Tag Archives: sensory processing

Kids With Low Muscle Tone: The Hidden Problems With Strollers

jeremy-paige-146338-unsplashWhether you live in the city or the ‘burbs, you almost certainly use a stroller for your infant or toddler.  Even parents who use slings or carriers for “baby wearing”  find themselves needing a stroller at some point.  Why are strollers a problem for children with low muscle tone?  The answer is simple:  sling seats and ineffective safety straps.

Strollers, especially the umbrella strollers that fold up into slim spaces, have a sling seat, not a flat and firm seat.  Like a hammock or a folding lawn chair, these seats won’t give a child a solid surface that activates their trunk.  When a child sits in a sling seat, they have to work harder to hold their body in a centered and stable position.

Why is that important when you are transporting your child in a stroller?  Because without a stable and active core, your child will have to work harder to speak and look around.  A child with low muscle tone or hypermobility that is in a sling seat may be inclined to be less active and involved, even fatigued from all that work to stay stable.  It could appear that they are shy or uninterested, but they might be at a physical disadvantage instead.  A collapsed posture also encourages compensations like tilting the head and rounding the back.  Will it cause torticollis or scoliosis?  Probably not, but it is certainly going to encourage a child to fall into those asymmetrical patterns.  Kids with low tone don’t need any help to learn bad habits of movement and positioning.

Safety strap location and use in many strollers is less than optimal.  There are usually hip and chest straps on a stroller.  Some parents opt to keep them loose or not use them at all, thinking that kids are being unnecessarily restrained.  I think this is a mistake for kids with low tone.

Good support at the hips is essential when a child with low tone sits in a sling seat.  It is their best chance to be given some support.  Chest straps are often not adjusted as the child grows.  I see two patterns:  Straps too low for an older child, and straps too high for a younger one.  The latter issue usually occurs when parents never adjusted the straps after purchase.  They left them in the position they were in from the factory.  Make sure that the straps are tight enough to give support but not so tight that a child is unable to move at all.  A child that is used to sliding forward may complain about having their hips secured so that they can’t slouch, but they will get used to it.

You may have to reposition a child with low tone from time to time you go about your errands or adventures.  They often don’t have the strength or body awareness to do so themselves.  They could be in a very awkward position and not complain at all.  Check their sitting position as you stroll along.  Good positioning isn’t “one and done” with these kids, but doing it right will benefit them while they are in the stroller, and also when they get out!

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Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior

 

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There is nothing worse than using a scientific study that correlates two variables and assuming causation. Translation:  If behaviors typical of disorder “A” are seen in a lot of people with problem “B”, we cannot assume that “A” is the cause of their behavior.   But we do it all the time.  People who love coffee adore studies that say coffee drinkers seem to live longer.  People who hate to exercise are validated by reports that find the number of heart attacks after exercise “is increasing”.

When it comes to labeling children’s behavior, we should take a couple of big steps back with our erroneous reasoning.  And when the label is ADHD, take three more.  Not because ADHD isn’t a big issue for families.  The struggles of kids, parents and educators shouldn’t be minimized.  We should be cautious with labels when two situations occur:  very young ages and multiple diagnoses that are determined largely by clinical observation, not testing.  Seeing ADHD in a child with hypermobility is one of those situations.

Hypermobility without functional problems is very common in young children.  Super-bendy kids that walk, run, hit a ball and write well aren’t struggling.  But if you have a child that cannot meet developmental milestones or has pain and poor endurance, that is  a problem with real-life consequences.  Many of them are behavioral consequences.  For more on this subject, take look at How Hypermobility Affects Self-Image, Behavior and Regulation in Children.

Yes, I said it.  Hypermobility is a motor problem that has a behavioral component.  I don’t know why so little has been written on this subject, but here it is:  hypermobile kids are more likely to fidget while sitting, more likely to get up out of their chairs, but also more likely to stay slumped on a couch.  They are more likely to jump from activity to activity, and more likely to refuse to engage in activities than their peers.  They drape themselves on furniture and people at times.

Why?  Hypermobility reduces a child’s ability to perceive body position and degree of movement, AKA proprioception and kinesthesia.  It also causes muscles to work harder to stabilize joints around a muscle, including postural muscles.  These muscles are working even when kids are asleep, so don’t think that a good rest restores these kids the same way another child gets a charge from a sit-down.

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When a hypermobile child starts to move, the brain receives more sensory input from the body, including joints, skin and muscles.  This charges up a sensory system that was virtually starving for information.  Movement from fidgeting and movement by running around the house are solutions to a child’s sense that they need something to boost their system.  But fatigue can set in very quickly, taking a moving child right back to the couch more quickly than her peers.  It looks to adults like she couldn’t possibly be tired so soon.  If you had to contract more muscles harder and longer to achieve movement, you’d be tired too!  Kids  develop a sense of self and rigid habits just like adults, so these “solutions” get woven into their sense of who they are.  And this happens at earlier ages than you might think.  Take a look at Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children to understand a bit more about this experience for hypermobile kids.

