Tag Archives: occupational therapy

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

 

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

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

  1. Avoid stretching joints, all of them.  This means that you pick a child up with your hands on their ribcage and under their hips, not by their arms or wrists.  Instruct your babysitter and your daycare providers, demonstrating clearly to illustrate the moves you’d prefer them to use. Your child’s perception of pain is not always accurate (how many times have they smacked into something and not cried?) so you will always use a lift that produces the least amount of force on the most vulnerable joints.  Yes, ribs can be dislocated too, but not as easily as shoulders, elbows or wrists.
  2. Actively discourage sitting, lying or leaning on wrists that bend backward.  This includes “W” sitting.   I have lost count of the number of toddlers I see who lean on the BACK  of their hands in sitting or lying on their stomach.  This is too much stretch for those ligaments.  Don’t sit idly by.  Teach them how to position their joints.  If they ask why, explaining that it will cause a “booboo” inside their wrist or arm should be enough.
  3. Monitor and respect fatigue.  Once the muscles surrounding a loose joint have fatigued, that joint is more vulnerable to injury.  Ask your child to change her position or her activity.  This doesn’t necessarily mean stopping the fun, just altering it.  But sometimes it does mean a full-on break.  If she balks, sweeten the deal and offer something desirable while you explain that her knees or her wrists need to take a rest.  They are tired.  They  may not want to, but it is their rest time.  Toddlers can relate.

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

Good luck, and please share your best strategies in the comments section so other parents and therapists learn from you!

Looking for information on toilet training your child with Ehlers Danlos, generalized ligament laxity, or low muscle tone?  My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, gives you detailed strategies for success, not philosophy or blanket statements.  I include readiness checklists, discuss issues that derail training such as constipation, and explain the sensory, motor, and social/emotional components of training children that struggle to gain the awareness and stability needed to get the job done.

My book is available on my website tranquil babies, at Amazon.com, and at yourtherapysource.com.

Infants With Sensory Sensitivity: When Your Fussy Baby Takes Over Your Life

Parents are often the first to suspect that their infant’s constant and intense complaints are more than just fussiness.  Sometimes pediatricians pick up on a pattern of edginess that cannot be explained by all the usual suspects:  teething, food sensitivity, temperament.  Having a baby who complains bitterly about the most common events, such as diaper changes and nursing, can take over a parent’s life and make them question their sanity.

Judging by the research literature, you would think that sensory sensitivity only happens to toddlers or preschoolers!  Those 4 year-olds who refuse to wear shirts with long sleeves and cannot handle a car ride without vomiting often started out as super-fussy babies.  Their parents may have tried the lactation consultant, the pediatrician, maybe even the neurologist, in a frantic search for help.  They could have used an OT.

I have treated babies as young as 6 months-old that displayed clear signs of sensory sensitivity after prolonged periods of peri-natal NICU stays or procedures.  Why would a few months in the NICU make a baby sensory-averse to diaper changes and being held?  Well, look at it from the perspective of an immature nervous system.  They got more stimulation than they could handle, and their brains responded by interpreting everything as a potentially invasive experience.  Turns out, a good percentage of children who require intensive and ongoing medical procedures to save their lives don’t recall the experience, but their body does. Ask psychiatrists doing fMRIs, or functional MRI’s, what they see in adult trauma victims.  Parts of the brain that encode emotion and memory will light up like Christmas trees when faced with innocuous stimuli.  Oops.

Progressive NICU’s are making changes, but those nurses have no choice to perform multiple and invasive procedures and do them in a very stimulating environment.  They are working hard at a very difficult task; saving the lives of really tiny, really sick babies.

Is a NICU stay the only way to become a sensory-averse infant?  Not at all.  It seems some infants are just wired to be more sensitive, and some babies need only a little bit of extra excitement to become sensitive.  I treated an infant under 6 months of age that struggled to nurse.  She had the oral motor skills to suck, the swallowing skills to avoid choking, but she disliked the feel of her mother’s skin touching her face.  She nursed until she wasn’t starving, then refused any more.  Her mother felt rejected and not in love with her little girl any more.  The baby wasn’t growing and was constantly agitated.  We worked hard in therapy to help this baby, but until we realized what the problem was, every time her mom tried to get her to nurse more, she was repeating the cycle of aversion and agitation.

