Tag Archives: sensory processing disorder

Why Pediatric Occupational Therapists Need The Happiest Toddler 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

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.

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 than blog posts?  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!

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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.

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!