Then there is pain.  Some hypermobile kids experience pain from small and large injuries.  They are more likely to be bruised,  more likely to fall and bump into things, and more likely to report what pediatricians may call “growing pains”.  Sometimes the pain is the pull on weak ligaments and tight muscles as bones grow, but sometimes it isn’t.  Soreness and pain lead some kids right to the couch.  After a while, a child may not even complain, especially if the discomfort doesn’t end.  Imagine having a lingering headache for days.  You just go on with life.  These kids are often called lazy, when in truth they are sore and exhausted after activities that don’t even register as tiring for other children their age.

How can you tell the difference between behaviors from ADHD and those related to hypermobiilty?  I think I may have an idea.

When a hypermobile child is given effective and consistent postural support, is allowed to rest before becoming exhausted (even if they say they are fine), and any pain issues are fully addressed, only then can you assess for attentional problems.  Occupational therapists with both physical medicine and sensory processing training are skilled at developing programs for postural control and energy conservation, as well as adapting activities for improved functioning.  They are capable of discussing pain symptoms with pediatricians and other health professionals.

I think that many children are being criticized for being lazy or unmotivated, and diagnosed as lacking attentional skills when the real cause of their behaviors is right under our noses.  It is time to give these kids a chance to escape a label they may not have.

Looking for more posts on hypermobility?  Check out Should Hypermobile Kids Sit On Therapy Balls For Schoolwork? , Hypermobile Kids, Sleep, And The Hidden Problem With Blankets  and Should Your Hypermobile Child Play Sports? for useful strategies to manage  hypermobility and support both physical health and functional skills.

How To Teach Your Child To Wipe “Back There”

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Potty training is a process.  For most kids, the final frontier is managing bowel movements.  Compared to learning to pee into the toilet, little kids are often more stressed by bowel movements and have less opportunities to practice.  Constipation or just the discomfort of normal elimination can make them wary, sometimes enough to convince some children that this is a process better done in a diaper.  In comparison, urination isn’t an uncomfortable experience for healthy children.  Bowel movements sometimes happen only a few times a week, instead of the multiple times a child needs to urinate per day.  Less practice and fewer opportunities for rewards (even if your reward is warm praise) make bowel training harder.

So when they finally make the leap and manage to do #2 in the toilet, a lot of parents decide to delay teaching their child how to wipe themselves.  After all, wiping can be messy and it has to be done well enough for good hygiene.  Here are my top suggestions to make “making” a complete success:

  1. Teaching should still be part of your narrative while you are the one doing the wiping.  In my book, The Practical Guide To Toilet Training Your Child With Low Tone, I teach parents how to transform daily diapering into pre-teaching.  While you are wiping, and even while you are waiting for them to finish on the toilet, your positive narrative about learning this skill doesn’t end.  You are telling your child how it’s done, in detail, as you are doing it. You convey with your words, your tone and your body language that this is a learn-able skill.
  2. Don’t forget the power of the “dry run”.  Practice with your child when he is in the bathroom, whether it is before bath time, before dressing, or during a special trip to the bathroom to practice.  Dry runs take away the mess but teach your child’s brain the motor planning needed to lean back, reach back and move that hand in the correct pattern.  The people that invented the Kandoo line of wipes have an amusing way to practice posted on their site:  spread peanut or sunflower butter on a smooth plate, and give your child some wipes or TP.  Tell him to clean the plate completely.  This is a visual and motor experience that teaches how much work it is to clean his tush well.  After this practice, your child will make a real effort, not just wave the paper around.  Brilliant!
  3. Will you have to reward him for this practice? Possibly.  It doesn’t have to be food or toys.  It could be the ability to choose tonight’s dessert for the family, or reading an extra two books at bedtime.  You decide on the reward based on your values and your child’s desires.
  4. Use good tools.  The adult-sized wet wipe is your friend.  The extra sensory information of a wet wipe versus a wad of dry paper is helpful when vision isn’t an option.  They are less likely to be dropped accidentally when clean, but having a good hold is especially important after it has been used. “Yucky”stuff  makes kids not want to hold on!  Wet wipes are more likely to wipe that little tush cleanly.  Don’t cut corners.  Allow your child to use more than one.
  5. Take turns.  Who wipes first and who bats “clean-up” (couldn’t resist that one!) is your decision.  Some children want you to make sure they are clean before they try, and some are insistent that they go first with anything.  This can change depending on mood and even time of day.  Be flexible, but don’t stand there like a foreman, ordering work but not willing to help out.  One of my favorite strategies is to always offer help, but be rather slow and inefficient.  This gives children the chance to rise to the occasion but still feel like you are always willing to support them.

