My readers know that I wrote an e-book on potty training kids with low tone ( The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived! ) but I have to admit, I learn a lot from other authors. Jamie Glowacki has written a terrific book that speaks clearly and directly to parents who aren’t sure they are up to the challenge of toilet training. Oh Crap Potty Training is a funny title, but it is filled with useful ideas that help parents understand their toddler better and understand training needs so they can tackle this major life skill with humor and love. I have to admit, I am really happy that she suggests parents of kids with developmental issues ask their OT for advice. So few parents actually do!
Here are a few of her concepts that illustrate why I like her book so much:
She gets the situation toddlers find themselves in: using the potty is a total change in a comforting daily routine. Jamie points out that since birth, your child has only known elimination into a diaper. The older they are when you start training, the longer they have been using diapers. WE are excited to move them on, but they can be afraid to sit, afraid to fail, and afraid of the certainty of the diaper always being there. You can’t NOT get it in the diaper! She also gets the power struggle that can be more enticing to an emerging personality after about 30 months of age. Just saying, she gets it.
Potty training success opens meaningful doors for kids, diapers keep them back. Some great activities and some wonderful schools demand continence to attend. By the time your child is around 3, they can feel inferior if they aren’t trained, but not be able to tell you. They express it with anxiety or anger. If you interpret it as not being ready, you aren’t helping them.
Some kids will NEVER be ready on their own. I know I am going to get some pushback on this one, and she already says she gets hate mail for saying it. But there is a small subset of kids who will need your firm and loving direction to get started. Waiting for readiness isn’t who they are. If you are the parent of one of these kids, you know she’s right. Your kid hasn’t been ready for any transition or change. You have had to help them and then they were fine. But this is who they are, and instead of waiting until the school makes you train her or your in-laws say something critical to your child, it might be OK to make things happen rather than waiting.
You must believe that you are doing the right thing by training your child. They can smell your uncertainty, and it will sink your ship. She really sold me on her book with this one. As a pediatric therapist, I know that my confidence is key when instructing parents in treatment techniques for a home program. If I don’t know that I am recommending the right strategy, I know my doubt will show and nothing will go right.
For children with either low muscle tone or spasticity, toilet training can be a real challenge. If it isn’t clothing management or making it to the potty on time, they can have a hard time perceiving that NOW is the time to start heading to the toilet.
Why? Often, their interoception isn’t terrific. What is interoception? Think of it like proprioception, but internal. It’s the ability to identify and interpret sensory information coming from organs and internal tissues. Among them, the pressure of a full bladder or a full colon. If you can’t feel and interpret sensation correctly, your only clue that you need the potty is when your pants are soiled. Uh-oh. A child with muscle tone issues is almost certainly going to have sensory issues. Tone will affect the amount and quality of sensory feedback from their body.
What can you do to help kids? The simplest, and the fastest solution I have found, is to tell them to stand up and see if they have changed their mind. Why? Because in a sitting position, the force of a full bladder or colon on the abdominal wall and the pelvic floor isn’t as intense. Gravity and intra-abdominal pressure increase those sensations in standing. More sensation can lead to more awareness.
So the next time your child tells you they don’t have to “go”, ask them to stand up and reconsider their opinion. Now, if they are trying to watch a show or play a game, you aren’t going to get very far. So make sure that they don’t have any competition for their attention!
These balls aren’t new, but they don’t get the recognition that they should. The ability to catch a ball is a developmental milestone. For kids with low muscle tone, sensory processing disorder (SPD) or ASD, it can be a difficult goal to achieve. The Gertie ball is often the easiest for them to handle. Here’s why:
It is lightweight. An inflatable ball is often easier to lift and catch. The heavier plastic balls can be too heavy and create surprisingly substantial fatigue after a few tries.
Gertie balls are textured. Some have the original leathery touch, and some have raised bumps. Nothing irritating, but all varieties provided helpful tactile input that supports grasp. It is much easier to hold onto a ball that isn’t super-smooth.
It can be under-inflated, making it slower to roll to and away from a young child. Balls that roll away too fast are frustrating to children with slow motor or visual processing. Balls that roll to quickly toward a child don’t give kids enough time to coordinate visual and motor responses.
They have less impact when accidentally hitting a child or an object. Kids get scared when a hard ball hits them. And special needs kids often throw off the mark, making it more likely to hit something or someone else. Keep things safer with a Gertie ball.
The biggest downside for Gertie balls is that they have a stem as a stopper, and curious older kids can remove it. If you think that your child will be able to remove the stem, creating a choking hazard, only allow supervised playtime.
If your special needs child isn’t experiencing a medical reason for incontinence (infection, blockage, neurological impairment) then you might be facing one of these three common roadblocks to total training success:
Your child has limited or incomplete interoceptive awareness. What is interoception? It is the ability to sense and interpret internal cues. The distention of the bladder, the fullness of the colon, etc are all internal cues that should send them to the potty. Unfortunately, just as poor proprioception can hinder a child’s ability to move smoothly, poor interception can result in potty accidents, among other things. Working with them to become more aware of those feelings can include monitoring their intake and elimination routines. You will know when they should have more sensory input, and can educate them about what that means. Listen to how they describe internal feelings. Kids don’t always know the right words, so use their words or give them a new vocabulary to help them communicate.
