Tag Archives: sensory processing disorder

Is It Sensory Treatment…Or Sensory Stimulation? How To Know The Difference

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I have spent the first part of my career in pediatrics convincing parents, teachers, and other therapists that sensory processing is important for development, and that sensory processing disorders are a real “thing”.  I am spending the latter part of my career trying to explain to the same groups that using a sensory-based activity does not constitute sensory treatment.

Why?

Results.  You will not get good results to any treatment if the underlying principles aren’t understood and used correctly.  This requires more than a therapy ball and a brush.  A local school district uses general sensory activities for the whole class, rather than sensory-based treatment for kids with sensory processing disorders.  I get a lot of private practice referrals from this neighborhood.  The district’s refusal to address children’s needs in the classroom, while telling parents that they are “sensory-aware”, is frustrating to everyone, including the therapists in the district.  They don’t seem to stick around…..

Therapy for sensory processing disorders requires an evaluation.  Assessing the problem and identifying a rationale for the related behaviors or functional deficits is essential.  Tossing out a sensory-based activity because it is fun, easy, or has worked for another child is the hallmark of a well-meaning provider that wants to help a child but doesn’t have the training of a licensed therapist.

A good example would be to offer teething toys to a child that chews their shirt.  Sounds like a solid plan:  oral seeking equals oral stimulation.  But wait! What if the child is using oral seeking to address severe sound sensitivity?  Isn’t it better to deal with the cause of the problem rather than the end-point behavior?  You would need an evaluation to know that their greater problem is poor modulation and sensitivity.

Treatment techniques follow a pattern that is based on the brain’s neurological response to sensory input.  I didn’t take courses in neuroscience because I liked looking at brain sections.  I took those courses so that I could understand the structure and function of the brain!

The right intervention (movement, pressure, etc.) uses intensity, duration, specificity of sensory input, location of contact/input, frequency, and timing to achieve results.  This sounds like a lot to consider, and….it is!  The way OTs create a sensory diet isn’t by looking at what worked for another child.  We look at what we observe, what we assess, and what the child’s performance demands are.  Only then can we identify what should be used, how and when it should be used, and how to determine our next steps in treatment. 

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A great treatment that isn’t used at the correct level of frequency or used when it is most needed is going to fail.  So will the right frequency of treatment used vigorously rather than with skilled observation.  Non-therapists can be taught a treatment intervention, but it takes training and experience to create a treatment program.  This is no different from any other type of therapy.  Psychotherapists aren’t just talking to you. Speech therapists aren’t simply teaching you how to pronounce the “r” sound.  If it was that easy, we wouldn’t need licensure or even a degree.   

It would be a lot more fun.  We make it look easy, and that is the art of OT.

 I have just explained (some of) the science.

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How To Remember to Do A Sensory Diet With Your Child

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A “sensory diet” is the cornerstone of managing a child’s sensory processing issues.  Every therapist knows that without a good home program that only addressing a child’s needs in a session, we aren’t going to see much progress.  Treatment sessions are spent half playing catch-up:  trying to increase postural activation, calming them down, or waking them up to participate .  When a child’s nervous system has the right input, their performance and how great they feel inside…it can blossom.  You can see what their potential really is, and their life gets better.

COVID-19 has halted many children from attending treatment in clinics.  Parents are now trying to do activities through telehealth, and their success is determined by many factors.  As therapists, we know that if we cannot see your child live, the sensory diet becomes even more important.

Sensory diet activities don’t always run smoothly.  Kids are busy, parents are stressed, caregivers aren’t around as much or as often.  Parents are asking “How do I remember to do these activities when I have so much else to do during the day?”

The answer is to build a routine that makes sense and that your child will use without a fight.  

  • Find the right time of day, when your child needs this imput.  Using the same things at the same times each day make them more familiar.  More familiar can mean less of a fight.
  • Find the right place, where you aren’t fighting their desire to see the TV or see kids outside playing.  Use a space that supports, not competes, with your goals.  Some kids don’t do well in bright lights, big spaces, or with competing sensory input.
  • Find the right sequence, in which a challenging activity is preceded by one that helps your child focus and get in a positive state of mind.  Ask your OT if there is a way to put activities in an order than makes sense for modulation.
  • Find the right toy, book, person, or food that makes a sensory diet activity a chance to play with something or someone special.  This may mean enlisting the other parent, a sibling or someone else in your pandemic pod.  It takes a village.

The perfect sensory diet is the one that you will do and your child will use.  Your therapist might suggest an amazing activity, but if you cannot do it, your child resists it, or you don’t have the time for it….it isn’t an amazing activity.  It is a burden, and a chance for you to feel like a failure and your child to act up.

Don’t let that happen.

If you cannot manage the current sensory diet with enough ease, ask for advice.  Ask for new activities, new toy recommendations.  Ask for more of a demonstration, even if you think you risk seeming less than perfect.  We like parents who show interest, and we don’t mind repeating our instructions.

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A Fun Way to Help Kids With Low Tone Stand Up Straight: Stomp-Stomp!

sven-brandsma-gn-I07tTixw-unsplashKids with hypermobility or low tone are often found standing in the most dysfunctional of positions.  Toes pointing in, feet rolled in or out, feet on top of each other: take your pick, because these kids will alternate between these wobbly choices and more!  Read How To Improve Posture In Children With Low Muscle Tone… Without a Fight! and How To Correctly Reposition Your Child’s Legs When They “W-Sit” for some other ideas.  But if you want a quick idea that works to help a child stand up with better control and stability, read on.

