.  By you (or your partner).

I know, most of us want privacy for this activity, even between couples.  Most women I know aren’t enthusiastic about the idea of demonstrations.  But many kids, and almost all kids whose communication and attention skills are delayed, really need to see what’s going on when you use the toilet.  Kids that have issues like ASD may have been present for your bathroom routine but they were paying attention to something else.  It is time to make a point of having them watch this very personal but important skill.

Sometimes you pick the moment, and sometimes it picks you.  If your child happens to be around and nature calls, bring them along.  If they wander in while you are using the bathroom, don’t send them out.   You may also have to make this “appointment viewing”.  Plan for it, so that you aren’t tearing them away from an activity they have chosen.  Being dragged away from fun to stand there watching isn’t going to work.

Be descriptive, use nouns and verbs.  Saying what you are doing provides them with more language about these activities.  They need to know how to describe to you what they are feeling before and during.  If your child signs, it is time to learn the relevant signs and teach them.  Here is the place where the signs make sense, in the bathroom.

If your son thinks that peeing into the shrubs/snow outside with daddy is the best thing in the world, take the show outside, neighbors permitting. Not everyone is so open to this idea.   I know a family that said that this game was so much fun that her son begged for more juice so that he would have more urine available for the game!!

 

 

Great news!  My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, is done and available!  Visit my website tranquil babies and click “e-book” on the top ribbon.  I will proudly say that there is nothing out there that explains exactly why low tone makes training so much harder, then gives you readiness checklists and real-life strategies that work!

 

Is My Child Ambidextrous?

I answer this question from parents about once a month, on average.  Here is the better question: Is my child developing age-appropriate grasp?

The statistics are against your child being ambidextrous:  only about 1% of people are truly ambidextrous.  Being able to hit a ball equally well with either arm is valued on a team, but when they sit down for supper, switch hitters probably don’t use both hands equally to twirl their spaghetti.  But….children who have poor core stability often do not reach across the center of their body and switch hands to reach what they need.  Children who have motor planning or strength/stability issues will switch hands if the become fatigued or frustrated. None of these children are truly ambidextrous. They are compensating for delays and deficits.

Studies I have read on the development of normal hand dominance suggests that some children are seen as having emerging hand dominance (consistent and skilled use of one hand rather than the other) as early as 12 months.  You know those kids; they pick up cereal bits with their thumb and index finger at 9 months and pop them into their mouths individually as if they were sitting at a bar with a bowl of peanuts and a beer!  They delicately hand you the bit of string they found while crawling, and are already trying to unzip your purse.  Those kids.  It is more common to see emerging hand dominance in the 18-24 month range.  Developmental issues often delay this progression, and issues such as cerebral palsy can result in a child whose neurology would be expressed as right-dominant requiring more left-dominance due to hemiplegia.  That’s right:  hand dominance is biological, not learned, and very likely inherited to some degree.

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terrific safe scissors for little hands!

In my professional career, the greatest predictor of age-appropriate grasping skills has been not core stability or even muscle tone, but exposure and interest.  I work with a child that is legally blind since birth, and his grasping skills are very delayed.  His exposure is biologically limited.  He cannot see what his fingertips are doing, and since he has some vision, he is not doing what totally blind children usually do. They increase their tactile exploration of objects because they don’t have any visual information, and in doing so, end up with generally good refined grasp and control.  This child has slowly developed his skills with carefully chosen and strongly emphasized activities in therapy.

Low muscle tone makes it difficult for infants to develop effective opposition, the rotation and bending of the tip of the thumb opposite to the tip of the index finger.  It is common to see opposition to the tip of the middle finger.  The stability offered by that finger’s placement between two fingers at knuckle-level, plus less rotation needed, explain that quite clearly.  Sadly, the middle finger doesn’t have the refined movement of the index finger, so control is lacking.  They tend to use a fist for gripping toys, and often end up dropping or breaking their goldfish crackers.  These kids often actively dislike using their hands in a skilled manner.  “Read me a book or let me run around” rather than “Give me tiny snacks and beads to string”.  If it is true pattern of avoidance and frustration, it isn’t simply a preference.  It’s an issue.