My approach for my youngest sensory-averse clients combines everything I know from Happiest Baby on the Block and all my training in sensory processing theory and practice as a pediatric occupational therapist.  The first step is convincing parents that they didn’t cause this behavior, and then convincing them that there is treatment that works.  Combining calming sensory input, environmental adaptations, and skill building in these little babies can make a huge difference in their lives and their family’s experience.  If your baby is incredible fussy and no one can find a good reason, pursue pediatric occupational therapy with an experienced therapist.  It could calm things down more quickly than you think!

Child Writing Too Lightly on Paper? It Might Not Be Hand Strength Holding Him Back

If your child barely makes a mark when he scribbles or writes, most adults assume that grasp is an issue. Today’s post suggests that something else could be the real reason for those faint lines.

Limitations in postural and bilateral control contribute far more to lack of pressure when writing  than most parents and teachers realize.  For every child in occupational therapy that is struggling to achieve good grasp, I see three whose poor sitting posture and inability to get a stable midline orientation are the real issues.

Think about it for a minute:  if you sat with your non-dominant (not the writing hand) hand off to the side and you shifted your body weight backward in your chair, how would you be able to use sufficient force on a pencil or a crayon?  Try this right now.  Really.  You would have to focus on pressing harder while you write and hope your paper doesn’t slip around.  That would require your awareness and some assessment of your performance.  Children don’t do “awareness and assessment” very well.  That ability comes from frontal lobe functions that aren’t fully developed in young children.  But they can learn where to place their “helper hand”, and that sitting straight and shifting forward is the correct way to sit when you scribble or write.

If a child has sensory processing or neuromuscular issues such as cerebral palsy, Ehlers-Danlos Syndrome or Down Syndrome, achieving adequate postural stability may take some effort on the part of the therapists and the teacher.  Well worth it, in my experience.  There are easy hacks that help kids; good equipment and good seating that won’t cost a fortune or inconvenience the class.  Every child can learn that posture is important for writing.  But the adults have to learn it first.  Kids take their cues from what adults appear to value, and if they figure out that they are allowed to slump or lean, they almost always will.

I am doing a lecture on pre-writing next week, and I intend to make this point, even though the emphasis of my lecture is on the use of fun drawing activities to prepare children to write and read.  Why?  Because it may be the only time these preschool teachers hear from a pediatric occupational therapist this year, and I want to make a difference.  Understanding the importance of postural control in pre-writing and handwriting could help struggling kids, and make decent writers into stars!

Low Tone and Toilet Training: Learning to Hold It In Long Enough to Make It to The Potty

 

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If your child can’t stay dry at night after 5, or can’t make it to the potty on time, there are a number of things that could be going wrong.  I won’t list them all, but your pediatrician may send you to a pediatric urologist to evaluate whether there are any functional (kidney issues, thyroid issues, adrenal issues etc.) or structural issues ( nerve, tissue malformations).  If testing results are negative, some parents actually feel worse rather than better.

Why?  Because they may be facing a situation that is harder to evaluate and treat:  low tone reducing sensory awareness and pelvic floor control.

Yes, the same problem that causes a child to fall off their chair without notice can give them potty problems.  When their bladder ( which is another muscle, after all) isn’t well toned, it isn’t sending sensory information back to the brain.  The sensors that respond to stretch aren’t firing and thus do not give a child accurate and timely feedback.  It may not let them know it is stretched until it is ready to overflow.  If the pelvic floor muscles are also lax, similar problems.  Older women who have been pregnant know all about what happens when you have a weak pelvic floor.  They feel like they have to “go”  but can’t hold it long enough to get to the bathroom!   Your mom and your daughter could be having the same problems!!

What can you do to help your child?  Some people simply have their kids pee every few hours, and this could work with some kids in some situations.  Not every kid is willing to wear a potty watch (they do make them) and the younger ones may not even be willing to go.  The older ones may be so self-conscious that they restrict fluids all day, but that is not a great idea.  Dehydration can create medical issues that they can’t fathom.  Things like fainting and kidney stones.