Telling a child to “fix your feet” often makes no sense to them, or gets ignored.  Passively repositioning their feet doesn’t teach them anything, and can annoy children who feel that they are being manhandled.

What Can You Do?

Tell Them To “Stomp-Stomp”!

Have the child stomp their feet. Repeat if necessary (or because they want to).   It is simple, you can demonstrate it easily, and most kids grin happily and eagerly copy you.  It is fun to stomp your feet.  It also give kids a chance to move in place, which they often need when socially distancing in a classroom.

 

Why Does It Work?

Because in order to stomp their feet, they have to bring their attention to their feet, shift their weight from one foot to the other in order to lift them up, and their feet almost always end up placed in a more aligned position after stomping.

Many of the goal boxes their PT and your OT have on their list are checked.  Kids don’t feel controlled or criticized.  They are having fun.  Sensory input happens in a fun way, not as an exercise.

Want more help with your child, or help improving treatment plans as a therapist?

I wrote three e-books for you!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone, and the JointSmart Child series on hypermobility are all valuable resources for parents and therapists.  I wrote them because there is simply nothing out there that provides an explanation for why these symptoms make life so difficult for kids (and parents, and teachers, and even therapists!) and what can be done to make everyday life better.

Learn why low tone and hypermobility both create sensory processing issues, and what kinds of social and emotional issues are understood to accompany hypotonia and hypermobility.  When parents see these issues as complex rather than only about strength and stability, they start to feel more empowered and more positive.

Read more about these books, available for purchase on Amazon and Your Therapy Source,  in A Practical Guide to Helping the Hypermobile School-Age Child Succeed, and The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today! as well as The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

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Is Your Child With Low Tone “Too Busy” to Make it to the Potty?

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Since writing my first e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, I have fielded a ton of questions about the later stages of potty training.  One stumbling block for most children appears to be “potty fatigue”.  They lose the early excitement of mastery, and they get wrapped up in whatever they are doing.  What happens when you combine the effects of low tone with the inability of a  young child to judge the consequences of delaying a bathroom run?  This can lead to delaying a visit to the bathroom until it is too late.  Oops.

Kids with low tone often have poor interoceptive processing.  What is that?  Well, interoception is how you perceive internal sensory information.  When it comes to toileting, you feel fullness in your bladder that presses on your abdominal wall, in the same way you feel a full stomach.  This is how any of us know that we have to “go”.  If you wait too long, pressure turns to a bit of pain.  Low muscle tone creates a situation in which the stretch receptors in the abdominal muscles and in the bladder wall itself don’t get triggered until there is a stronger stimulus.  There may be some difficulty in locating the source of pressure as coming from the bladder instead of bowel, or even feeling like it could be coming from their back or stomach.  This leads to bathroom accidents if the toilet is too far away,  if they can’t walk fast enough, or if they cannot pull down their pants fast enough.  You have to work on all those skills!

Add in a child’s unwillingness to recognize the importance of the weak sensory signals that he or she is receiving because they are having too much fun or are waiting for a turn in a game or on a swing.  Uh-oh.  Not being able to connect the dots is common in young children.  That is why we don’t let them cross a busy street alone until they are well over 3 or 4.  They are terrible at judging risk.  Again, this means there are skills to develop to avoid accidents.

What should parents do to help their children limit accidents arising from being “too busy to pee?”

  1. Involve kids in the process of planning and deciding.  A child that is brought to the potty without any explanations such as “I can see you wiggling and crossing your legs.  That tells me that you are ready to pee” isn’t being taught how to recognize more of their own signs of needing the potty.
  2. Allow kids to experience the consequences of poor choices.  If they refused to use the potty and had an accident, they can end up in the tub to wash up, put their wet clothes in the washer, and if they were watching a show, it is now over.  They don’t get to keep watching TV while an adult wipes them, changes them, and cleans up the mess!
  3. Create good routines.  Early.  Just as your mom insisted that you use the bathroom before leaving the house, kids with low tone need to understand that for them, there is a cost to overstretching their bladder by “holding it”  Read  Teach Kids With Ehlers-Danlos Syndrome Or Low Tone: Don’t Hold It In! to learn more about this.  The best strategy is to encourage a child to urinate before their bladder is too full, make potty routines a habit very early in life, and to develop the skills of patience stretching Stretch Your Toddler’s Patience, Starting Today!  from an early age.  Creating more patience in young children allows them to think clearly and plan better, within their expected cognitive level.

Looking for more information on managing daily life with your special needs child?

I wrote three e-books for you!

My e-book on toilet training, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, and my e-books on managing pediatric hypermobility, are available on Amazon as read-only downloads, and on Your Therapy Source as printable downloads.  The JointSmart Child:  Living and Thriving With Hypermobility  Volume   One:  The Early Years and Volume Two:  The School Years are filled with strategies that parents and therapists can use immediately to improve a child’s independence and safety.

Your Therapy Source has bundled my books together for a great value.  On their site, you can buy both the toilet training and the Early Years books together, or buy both hypermobility books together at a significant discount!

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CPSE or CSE Review Without a Re-Eval Because of COVID-19? Here’s What You Need To Ask For

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One of my private clients just called me for some backup.  Her son, who is on the autism spectrum, may lose some of his school OT sessions due to his increased handwriting ability (thank you; we have been very working hard on it!), but no further formal testing could be done before schools were shut down due to COVID-19.  His fine motor scores were in the average range. Everyone knows he is struggling with attention and behavior in class.  Everyone.