Wok and Roll!

Playing Wok ‘n Roll with Edison Chopsticks!

How can parents support the development of hand skills at all ages?

  • Infants under 12 months:  Provide safe and desirable things to pick up.  Bits of food that aren’t choking hazards.  Toys with tags firmly sewn on.  Toys with parts that spin and have textures to explore.  Show your interest and delight in this exploration.
  • Toddlers:  Even more opportunities and enthusiasm.  Let them scribble on magnetic boards, use food as fingerpaint, and introduce utensils as early as safe.  Us lots of containers that need to be opened, closed and held for filling and emptying.  Check out Easy Ways To Build Bilateral Hand Coordination for Writing for more ideas.
  • Preschoolers:  Don’t tape down that paper!  Teach the  use of the “helper hand” Better Posture and More Legible Writing With A “Helper Hand” if it isn’t being used, and double-down on toys that require both hands.

What are your best methods for refining grasp and dominance?  All you teachers, therapists and parents out there, please comment and add your ideas!

 

Low Tone and Toilet Training: The 4 Types of Training Readiness

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When clients ask me if I think their child is ready to potty train, my answer is usually “Tell me more about the readiness signs you believe you are seeing.”  There are numerous factors to consider when assessing toilet training readiness if a child has low muscle tone.

Here are the four types of readiness that every parent needs to look at to determine whether their child with low muscle tone is ready to start potty training:

Physical Readiness

After about 18 months, most children can keep a diaper dry for an hour or more.  Their sphincter control increases, and their bladder size does too.  This isn’t conscious control; it is physical development.  Kids with low tone can take a little longer, but without additional neurological issues, by 24 months many of them will be able to achieve this level of physical skill needed to accomplish daytime urinary continence.  Bowel control is usually later, and nighttime control is later still.

Achievement of the OTHER physical readiness skills are less predictable.  These skills include:

You will notice that children need enough skill, not amazing or even good skills.  They just need enough ability to get the job done.

I need to mention that issues such as constipation can derail a parent’s best plans.  Kids with low tone are more likely to have this problem.   Read my post Constipation and Toilet Training  for some ideas on how to manage this issue and who can help you.  The best time to manage constipation is before you start training.

Cognitive/Communication/Social Readiness

The trifecta for toilet training readiness in typical children is a child who is at the 16-20 month level of cognitive/communication/social skills.  This child has the ability to follow simple routines and directions, can understand and communicate the need to use the toilet and express their basic concerns, and is responsive to praise or reward plus interested in learning a skill.  If your child has receptive language issues (difficulty understanding what you are saying) then read Targeted Toilet Training Strategies to Help The Child With A Receptive Language Delay for some specific strategies for this situation.

What about children with global developmental delays?  They absolutely can be toilet trained.  I have worked with children who have no verbal skills and perform tasks like dressing and self-feeding only by being prompted, but they can use the toilet with very little help.  Do they always know when to “go”, or do they simply follow a schedule?  Well, to be honest, sometimes they toilet on a schedule for quite a while before they connect the physical impulse with the action by themselves.  But they are dry all day.  The essential abilities are these:  they know what they need to do when they sit on the potty, and they know that they are being praised or rewarded in some other way for that action.  That’s it.  Have faith; children with developmental delays can do this!!

Some children with low tone have no delays in any of these areas, but many have delays in one or more.  The most difficult situation with cognitive/communication or social readiness?  A child who has developed a pattern of defiance or avoidance, and is more committed to resisting parental directions than working together.  Toddlers are notoriously defiant at times, but some will spend all their energy defying any directive, must have everything their way or else, and can even enjoy being dependent.