Your child’s clothing is difficult to manage, or their dressing skills aren’t up to the task. They run out of time before nature calls. Tops that are hard to roll up, pants that have tricky fasteners, even fabrics that are hard to grasp and manipulate. All of these can make it a few seconds too long once they get into the bathroom. If you are not in there with them, you may have to ask them to do a “dry run” so you can see what is going on and what you can change to make undressing faster. In my e-book, The Practical Guide To Toilet Training Your Child With Low Muscle Tone, I teach parents the best ways to teach dressing skills and the easiest clothing choices for training and beyond. If you have ever had to “go” while in a formal gown or a holiday costume, you know how clothing choices can make it a huge challenge to using the toilet!
Your child is too far from the bathroom when they get the “urge”. Children with mobility problems or planning problems may not think that they are in trouble right away. They might be able to get to the bathroom in time in their own home. When they are out in public or at school, the distance they have to cover can be significant, and barriers such as stairs or elevators can be an issue. Even kids playing outside in their own yards might not be able to come inside in time. If you can’t alter where they are, teach them to use the potty before they go outside or when they are near the bathroom, instead of waiting. Taking the time to empty a half-full bladder is better than an accident.
Parents anxiously wait for their special needs infants to sit up, crawl and walk. That last skill can take extra months or years. Everyone, and I mean everyone, uses walking as a benchmark for maturity and independence.
They shouldn’t. A child with poor safety awareness isn’t safer when they acquire mobility skills. Sometimes they are much less safe. Yes, they may be able to move without your help, but they may need to be more highly monitored and given more assistance to learn how to be safe. They are exploring their environment and their new skills that took them a long time to develop. They have been wanting to climb on the couch for months. Now they can. Getting down the “safe” way isn’t as important to them, and maybe not as easy as sliding or rolling off. Oops.
What can parents do to help their child be a safer (notice I didn’t say “safe”) ambulator, crawler, cruiser, etc?
Talk about safety before they are independent. Will they understand what it means? Probably not, but your tone and your insistence on how movement is done says that you value safety and you want them to do the same. Kids learn from all of our actions. Make this one familiar to them by being very obvious and explicit.
Take your physical therapist seriously when she or he teaches you how to work on core strength and balance skills. Yes, I still maintain that safety is more than a sensory-motor skill, but having the best possible sensory and motor skills is important. Having good safety awareness and safety behaviors without these skills will make a child more vulnerable to falls and injuries.
The same goes for sensory processing activities. If your child cannot perceive the movement of falling, the tactile and proprioceptive change as they crawl or step on something, or tolerate multiple sensory inputs at once, they are much less safe, even with good strength and coordination. Really.
Know your child’s cognitive and social/emotional skills. Impulsive children are less safe overall. Children that cannot process your instructions or recall them without you are less safe. Children that enjoy defying you more than they want to avoid falling are less safe. If you know any of these things, you can gauge safety and react more appropriately. You will be less frustrated and more helpful to them.
Reward safe execution and do not reward unsafe behavior. My favorite way to avoid punishment but also to send my safety message home? Not providing eye contact or much at all in the way of conversation as I stop unsafe actions, and either removing a child from an unsafe situation or assisting them in using the safe method to execute their move. They get no satisfaction from seeing me react strongly, and they get the message that I am not accepting anything but their best safety skills as they move.
Stop a child that is moving in an unsafe way, and see if they can recall and initiate the safe choice before assisting. You don’t want to teach them that only you will make them safe and they need someone to be safe out there. They have to learn how to assess, react and respond, and all children can build their skills. Some need more teaching, and some need more motivation to begin to take responsibility for their safety. Give them both.
Carrying and holding kids is such a natural thing to do. But when your child has hypermobility due to low muscle tone, joint issues or a connective tissue disorder, howyou accomplish these simple tasks makes a difference. Your actions can do more than get them from one position or location to another: they can build a child’s skills, or they can increase the risk of damage by creating excessive flexibility or even accidentally injure a child’s joints.
How could something so simple be both a problem as well as an opportunity? Because hypermobility creates two issues that have to be addressed: Less strength and stability at vulnerable joints, and less sensory feedback regarding pain and position sense in your child. The ligaments, tendons, muscles and joint capsule at every hypermobile joint are more likely to be damaged when excessive force is placed on them.
Knowing how much force is too much isn’t easy without some instruction from a skilled therapist. Depending on your child to react quickly and accurately to accidental stretch or pressure by crying or pulling away isn’t a good idea. Their excessive flexibility reduces firing of receptors deep within all of these tissues in response to excessive force. You may have looked at your child’s shoulders or ankles and think “That looks uncomfortable. Why isn’t she fussing?” This is the reason. It means that you will have to be altering your actions to reduce the risk of harm.