My strategy?  I gave her the Sensory Profile for ages 3-10 (SP) to complete.  Almost all of his scores were in either the “probable difference” or “definite difference” categories.  This means that his behavior on most of over 125 different items is between one and two standard deviations from the mean.  Even without a statistics course, you can understand that this is likely to be impacting his behavior in the classroom!

Many of the modulation sections of the SP, including “modulation of visual input affecting emotional responses” and “modulation of movement affective activity level” directly relate to observed school behaviors.  Scores in “multi sensory processing” and “auditory processing” were equally low.  Think about how teaching is done in a group:  it is visual and verbal.  Kids have to sit to learn.  They have to tolerate being challenged.

This is why OT in the schools is more than how to hold a pencil.  We address the foundational skills that allow children to build executive functioning skills.  Without these skills, all the routines, prompts, reward systems and consequences aren’t going to be very effective.

School therapists cannot test your child accurately using a standardized instrument when schools are closed due to COVID-19.  But parents can respond to a questionnaire, and it can be sent and scored remotely.  The Sensory Processing Measure is another sensory processing questionnaire able to be completed remotely.  These scores will help your therapist and your district understand the importance of OT for your child.  When school does resume, related services are going to be essential services!

For more information on how to work on OT issues at home, read Using A Vertical Easel in Preschool? WHERE You Draw on it Matters! and Does Your Older Child Hate Writing? Try HWT’s Double-Lined Paper.

If your child is hypermobile, you will need my newest e-book, out on Amazon right now!

The JointSmart Child:  Living and Thriving With Hypermobility Volume Two:  The School Years, is designed to address the challenges and needs of the school-aged child 6-12.  It has plenty of add-ons in the appendix to help you at home and at school. Learn how to pick the right chair, the right spoon, the right desk and even the right bike!  It gives you ideas to build ADL skills like dressing and independent bathing, and ways to build your confidence when speaking to doctors and teachers!

My earlier book, The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years, is also available on Amazon and at  Your Therapy Source.  It addresses development from birth to age 5.  It provides parents with all the ADL strategies to build independence AND safety, plus ways to teach your family    and babysitters how to work with your child more effectively.  Parents start feeling empowered, not overwhelmed, right away!

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Is this recess in your house during the COVID crisis?

How Using Dr. Karp’s Fast Food Rule Transforms Kids With Special Needs

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Yes, I said the word transform.  I know that hyperbole isn’t always appropriate when you are a therapist (we try to hedge our bets with predictions), but I am willing to go out on a limb in this instance and say that learning this single Happiest Toddler on the Block technique will make a difference with any child with special needs that functions with over a 12-15 month cognitive level.  Will it work with older children?  Absolutely.  Done right, it will also work on spouses and co-workers!

What is the Fast Food Rule?  You can read more about it here Help Your Child Develop Self-Regulation With Happiest Toddler On The Block but the simplest way to explain it is that when you have an upset person, they get to express themselves first, then the adult paraphrases the upset person’s expression with about 1/3 of the emotion that was used.  The paraphrasing is done at the level of comprehension of the upset person.  This means that someone who has a very low language level and is very upset may only hear “You say NO NO NO”.  Remember that any degree of agitation immediately lowers language comprehension IN EVERYONE.  Even you.

That’s it.  The phrase may have to be repeated a few times until the adult observes signs that the upset person’s agitation is decreasing (not necessarily over).  What are those signs?  A decrease in screaming volume or intensity, more eye contact, stillness of the body, turning to the adult rather than turning away, etc.  If the problem isn’t clear, altering the phrase is OK.  No harm done if you get it wrong; try again to state what their problem is.

ONLY WHEN THE UPSET PERSON HAS DECREASED THEIR AGITATION IS IT PERMISSIBLE TO OFFER A SOLUTION, OR EVEN CONSOLATION.

Why?  Because until the upset person REGISTERS that the adult understands the nature and the degree of stress, they will continue to protest to make their point.  It doesn’t matter if the point is pointless.  All the better.  Being understood is more important than being corrected.  Always.

Because young children’s brains are immature, their agitation may start up again after the problem is solved.  This is neurological, not psychological.  Rinse and repeat the FFR, and come out on the other side calmer.

Why does this transform the life of a special needs child?

Kids with special needs often need to be more regulated than the average child.  They can be unsteady, difficult to understand even when calm, have medical issues that get worse when they are agitated, and fatigue rapidly on a good day.  Being upset makes safety, endurance, sensitivity and sensory seeking worse.  Sometimes much worse.

If your child or your client has any of these issues (and I have yet to work with a child with special needs that doesn’t have ONE or more of them), then you need to learn the FFR today and use it consistently.

  • Kids with cerebral palsy can move with better safety awareness and expend less energy.
  • Kids with hyper mobility are also safer, less fatigued and can focus on movement quality.
  • Children with sensory processing issues are more modulated, less aversive or sensory seeking.
  • Kids with ASD do less self-stimulation and have less aggressive behaviors.

 

The biggest obstacle for me?  Fear of using Dr. Karp’s Toddler- Ese language strategy, which sounds infantile to the ears of an adult, because I thought that I sounded like an idiot in front of parents (who were paying me a lot of money to treat their child).  It turns out that not being able to calm a child makes me look much more like an idiot, and effectively getting a child calm and focused makes me look like a skilled professional.