Believe it or not, many pediatric urologists don’t want kids to empty their bladder before bedtime.  They want kids to gradually expand the bladder’s ability to hold urine for a full 8-10 hours.  I think this is easier to do during the day, with a fully awake kid and a potty close at hand.  Too many accidents make children and adults discouraged.  Feeling like a failure isn’t good for anyone, and children with low tone already have had frustrating and embarrassing experiences.  They don’t need more of them.

There are a few ideas that can work, but they do take effort and skill on the part of parents:

First, practice letting that bladder fill up just enough for some awareness to arise.  You need to know how much a child is drinking to figure out what the right amount is, and your child has to be able to communicate what they feel.  This is going to be more successful with children with at least a 5-6 year-old cognitive/speech level.  Once they notice what they are feeling down there right before they pee, you impress on them that when they feel this way that they can avoid an accident by voiding as soon as they can.  Try to get them to create their own words to describe the sensation they are noticing.  That fullness/pressure/distention may feel ticklish, it may be felt more in their belly than lower down; all that matters is that you have helped your child identify it and name it.

You have to start with an empty bladder, and measure out what they are drinking so you know approximately how much fluid it takes them to perceive some bladder stretching.    It helps if you can measure it in a way that has meaning for them.  For me, it would be how many mugs of coffee.  For a child it might be how many mini water bottles or small sport bottles until they feel the need to “go”.  You also need to know how long it takes their kidneys to produce that amount of urine.  A potty watch that is set to go off before they feel any sensation isn’t teaching them anything.

The second strategy I like involves building the pelvic floor with Kegels and other moves.  Yup, the same moves that you do to recover after you deliver a baby.  The pelvic floor muscles are mostly the muscles that you contract to stop your urine stream.  Some kids aren’t mentally ready to concentrate on a  stop/start exercise, and some are so shy that they can’t do it with you watching.  But it is the easiest way to build that pelvic floor.  There are other core muscle exercises that can help, like transverse abdominal exercises and pelvic tilt exercises.  Boring for us, and more boring for kids.  But they really do work to build lower abdominal strength.  If you have to create a reward system for them to practice, do it.  If you have to exercise  with them, all the better.  A strong core and a strong pelvic floor is good for all of us!

Finally, don’t forget that the same things that make adult bladders edgy will affect kids.  Caffeine in sodas, for example.  Spicy foods.  Some medications for other issues irritate bladders or increase urine production.  Don’t forget constipation.  A full colon can press on a full bladder and create accidents.

Interested in learning more about toilet training?  My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone is available on my website, tranquil babies.  Just click ‘e-book” on the ribbon at the top of the home page, and learn about my readiness checklists, and how to deal with everything from pre-training all the way up to using the potty in public!

 

 

 

 

Why Dot-To-Dot Letter Practice Slows Down Writing Speed and Legibility

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These beach umbrellas look like a dot-to-dot picture!

Most workbooks feature dot-to-dot practice for writing letters.  They shouldn’t.  Why?  The answer is obvious if you know how to teach handwriting.  The biggest problem is that so few people understand how children learn to write, and what gets in their way.

There are 3 stages of learning:  imitating an adult, copying printed materials, and independently writing a letter.  When the first stage of instruction is too short, poorly attended to (imagine a distracting preschool room) or nonexistent (“go practice at the writing table during your free period”), children end up drawing their letters, unaware of how letters are correctly constructed.  Dot-to-dot worksheets encourage drawing letters. They do a very poor job of teaching correct formation and a good job of encouraging bad habits in handwriting.

These worksheets, even the ones with a starting dot or arrow, cannot be followed correctly by most very young children.  They look at the letter “a” in the same way I look at a Chinese character or a hieroglyph.  I could probably copy it, but I have no idea which lines make a single stroke, which to write first, second and third, and no sense that it should be similar to other characters.  Children really don’t follow a tiny arrow or understand that numbering the strokes means that a tiny number two at the top means “This is your second stroke”.  Older children do, but they aren’t the ones laboring over the dot-to-dot letter pages.  There is a better way.