If this is your child, job #1 is to turn this ship around.  Toilet training will never succeed if it is a battle of wills.  And no adult wants it to go that way.  Repair this relationship before you train, and both of you will be happier.  You don’t need a child psychologist consult to do it, either.  Read my posts on the Happiest Toddler on the Block methods for ideas on how to use “Gossiping” Let Your Toddler Hear You Gossiping (About Him!)and  Turn Around Toddler Defiance Using “Feed the Meter” Strategies to build a more cooperative relationship with your child.

Family Readiness

Research suggests to me that the number one indicator for training is when the parents are ready.  Sounds off, right?  Isn’t it all about the child’s abilities?  But if the family isn’t really ready, it isn’t likely to work.  I worked with a family that had their first 3 children in rural Russia.  Boiling dirty diapers on a wood stove makes you ready ASAP! Their son born in America was trained much later than his sisters because Pull-ups made it easier to wait, not because he wasn’t ready. Families need the time to train, time to observe voiding/elimination patterns, and time to identify rewards that work for their child.

They need to be prepared to be calm, not angry, when inevitable accidents happen and to avoid harsh punishments when a child’s intentional avoidance creates an accident.  They have to be ready to respond to fears and defiance, and then handle the new independence that could bring a child freedom from diapers, but more insistence on control in other areas.  Many of my clients have nannies, and most parents have partners. Every adult that is part of the training process has to be in agreement about how to train.  Even if they are more cheerleader than “chief potty coach”, it is either a team effort or it is going to be a confusing and slower process.  Check out Toilet Training Has It’s (Seen and Unseen) Costs for more information about how the process of training has  demands on you that are not always obvious.

Equipment Readiness

Do you have a stable and comfortable potty seat or toilet insert?  How will your child get on and off safely?  Do you need a bench or a stair-like device?  Grab bars?  Do you have wipes or thick TP? Enough clothing that is easy to manage?  Underwear or pull-ups that also do the job?  One of my clients just texted me that having a mirror in front of her daughter seemed to help her manage her clothing more independently.   A few weeks ago we placed the potty seat against a wall and in the corner of the room so that if she sat down too fast or hit the edge of the seat with her legs while backing up or standing, it wouldn’t tip and scare her.  No rugs or mats around, so she won’t have to deal with uneven or changing surfaces as she gets to the potty.

Really think out the whole experience for safety, simplicity, and focus. You might want to install a child-sized potty in your child’s main bathroom Should You Install a Child-Sized Potty for Your Special Needs Child?.   If you want to learn what your child’s occupational and physical therapists know to assist you with toilet training, ask them Low Tone and Toilet Training: How Can Your Child’s Therapists Help You ?

You can now see why parents rarely get a simple answer when they ask me if their child is ready to train.  I will say that since they are asking the question, they may be ready, and that is one of the four types of readiness!

Need more help with toilet training?  I wrote an e-book on toilet training for you!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone, is available as an e-book on my website, tranquil babies, on Amazon  or at Your Therapy Source ( a terrific site for parents and therapists!).  If you want more guidance to evaluate your child’s toilet training readiness and learn how to prepare them well, this is your book!  It includes readiness checklists and very specific strategies to build readiness.  Think you are ready to jump in and start training?  My book will guide you to choose between the gradual and the “boot camp” approach, and it addresses the most common stumbling blocks children experience on the road to independence.

Read my post The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Help Has Arrived! , to learn more about this unique book and see what it can do for you today!

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Low Tone And Toilet Training: Pull-Ups or Cloth Training Pants?

My post on clothing choice when toilet training a child with low muscle tone  Low Tone and Toilet Training: Teaching Toddlers to Wipe covered a lot, but it did not include a very important garment:  underwear.  I am putting pull-ups and their generic equivalents in the underwear category.  Many would not, as they are as absorbent as a diaper, disposable, and most children themselves do not think of pull-ups as step toward being a big boy or girl.  Apparently they do not watch or believe the ads.