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How To Correctly Reposition Your Child’s Legs When They “W-Sit”

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Hypermobile kids, kids with low muscle tone, and kids with sensory processing issues are champion “W-sitters”.  What’s that?  If your child sits with their thighs rotated inward, knees bent, and their feet rotated so their toes point outward, you have a W-sitter.   This sitting pattern isn’t abnormal if it is only one of many positions your child uses while playing on the floor.  It really isn’t.  But if it is the ONLY  way they like to sit, the only way they are able to sit without falling over, or the only way they are comfortable sitting on the floor, you may have a problem.

What kind of problems?

Persistent W-sitting can tighten hip and leg muscles to the point at which walking is negatively affected.  It also overstretches and discourages the development of the muscles needed for good walking and postural control.  It can loosen important hip and knee ligaments that are also essential for walking.  W-sitting inhibits active trunk muscle activation (that core thing again!).  We all know that having a weak core is a problem for good quality movement.  And finally…poor gait quality is a safety issue.  More falls, more tripping, more leaning on things and people.  Read Safety Awareness With Your Hypermobile Child? Its Not a Big Thing, Its the Biggest Thing for a deeper dive into safety awareness.

There is a sensory impact as well.

What isn’t always so obvious is that having a weak core and only using a sitting position that locks the lower body into a collapsed position tells a sensory-sensitive kid that their brain is telling the truth; they are vulnerable and it is not that easy or safe to move.  This inhibits movement exploration and opportunities to build balance, strength, etc.

So….What is the best way to reposition your child’s legs?

  1. Don’t pull their feet out and around.  If your kid has issues such as hypermobility, you may be contributing to more joint problems if you place force on delicate tissue.
  2. You can demonstrate alternate sitting patterns and see if they will copy your position.  This requires the language, cognitive and motor skills to do so, and the willingness to comply.  Young children and special needs kids may not be able to follow your directions.  Some parents tell their child “Legs out” or “Fix your feet” and they slowly learn what that means.
  3. Try practicing regularly and rewarding other sitting patterns.  Praise will work for some kids but not all kids.  You know if you have a child that will take the bait.
  4. Tilt their trunk to one side, and wait for their brain to elicit a “righting reaction”; kicking the opposite leg out and forward.  Repeat on the other side.  A child with CP may not be able to overcome their spasticity to perform this, but you certainly can try it with any child.  If your child fights you on this, tip them to the side faster so that the reflexive response happens before they realize it, and use all your Happiest Toddler techniques Use The Fast Food Rule For Better Attunement With Your Child to decrease the oppositional behavior.
  5. Think of other more dynamic positions for play.  Read Three Ways To Reduce W-Sitting (And Why It Matters)

 

Looking for more help with your hypermobile child?

I wrote an e-book for you!  The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years is finally available!  It helps parents understand how hypermobility affects behavior, safety, attention and learning.  Filled with practical strategies, this book gives parents the confidence to pick out the best high chairs, trikes, desks, and even pajamas to build their child’s safety and independence.  Read more, and see a short preview of chapter three, here:The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today!

 It is available on Amazon as a read-only download or on Your Therapy Source as a printable and clickable download.

Why Is The Wilbarger Protocol So Hard To Get Right?

 

michael-mims-134037-unsplashThe Wilbarger Protocol has been a staple of therapeutic treatment of sensory processing disorder for decades.  I will reveal my age, and admit that I learned directly from Pat Wilbarger.  She was an amazing teacher and a highly skilled clinician to see in action.  But I have lost count of the number of times parents have shown me how they have been instructed to administer deep pressure brushing and joint compression, and I had to decide exactly how to respond in a professional manner.  My initial internal reaction is often something akin to “STOP!”

So many parents have been incorrectly taught.  They are wondering why this technique hasn’t worked very well for their child.  Internet-savvy parents have consulted “Dr. Google” and heard both positive and critical remarks about the Wilbarger Protocol from other parents.  They are discouraged; concerned that their child is too impaired for it to work, or they are just not coordinated enough to be successful.

Well, I can tell them that the Wilbarger Protocol won’t work well if you don’t do it right.  And you won’t do it right if you weren’t shown correctly.  I suspect that, like a child’s game of “telephone”, their former therapist learned the method from her supervisor, and her supervisor learned the technique from HER boss or teacher.  And THAT therapist learned from her clinical director.  On and on, until there is no understanding of the concepts that form the basis for the technique, such as Gate Theory, or that Pat left the cranial compressions behind in the early to mid-90’s due to the risk of cervical injury.

This technique isn’t easy to do on toddlers or children with ASD.  Being comfortable with  manual treatment helps.  Understanding what not to do helps.  Knowing how to create a receptive state in a special needs child helps.  It takes a level of confidence, experience, and the ability to understand how to adapt it to the specific client without losing the benefit we are seeking:  neuromodulation.  It is possible to do it wrong and unfortunately increase sensory sensitivity or put a child into overarousal.  It is also possible to create joint or tissue damage (likely small, but still possible) with too-vigorous force.