As I mentioned earlier, this is also an opportunity. It is an opportunity to teach your child about safe movement and positioning, right from the start. Even the youngest child will pick up on your emphasis on alignment, control and safety. They are always listening and learning from you every day, so incorporate effective movement into your handling and help your child build awareness and independence today!
Here are some strategies for you and your child:
Always spread the force of your grasp over their body, and place your hands on the most stable locations, not the most flexible. Lift a child through their trunk, not by holding their arms. If they cannot steady their head, support it while you lift. If you feel those little bones in their wrists and ankles moving under your grasp, support those joints instead of pulling on them. Not sure how to do this correctly? Ask your therapist for some instruction.
Do not depend on a child’s comfort level to tell you how far a joint should stretch. Think about typical joint movement instead. If their hips spread very wide when you place them on your hip, think about holding them facing forward, with their knees in line with their hips, not pressed together.
Give them time to move with you. Those over-stretched muscles are at a mechanical disadvantage for contraction. This means that when you tell a child to sit up, you have to give them time to do so before you scoop them up. They aren’t being defiant or lazy (I have not, in fact, ever met a lazy baby!). This is a neuromuscular issue.
Discourage unsafe movements. Some children find that overstretching their joints gives them more sensory feedback. It feels good to them. This is not OK. You will not be able to stop them every time, but they will eventually learn that their is a right way and a wrong way to move. Knowing why isn’t necessary. Yet. Teach them to respect joint movement and use things like graded joint compression and vibration (your occupational therapist should be able to help you with this) to give them the sensory feedback they want.
Bright kid: “Are there any sharks out there?” Gifted kid: ” The most common shark in the Atlantic Ocean is the ….”
Do you have a gifted kid? Do you teach one? You might not be able to tell the difference between a bright child and a gifted child by the number of letters they know, or the facts about dinosaurs they can recall. Here are some distinct signs that your child, student or therapy client is actually gifted:
They are not a joy to teach. Bet you didn’t expect that! Yes, the gifted child isn’t usually sitting there soaking up knowledge. They are out there arguing points and doing their own experiments. They see the subtle differences, so they are going to bring up the exceptions to ALL of your rules. They don’t like rules and correct answers nearly as much as the bright kids. They are interesting to teach, but they won’t be as easy to teach as the bright children who simply learn what they are told and repeat it back to you.
They learn fast. Really fast. The typical child will need 15-20 repetitions or demonstrations and practice to learn a skill. The gifted children may only need 1-2 repetitions to learn. The bright children need 5-8 reps. So if you demonstrate a dance move or how to write a letter and your child copies you perfectly the first time, you may have a gifted child in front of you!
They NEED complexity and novelty. Note that I said “need” versus “prefer”. These kids don’t love routines. They learn them quickly, but they find them boring, not comforting. They don’t want to hear a favorite book again as much as they want you to read the next book in the series. Without sufficient stimulation, the gifted child will go find her own entertainment and probably tell you what to do with your routines! Bright children are often happiest when they can show you what they remember. Gifted kids like to show you what you aren’t seeing or mentioning about a topic.
Gifted children are intensely curious. This is different in magnitude from a bright child, who is interested in many things and consistently pays attention to stories and lessons. The gifted child wants to know everything, and they want to know it now. If the questions that you are asked show a level of synthesis you would not expect based on age and exposure, you may have a gifted child in front of you!
They have a lot of energy. The gifted child may not need that nap, or they may collapse suddenly due to their full-on approach to life. They could wake up totally ready to go, and go to sleep talking as well. This is a child that isn’t going to want to be quiet when they have something to say. The bright kids raise their hands and wait to be called on. Be prepared to expend some energy yourself to engage with a gifted child.
Their passions and ideas can result in daydreaming and preferring to work alone on their projects. This doesn’t mean they can’t be social. But it may mean that they see no point in gluing construction paper triangles onto a pumpkin when they could be creating a pumpkin patch and a corn maze like they visited this weekend. They won’t passively complete your project when they have a better idea of their own.
If you have spotted a child that may be gifted, you will want to offer them the opportunity to expand and explore within your classroom or your home. You don’t need to label them. If you find that their abilities place them far outside the reach of your class plan or they complain about school, it may be time to pursue formal testing. Linda Silverman, a psychologist with a specialization in working with the gifted, suggests that any child that tests more than 2 standard deviations from the the mean (statistically far from average) is in need of special educational services. Just because gifted kids are not below average doesn’t mean that they don’t have needs. To learn more about gifted kids, read How To Talk So Your Gifted Child Will Listen and Sensitivity and Gifted Children: The Mind That Floods With Feeling. Some gifted kids have other issues. Read Gifted and Struggling? Meet the Twice Exceptional Student and How OT Can Help.
And remember that “gifted” doesn’t mean “better kid”. It just means better skills. The gifted population has been hammered for being elitist, when in fact, they receive a lot of criticism and prejudice as well as glory. Treating these kids fairly will allow them to thrive!