To make my point clear, look at the letters that Handwriting Without Tears calls the “magic c letters”:  c, o, a, d, and g.  By the way, are you wondering why “q” isn’t in the group, since it is formed in a similar manner?  They add “q” later in instruction, due to the potential confusion with “g”,which is a more commonly used letter in English.  I have seen a single child write the letter “c” made starting at the baseline and curving up, then make the letter “o” correctly by first writing a “c”, and then write letters “a”, “g” and “d”  by drawing circles and adding straight or curved lines.

This method of letter formation never looks neat once children have to write full sentences with some speed.  It can’t look good, as the pencil control required to write well with these strategies is too challenging for young children once they have to write more than a few letters.  Ooops! Where did they come up with all those different methods of writing letters that should be made by starting with the letter “c” and then continuing to form the specific letter?   They figured it out for themselves, since no one was watching!

The “Magic C” approach is brilliant because it is simple to recall and it creates control and automaticity, two hallmarks of legible handwriting.  Dot-to-dot writing leads children down a path riddled with possible bad habits.

So are dot-to-dot pictures a terrible idea?  Not at all.  I love the way children have to control pencil strokes and visually scan the page.  They are great visual-motor fun.   There are complex dot-to-dot pictures with over 200 dots that really challenge kindergarteners who can count.  Just don’t teach letters this way!

Sensory Sensitivity In Toddlers: Why Responding Differently to “Yucky!” Will Help Your Child

Sensory sensitivity and aversive behaviors are among the most common reasons families seek occupational therapy in Early Intervention.  Their kids are crying and clinging through meals, dressing, bathing and more.  What parents often don’t see is that they can help their child by being both empathic and educating them throughout the course of the day.

My clinical approach has matured over the years from the standard OT treatments to a whole-child and whole-family strategy.  One important part of my approach is to alter how adults react to their children.  It isn’t complex, but it is a shift away from thinking about the problem as being exclusively “my child’s issues with sensory processing”.  Once adults understand the experience a child is having from the child’s point of view, they can learn to respond more effectively to a child, and get results right away.

I recently did a therapy session with a toddler and her mom.  When the child became overwhelmed by her dog barking and rushed to her mom to be picked up, I warmly and clearly said “You want up?” twice while using explicit body language to convey calmness, while the mom looked at her child but didn’t scoop her up right away.  The child turned to look at me, stopped whining and dropped her shoulders.   She relaxed at least 50%, stuck her thumb in her mouth for about 30 seconds, then started to play quite happily.  What I know is that this short interaction affected her body’s level of neuro-hormonal arousal, her thinking about how adults handle sensory events, and her memory of how she feels when she is overstimulated changed. I believe that those differences physically change the wiring of her brain in a small but meaningful way.

I cannot take full credit for this strategy; I used the Fast Food Rule from Dr. Harvey Karp  Use The Fast Food Rule to Help ASD Toddlers Handle Change.  I am using it for therapeutic means, but it the same tantrum-defusing method he developed.   I responded with loving calmness to her over-the-top reaction, acknowledging her request while not granting it. She was “heard” and accepted.   I gave her a moment to come up with an alternate response (quick thumb-suck and then search for fun a fun toy).

This little girl has a habitual reaction to sensory input that puts her into a fear-flight pattern on a regular basis.  Cuddling her works for the short-term, but it leaves her seeking adult assistance for any fears, and it doesn’t give her any skills to handle things or suggest that she could handle situations differently.  Shifting her habitual reactions to  these benign events is essential to make progress, and telling her that it was “just the dog barking” doesn’t work.

Why?  Because Dr. Karp will tell you himself that toddlers hear you saying”just” as if you were telling them “you are wrong”.   They protest more to make you exactly see how upset they are.  Explaining things rationally doesn’t help a little person in the throes of emotion.  Modeling calmness while acknowledging their feelings is what helps them learn and grow.

Your child is wiring his brain every moment of every day. Your sensitive child is assessing all of your reactions to learn about what is a danger and what is not.  His brain, not his hands, are interpreting the world as irritating or frightening.  Your reactions to events and to his responses will help to hardwire his brain to believe something is scary, or challenge him to adapt and change that automatic pattern of response.  It isn’t all psychological, it is neurobiological as well.  Most researchers don’t differentiate between the two any longer.  They know that biology drives thought and that thought can alter biology.  The rubber meets the road right here, right now, in your own home!