Pat used to have her teaching assistants assess every participant in her training courses to ensure that therapists left knowing what to do and what not to do.  She couldn’t control what happened in anyone’s clinic or school.  If therapists or parents find that they aren’t getting the desired results from this treatment technique, I would encourage them to do some research and find older therapists that may have had direct contact with the inventor of this protocol, or at least a therapist that learned from someone that had the good fortune to learn directly from Pat Wilbarger.

Looking for more information about the Wilbarger Protocol?  Read Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome? for some methods to adapt this brilliant technique for children with connective tissue disorders.

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For Kids Who Don’t Know They Need to “Go”? Tell Them to Stand Up

 

photo-1453342664588-b702c83fc822For 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!

Looking for more information on toilet training?  Well, I wrote the (e) book!  The Practical Guide To Toilet Training Your Child With Low Muscle Tone gives you readiness checklists and ways to make readiness actually happen.  It has strategies you can use today to start making progress, regardless of your child’s level of communication and mobility.  Learn what occupational therapists know about how to teach this essential skill!  It is available on my website tranquil babies, on Amazon and on a terrific site for therapists and parents Your Therapy Source.  Read more about my unique book:The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

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Halloween is Coming: For Sensory Sensitive Children, It’s No Celebration

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I wonder what the little girl with the sparkler is really thinking?

I love Halloween, but not everyone does.  Kids with sensory sensitivity top THAT list!  The strange transformation of their classrooms, homes and yards aren’t exciting; they are disorienting.  The masks and loose costumes?  Pure Hell.  But at least here in America, it often seems like it is almost unpatriotic to shun this holiday unless you have a religious objection.  What can you do?

I am re-blogging this post since I think it is worth another look: Have More Halloween Fun When Kids Don’t or Can’t Trick-Or-Treat , and because even if you DO take your child out for treats, the ideas could help them handle things more easily.

In this climate of diversity challenge, I sincerely hope that there is room for all of the people, young and old, who don’t really have fun with Halloween in it’s traditional forms.  I would like to think that holidays could be what you make them.

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Just because the squash on the left aren’t orange, that shouldn’t mean they aren’t great symbols of the season!

Spatial Awareness and Sound: “Hearing” The Space Around You

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Just floating along in a big ocean……..

I hear a lot about kids who aren’t comfortable in big spaces: cafeterias, churches, gyms. Many parents, and even some therapists, attribute it to lack of familiarity: these are places they use inconsistently and are filled with more strangers.  Or they mention noise intolerance:  to music, to shouting, and to sounds like balls bouncing or people clapping.

But how about spatial issues?  We use our hearing to know where we are in a space, and to monitor our position in relation to people and objects as we move through space.  Kids who are poor at orientation to sound (I hear it, and I know where it is coming from) are usually also fair to poor at discriminating sound (I know what that sound is like and what it is or could be).  They may have a diagnosable hearing issue, or they may have a processing issue with no organ limitation.  Or they have both.

As sounds bounce off surfaces, we hear them and determine, like RADAR, how close we are to that surface.  We might turn our heads slightly, but we can hear in both ears, giving us stereo comparisons that tell us about what is behind us, above us and even below us.

In large spaces, sounds are “swallowed up” and give us less information.  This is part of the design of gothic cathedrals; you have a different sense inside them, a sense of being a bit “lost”, of how small you are in the face of the almighty. Not just luck.  Our ancestors understood the effect of altering spatial awareness on our sense of safety and stability.  But for people with spatial issues, they feel uncomfortably lost, very off kilter in environments that make them struggle to get a sense of their position in these types of locations.  For kids with poor sensory processing, it can happen in a grocery store or a new classroom.

What other sense is involved in spatial awareness?  Vision.  Vision is only helpful for about the 180 degrees in front of us, and not all of that vision is acute.  Our peripheral vision is fuzzy but still gives us some information about things going on to our extreme right and left.

The kids with poor auditory skills will use their vision excessively, and the kids with poor vision will try to use their auditory skills to shore up what they can’t see.  What does this look like?  Kids who are turning their heads constantly as they move, trying to get a sense of their location as they move, when their auditory system should be telling them about the distance between them and the boundaries of the room and it’s contents.  Kids who seem to hear everything, and yet not your voice telling them not to step on their brother’s LEGO car, which they don’t seem to see on the floor.

Poor spatial awareness often makes kids anxious.  This can sometimes be interpreted as a psychological issue, but CBT and drugs will never make it better.  That is a hint that perhaps it is a sensory issue.  Spatial issues can also make kids rigid about where they will go.  They may refuse unfamiliar parks, pools, playgrounds and new classrooms.

What can you do to help kids?  Work on auditory and visual skills, and always use vestibular and proprioceptive input as modulators and regulators.  I especially like the Therapeutic Listening Spatial series.   I am using the “Space” and “Body n’ Space”Quikshifts successfully Quickshifts: A Simple, Successful, and Easy to Use Treatment For Processing, Attention and Postural Activation with so much less hassle than the modulated music; they are downloadable too!

Spatial skills are important for kids to function in school, home and the community, and they can be improved!

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Teaching Safety Awareness To Special Needs Toddlers

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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?  

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.

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Have a Child With Low Tone or a Hypermobile Baby? Pay More Attention to How You Pick Your Little One Up

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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, how you 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.

Still concerned about safety?  Read Teaching Safety Awareness To Special Needs Toddlers  and  Is Your Hypermobile Child Frequently In An Awkward Position? No, She Really DOESN’T Feel Any Pain From Sitting That Way to learn more methods to build independence without injury.