Here is why it is worth thinking about your choice of undergarment:

  1. Kids with low tone often aren’t as aware of touch input as other children, and aren’t bothered by the very mild warmth and wetness of an absorbent undergarment.  Sometimes they don’t even notice it at all.  That will make it harder to recognize when they have had an accident, or when they need to get to the toilet right now.  This sensory-based issue is one of the two big issues with teaching low-toned kids Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!).  Being able to dash to the potty and successfully avoid an accident is a big deal for them.  This is an accomplishment, and wearing a garment that prevents them from experiencing success reduces training progress.
  2. I understand that having an accident is not fun for either the child or the parent, but it is memorable.  No one learns unless the lessons are memorable.  Understanding what those body signals mean and respecting them is the cornerstone of training, and for kids that need to listen to their bodies, it is essential that they not ignore them.  The Baby Whisperer even encourages parents with children that refuse to sit on the potty and intentionally make in their pants (not exactly an accident, but a mess nevertheless) to take off their clothes themselves and jump in the tub, then wash themselves off.  They get some help, but this isn’t playtime.  There is no quick wipe-off as they stand in front of the TV, watching the show they refused to leave to go potty.  Her thinking is that it is not done as a punishment at all, it is a natural consequence of intentionally not answering the call of nature.  No harsh words, no threats, but no continued watching of that show either.
  3. These children are often unsteady when they are calmly standing still, so being in a rush to pull their underpants down to use the potty is not likely to make them more stable and coordinated. Picking a garment that they can pull up and down easily under pressure is the only kind way to go.   You may have to try both to see what your unique child can manage, and do dry runs Low Tone and Toilet Training: The Importance of Dry Runs (Pun Totally Intended).  I explained it to a stylish mom this way:  if you have to use the toilet really badly and you have spanx and stockings on, think about how embarrassed you would be not to make it in time.  That is what many kids feel every time they need to go.  Dads, if you do not know what spanx are, ask!  Imagine wearing bike shorts under your khakis. Then add thin long underwear over the bike shorts.  Got it?
  4. Some kids are mature enough to care about the graphics on their clothing, and it’s enough to motivate them to commit to toilet training in the first place.  If you can only find the specific superhero that your son adores on a pull-up, you may have to use it, at least at first, to get him excited about learning.
  5. The companies that manufacture pull-ups would like you to believe that they are the only way to get out of diapers.  They are not. You can use cloth training pants, which have a thick crotch area to absorb small accidents.  Some parents have their kids wear 2 pair at a time for extra protection.  They aren’t that bulky.  You can also buy breathable waterproof covers for these pants.  The quality and comfort of these covers has improved over time.  But they do not have a princess on them…
  6. If you go for the cotton pant/waterproof liner combo, you will have to be more vigilant and have kids change out of them more often.  Some kids have more sensitive skin, so make sure you are giving them a little diaper cream as a barrier if you know that your child has had some diaper rash as an infant. As your child stays dry for longer periods, you can even take off the cover for more breathability.
  7. Pull-ups are one-and-done, no way to decrease the level of absorbency and safety.  There is one strategy that “kinda” works for the younger kids:  a pair of underwear and then the pull-up.  They get wet/soiled and kids have a modified experience of an accident without as much mess.  But even this solution limits the real-life experience of really, really having to get to the toilet on time.  This is one reason why children do not want to give up the pull-up.  The older toddlers understand all too well that it is a huge leap from diapers or pull-ups to a thin pair of underwear.  That seems to me to put a lot of pressure on a small child.  I think that this is one reason that toilet training all children has moved later and later.  It has nothing to do with less pressure on them to train or more freedom of children to choose.  They are afraid to fail at something that their parents clearly value.  They want to please us and succeed for themselves.   We should do absolutely everything we can to help them feel good about themselves while learning this important life skill.  Having an accident can be an opportunity to learn and not be judged.