OTs working with sensory processing disorders generally believe that an aversive response to a benign stimulus (hysteria when touching lotion or oatmeal) is not a skin issue or a mental health issue, but a brain interpretation gone wrong.  There are many reasons why this would happen, but most of us believe that experience and exposure, done well, can change the brain.  Some exposure is done with programs like the Wilbarger Protocol, the use of weighted or pressure garments, and many other great therapeutic techniques.  Changing adults’ responses hasn’t been researched nearly as much, but my clinical experience tells me it probably should be.  I know that teaching parents how to shift their behavior has made a difference for my clients almost immediately.

Good therapy can diminish a child’s aversions substantially, and even create exploration and excitement.  It is wonderful to see a formerly anxious child move through her day exploring and enjoying the world around her!

Does your sensitive toddler struggle with toilet training?

 The Practical Guide to Toilet Training Your Child With Low Muscle Tone is my new e-book (hard copies can be obtained by contacting me directly) that may help you tonight!  Sensory-based strategies can really help children with sensitivity, and good instruction minimizes all the multi-sensory mess that training can become when you don’t know what to do.  Your child doesn’t need to have severe issues with low tone.  Many children have both sensory sensitivity and low muscle tone.

Visit my website tranquil babies, and click “e-book” on the top ribbon to learn more about this unique book!

Gifted and Struggling? Meet the Twice Exceptional Student and How OT Can Help

 

 

rockybeachI work with two amazing children that could be diagnosed as “twice exceptional”.  Both boys, they have amazing intellectual gifts (one verbal, one in math) but they work with me on their handwriting and their behavior.  Neither can write a simple sentence without significant errors in letter placement or formation.  But both can shock me with their mental abilities.  They are very familiar with what happens when your mom gets a note from the teacher.  It usually isn’t because of their giftedness.  Helping them to succeed in school shouldn’t be that difficult if you look at their test scores.  But it is.

Both kids feel that they are failures in school.  They get in trouble more often than their peers, their homework comes back with lots of red-lined comments, and they have no idea why people alternately compliment them on their skills and then make it clear that they are a problem in some way.  Their minds generate lots of ideas; many of them are clever ways to decrease the amount or level of challenge I throw at them in our sessions.

What is going on?  I think that the whole child has to be seen to be understood.  The gifted brain is different, not just high-powered.  Some kids have  wonderful ideas and thoughts they cannot get on paper fast enough.  Some have struggled with emotional or physical sensitivity.  They freeze or run (mentally) almost before they have written anything.  Some were not paying attention to handwriting in preschool, or figured out that the teacher would accept any effort, so they ignored the class instruction in letter formation and placement.  The other children glowed with pride to write their names neatly.  These children were gazing at the stars, quite literally!

Many, many gifted children struggle with motor skill development, and many more just don’t have the patience for practice.  The incidence of learning issues such as dyslexia in the gifted population is not insignificant.  Their cumulative test scores on their achievement tests mask the learning disability too often.  On paper, these kids look average.  They are nothing of the kind.  Look for striking subtest score disparities to identify them.  But then you have to help them.

Occupational therapists are the secret weapon for the twice exceptional student.  OT has a lot to offer these kids.  We can help self-regulation issues, we can adapt seating, listening, and learning environments for these kids.  We have skills to help them deal with anxiety and the performance issues that arise, and we have handwriting instruction and remediation strategies that work well and work fast with bright students.   Twice exceptional kids often don’t get services because they can “game” the evaluations.  Their great visual-perceptual or cognitive skills allow them to get an average score, but if their approach is carefully observed, the OT can see that happening.  The narrative in the evaluation has to highlight the issues, and the parents have to advocate for treatment.

Working with twice exceptional kids is a joy for me.  They are just as deserving of good therapy as the globally delayed children I treat.  I just have to pay attention to issues of global significance and make sure that I can keep up with the conversations they initiate!

Does your twice exceptional child have a stubborn streak a mile wide?  If so, read Is Your Gifted Child Also Your Most Strong Willed Child As Well? for my perspective on why someone so clever can also get stuck defending a position that makes no sense!