 

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Why Pediatric Occupational Therapists Need The Happiest Toddler On The Block Techniques: Neurobiological Regulation

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Pediatric occupational therapists are usually all-in when it comes to using physical methods to help children achieve affective modulation.  We use the Wilbarger Protocol, Astronaut Training, Therapeutic Listening, and more.  But are we using Dr. Harvey Karp’s Happiest Toddler on the Block techniques?  Not so much.  All that talking seems like something a teacher or psychologist should do.  Folks, it’s time to climb off that platform swing and look at all of the ways children develop state regulation.  Early development is the time when children experience attunement with caregivers and create secure attachment.  But this is a learning process that grows over time and can be damaged by events and by brain-based issues such as ASD.  The Happiest Toddler on the Block techniques aren’t billed as such, but they are the best methods to create attunement and attachment while teaching self-regulation skills that I have found.  Combined with sensory-based treatment, progress can be amazing!

Research has told us that the way we interact with children and the way they feel has direct effects on neurotransmitters and the development of autonomic reactivity.  If you don’t believe me, check out Stephen Porges’ work on the ventral vagal component of the autonomic nervous system.

When we use The Fast Food Rule, Toddler-Ese and Patience Stretching ( Use The Fast Food Rule to Help ASD Toddlers Handle Change and Stretch Your Toddler’s Patience, Starting Today! ) to get a child focused, calm, listening, and recognizing that we “get them” even if we don’t agree with their toddler demands, we shift more than behavior.  We shift their neurophysiological responses that can become learned pathways of responding to stressors of all kinds.  We are using our social interactions to create neurobiological regulation.  I believe that the use of Happiest Toddler techniques can make a significant neurophysical change in a young child even before we put them on a swing.  I am going to go out (further) on a limb and say that if our interactions aren’t informed by understanding attunement and engagement, our sensory-based treatment might be seriously impaired.

Long story short:  if you aren’t using effective methods of developing social-emotional attunement and engagement with young children, your treatment isn’t taking advantage of what we now know about how all children learn self-regulation.  And if the child you treat has ASD, SPD, trauma from medical treatment, etc…..you know how important it is to use every method available to build the brain’s ability to respond and self-regulate.

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Improving Daily Life Skills for Kids With Special Needs

 

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Therapro, the terrific source for a lot of handy therapy equipment and especially for items that help kids with sensory processing issues, has posted another piece from me on ADLs.  Take a look: What Helps Special Needs Kids Tolerate Grooming and Hygiene?

“Activities of Daily Living” don’t have the cache’ of kineseotaping or therapeutic listening, but helping families improve the little things in life is something I haven’t ignored.  The basics of life are still the basics, and when they are a struggle, life gets harder.  Every single day.

Sometimes using SI techniques like the Wilbarger Protocol Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome? makes self-care activities better, but sometimes you need a targeted approach.  This post describes some of my best strategies to make face-washing, tooth-brushing, dressing and bathing easier for kids to tolerate and they also help them to become independent at these important skills.  After all, one of the best techniques to reduce defensiveness/aversion is to have a child do the task independently.  They can control the pace, the amount of force and the timing.  And they are empowered.  So many kids with special needs develop the impression that they don’t have the ability to do things for themselves.

So check out my post on Therapro, and then go shopping for some of their terrific materials for your child or for your therapy practice!

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The view north from West Point.  Welcome spring!

What Helps Sensitive Kids Handle Haircuts?

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Depending on your child’s age and issues, getting a haircut can be anything from a chore to a dreaded event that you put off, and then put it off a bit more.  So many kids fear them:  kids with ASD, kids with sensory issues, children that have had multiple hospitalizations or procedures, children with anxiety disorders.   I have been asked by parents of children well into grade school to help them with the problem of getting their child to the barber or hairdresser without a major fight.  My strategies are informed by my training as a pediatric OTR and as a Happiest Baby on the Block educator.

My approach to improving a child’s tolerance for a haircut is based on three goals: reduce the novelty of the experience, reduce the sensory impact of the haircut, and build their overall coping strategies based on their developmental level.

  1. You can borrow techniques from “exposure therapy” to make the experience of getting a haircut more familiar.  The very first step could be making combing or brushing their hair a non-event.  Explore what tool is the most comfortable for your child, and gradually introduce combs and even hair clippers.  Let them turn the clippers on and off ( establish safety rules first) and let them hear the clippers both far away and close to their ears.  Let them comb their hair first, then allow you to do so.  Washing their hair in the bath is another experience that you can use for pretending that you are giving them a haircut.  You can also get a bit wet and allow  them to pretend to cut your hair.  I have safety scissors that don’t cut anything but paper  Lakeshore Scissors for Toddlers That Only Cut the Paper, Not the Toddler  that work very well for this experience.  Expand grooming so that it can happen at different times of the day and in different locations in your home.  It needs to become as much of a non-issue as possible at home before a child is truly comfortable in the hair salon.
  2.  Remember that the entire experience of receiving a haircut has strong sensory components:  the salon and the sight, sound and smell of it’s other staff and customers, the tools used to cut hair, the feel of the chair and the drapes on your child.  They can all be contributors to agitation and aversion.  How can these be minimized?  Early appointments might be less crowded, there may be ways to apply water or lotions to reduce the experience of being sprayed, or children can be actively involved in saying that they are ready rather than feel attacked when they don’t expect touch.  Some kids just to be told before the event that their hair will be sprayed, or they need to feel in control of the timing.  Your child may seem too old to sit on your lap, but it could help them stay calm.  Ask if this is something they would like.  Your hairdresser is interested in doing a good job without a lot of drama.  Most of them will work with you.
  3. Many of the kids I see that struggle with haircuts also struggle handling frustration and anticipatory anxiety in general.  They are used to big dramatic exchanges when asked to do the things that are expected of them that they CAN tolerate.  These kids have often spent years developing a dance of refusal and opposition that they are now stuck in with their parents.  In my sessions, they quickly learn that I don’t engage this way; I am a no-drama girl.  I set limits and consequences, and I provide options so they feel they are working with me, not against me.  I use Dr. Harvey Karp’s Fast Food Rule and use all of his “Feed The Meter” strategies Turn Around Toddler Defiance Using “Feed the Meter” Strategies to build a sense of compassion and communication.  Both of these Happiest Toddler strategies work well with older children because anyone that is upset is thinking and behaving at a lower developmental level.  My best strategy is simple:  I stop a challenging task before a child has the chance to bail.  I may introduce another task that is similar and still offers challenge.  Stopping isn’t always ending the overall challenge.   The child’s experience is that they don’t have to fight to get a break, as for support or have adjustments made.  I am now their partner in learning to handle haircuts, dressing or nail cutting, not an authority making demands.
  4. Try not to minimize their distress, even if you can’t see why they feel that way.  In Why Telling Your Toddler “It’s OK” Doesn’t Work (And What To Do Instead)  , I wrote about how important it is to actively validate a child’s perspective.  with children that have sensory issues, this is huge, absolutely huge.

It is my belief that if you can help a child handle the daily challenges of their life with compassion, respect and skill development, that child will trust that you can help them with the other events in life that make them frightened or overwhelmed.  They have a new sense of how to manage their behavior, and believe that adults are resources for learning and partners in growth.

Looking for ideas on nail trimming or dressing as well? Read Why Cutting Nails Is Such a Challenge for Autistic and Sensory Kids and Dressing Without Tears: Sensory-Sensitive Strategies That Work

And don’t forget that my e-book on toilet training is out there to help you with this challenging skill:  The Practical Guide To Toilet Training Your Child With Low Muscle Tone isn’t just for kids with low tone; kids with ASD and sensory processing issues can use these strategies to build skills that help them make real progress quickly! You can buy my e-book on my website Tranquil Babies, at Your Therapy Source (a terrific site for OT workbooks and other products), and on Amazon.

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Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome?

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My posts on proprioception and hypermobility have been popular lately, leading me to think that parents (and therapists) want more information on the sensory basis for their children’s struggles, and that often their treatments don’t include addressing their sensory processing issues.

The Ehles-Danlos Syndromes (yes, there are more variants than just vascular and hypermobile!) are somewhat rare connective tissue disorders that can create generalized joint hypermobility.   Kids with EDS are often diagnosed as having a coordination disorder before they get the EDS diagnosis, and their families describe them as “clumsy” or even “lazy”.  I see them as having sensory processing issues as well as neuromuscular and orthopedic issues.   Take a look at Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior and Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children for more on this subject.  If you are an OT or a PT and you are thinking of using K-tape, read my post Can You K-Tape Kids With Ehlers-Danlos and Other Connective Tissue Disorders? before you begin.  You may change your approach and expand your thinking about taping after you read it!

There are some caveats in using techniques from sensory integration protocols with this population.  This doesn’t mean “no”; it means think about it first.  The use of the Wilbarger Protocol is one that requires some thought before initiating with EDS kids.

The Wilbarger Protocol:

For those of you who are unfamiliar with the Wilbarger Protocol, it is a common treatment approach for children with sensory sensitivity, sensory discrimination issues and poor sensory modulation.  Created by Patricia Wilbarger, a terrifically talented OTR  who directly trained me as a young therapist, it is a neurologically-informed treatment that can be used quickly for both immediate improvement in sensory processing and it can make long-term alterations in the brain’s ability to use sensory input for movement and state control.  The Wilbarger Protocol involves skin brushing and joint compression in a carefully administered method that uses the “gate theory” of sensory processing to assist the nervous system in regulating awareness and arousal.

There have been other protocols for regulation developed over the years, and adaptations to the Wilbarger Protocol have occurred since it’s creation.  But daily and repeated use of brushing the skin and use of joint compression to deliver deep pressure input (to inhibit light touch registration and enhance proprioceptive discrimination) are the cornerstones of treatment delivery.

Adapting the Protocol for Ehlers-Danlos Syndrome

Understanding the systemic nature of EDS is important.  Often therapists are unaware of the precautions since the child doesn’t have a formal diagnosis Could Your Pediatric Therapy Patient Have a Heritable Disorder of Connective Tissue?.  Since the Wilbarger Protocol was not created to treat EDS, I am recommending that therapists and parents consider adapting it to protect the joints and skin of children with EDS while still gaining benefit from this technique:

  • Reconsider using the brush.  Although the dual-treatment of brushing and joint compression makes this technique a powerful approach, kids with EDS often have skin that is more fragile than average.  It can bruise and tear more easily, especially with the vascular or classic EDS subtypes.  Small children will be brushed repeatedly over the same skin area, increasing the risk of shear, abrasion and bruising.  Children (and adults) with EDS will have skin reactions far in excess of the amount of pressure applied.  This is related to the assumption that the connective tissue that makes up skin and blood vessels is either weaker or thinner than typical children.  My advice: go with the joint compression component alone, and see if you get a clinically valid result without the risk of skin damage.
  • Make sure that you are well-trained in the positioning and administration of joint compression.  I have taken joint mobilization training courses, as well as having dual licenses in massage therapy and occupational therapy.  Being able to feel correct joint position and alignment is absolutely key when children have loose joints, so use this technique with care.  Avoid painful joints and limit repetition to the shortest amount needed to see a clinically meaningful response.
  •  Train parents extremely well before recommending home use.  Most parents can learn this technique with the right explanation and some practice.   If a parent seems unable to perform joint compression correctly, reconsider the use of a home program.  This has only happened once in my career.  A mom was truly unable to perceive the amount of force she was using.  She admitted that this had been an issue for her since childhood, and I suspected that she had her own sensory processing issues.  We moved on to other treatment choices.  There is never a reason to stick with a treatment that causes a risk to a child or makes a parent feel like they are a failure.  Ever.  To read more about the Wilbarger Protocol, read Why Is The Wilbarger Protocol So Hard To Get Right?

The true skill of a therapist is the ability to offer the just-right challenge to each child, based on a therapist’s observations, assessment and knowledge base.  I believe that there are many kids with EDS that could benefit from the Wilbarger Protocol when it is effectively adapted to their needs.

 

Looking for more information?

I wrote 2 books to help parents and new therapists address hypermobility in  children!

The JointSmart Child:  Living and Thriving With Hypermobility Volume One: The Early Years and Volume Two:  The School Years are  guides that tels you how to pick the right seating, the right clothing, the right utensils and how to adapt your home for safety without making it look like a therapy clinic!  These unique books teach parents how to help their children build independence in all the basic self-care and school skills they need.  There are chapters that explain how to communicate with babysitters, family members and even doctors.  Good communication makes parents feel empowered and confident.

They are available on Amazon as read-only downloads and on Your Therapy Source as  printable and click-able downloads.

Read more here:    A Practical Guide to Helping the Hypermobile School-Age Child Succeedand The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today!

 

Need more than blog posts or a book?  Visit my website tranquil babies and purchase a phone/video session to discuss your concerns and learn about what occupational therapy has to offer your child!  Are you a new therapist, or new to pediatrics?  Let me help you build your skill set and amaze your clients with a mentoring session.

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Are YOU A Sensory Sensitive Parent?

If you fill out the Infant/Toddler Sensory Profile for your child and see yourself on the page too, don’t be too surprised. Actually, you might feel relieved, and even a bit excited. Because now you know that you aren’t “crazy” or “weird” or even “difficult”. If you have some sensory processing issues of your own, you can learn how to address them and improve your situation while you are helping your child learn to build her own sensory processing skills.

About one in four of the families I work with will admit that at least one parent has or had difficulties with sensory processing at one time. They rarely offer this information at the evaluation. Only with the reframing that occurs as I explain the process of therapy for sensory processing disorder for their child do I hear about how they or their partner only eats certain textures of food or cannot tolerate wearing clothes with long sleeves.

Now, that revelation is just the beginning of a conversation about themselves, because one or two issues with sensory experiences doesn’t indicate a sensory processing problem. Eventually I will hear about all the small and sundry things that this person avoids or alters in order to manage life as a functioning adult. Then it becomes clear to both of us: the story they told themselves about their preferences or personality quirks is likely to be based in sensory processing struggles, not psychology.

Older children and adults who have never had treatment are told (or tell themselves) that they are difficult, rigid, controlling, and too sensitive. This sounds very demeaning, but in fact it is often not intended to be hurtful. Behavior is often seen as only occurring for cognitive or emotional reasons. You have a feeling, and the reason is how you are thinking or feeling.  But behavior is now understood to have many drivers, and it isn’t always cognitive or emotional.

The truth is that sensory processing creates the impetus for many of our behaviors in childhood and beyond. Not seeing the effect of the body on behavior is a huge impediment to addressing issues effectively.  Yes, people who are overwhelmed with sensory input can and do try to control their environment and the people in it. It looks like they are rigid and difficult. But it is not the same as being manipulative and aggressive due to interpersonal or emotional events.

Avoiding touch or movement can also appear to be relational when it is a sensory-based issue. The relational problems begin when the person or other people interpret the behavior as indicating something else, such as shyness or social aversion. How you define yourself and how others define you is like choosing which road to travel. It means that you may not see all the reasons for behavior and all the possibilities for change.

People who have experienced trauma in childhood OR adulthood appear to be more likely to exhibit sensory processing issues.  There are some researchers that are very interested in sensory processing and trauma, such as Ulrich Lanius, but the treatment tends to be psychodynamic or EMDR, not the types of treatments that OTs use.  That is a shame, because we have a lot of helpful, effective, and affordable treatment strategies that work WITH psychotherapy, not against it.

Adults rarely receive effective treatment for long-standing sensory processing issues. Sometimes they have come up with their own solutions, such as doing yoga to receive deep pressure input. They may tell their friends that they can’t digest certain foods, when in fact just seeing some foods makes them nauseous. I am more than happy to work with parents and help them creatively explore solutions for themselves when it is indicated. I have even treated adults formally as an OT from time to time. When parents see themselves more clearly as they support their child, both parties can address sensory processing issues more effectively.

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!