 

Looking for more information on toilet training?  Take a look at my e-book, The Practical Guide To Toilet Training Your child With Low Muscle Tone to get a clear understanding of how to prepare for and execute your plan without tears on both sides.  Will it help you even if your child doesn’t have low muscle tone?  Of course!  Most of my techniques simply speed up the learning process for typically-developing children.  And who doesn’t want to make potty independence happen faster?

This e-book is available on my website tranquil babies, at Your Therapy Source (a great site for parents and therapists), and on Amazon.  Read more about my book with Amazon’s “look inside” section, or by reading The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

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

 

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

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

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

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

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

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

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

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

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

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

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

 

 

 

 

How Occupational Therapy Can Help Gifted Children (And Their Exhausted Parents!)

rockybeachGifted children have abilities that make them more sensitive to their bodies, their world and the people in it.  They notice sensations, emotional states and the interplay between the physical and the non-physical world in ways that non-gifted people do not.  Exquisite sensitivity often comes at a price for gifted children and their parents.

Think about this in the same way an electrical device cannot support additional volts of current.   A parent’s pride in her child’s amazing abilities can be overshadowed at times by the fatigue and frustration in dealing with tantrums, rigidity, sensitivity, and a child’s seemingly inexhaustible energy.  Occupational therapy can help manage the current and “keep the lights on” without power surges destroying the functioning of the computer.

Particularly in the early years, gifted children can become easily overwhelmed when their emotions, their impulses and their perceptions exceed their ability to process everything they experience.  They may feel clothing or food as intensely strong sensations.  They may want to swing for an hour, then cry when it is time to leave the playground. They might be aware of a parent’s sadness or another child’s frustration more acutely, but have no idea what is happening or what to do.  They really “get” the plight of the polar bears on the disappearing ice sheets.  After all, they can read the New York Times at 5!    They just don’t know what to do with all these feelings, thoughts, desires and sensations.

Some abilities in gifted children are advanced by years, such as reading or math.  The ability to share with a sibling?  Not advanced at all!  This “asynchronous development” can cause internal conflict and may result in more frequent and more intense outbursts, refusal to participate in school or playdates, sleep issues and more.

OT’s with a strong sensory processing background can help gifted children and their families navigate the complex sensory-motor, cognitive and emotional/social overload that happens when brainpower exceeds management capacity.  What unique skills does an OT bring to the table?  The ability to assess and implement a whole-person approach.    Talking about behavior, making a rewards chart, and cognitively understanding where all that energy comes from is simply not enough to make the days and the weeks easier for a gifted child.  The occupational therapist’s toolbox is deeper and wider, and includes physical interventions that look like play, social/emotional mastery experiences (not just talk), and sensory-based activities that support self-regulation as a child grows into their amazing abilities.  Take a look at Gifted and Struggling? Meet the Twice Exceptional Student and How OT Can Help if your child is gifted but dealing with issues such as sensory processing, ADD, learning issues or ASD.

Occupational therapists do use cognitive strategies such as the “How Does Your Engine Run?” program by Williams and  Shellenbarger.  A cognitively gifted 4 year-old may be fully capable of engaging in this useful program.  A sensory diet, one of the core concepts of most sensory processing treatment programs, can help children discharge and manage sensitivity and excitement throughout the day.  Check out Gifted Or Disordered? The Unrecognized Behavioral Traits of Young Gifted Children  for more thoughts on how the behavior of gifted kids can be misdiagnosed as a disability.  I wrote a helpful post on how to use The Happiest Toddler strategies, informed by what we know about the gifted mind, to improve your communication with your child  How To Talk So Your Gifted Child Will Listen.  Is your child misunderstood or mislabeled at school?  Gifted kids can be labeled as troublemakers instead of talented.  Read Is Your Gifted Child A “Troublemaker”?  and  How To Spot A Gifted Child In Your Preschool Class (Or Your Living Room!) for some ways to think differently about those strong opinions and the resistance to rules.

Parents that know how to help their child regulate their arousal feel empowered, not defeated, when their child becomes overwhelmed.  Children learn that their parents “get” them, and that they can turn to them for support instead of criticism.  Feeling understood and feeling capable is the bedrock of self-confidence and self-esteem.  Gifted individuals need to know that they are more than their stratospheric IQ, and this is where it begins. Take a look at Should You Tell Your Gifted Child About Their Giftedness?   to learn more about how to communicate with your child about his or her gifts.

Dr. Harvey Karp’s Happiest Toddler on the Block program is amazingly effective at teaching children how to handle the strong emotions of early childhood, and teaching parents how to support their children without crushing their spirit.  I use his incredible techniques with every gifted client I see.  Children with ASD respond, children with SPD respond, and gifted children respond.  Dr. Karp’s strategies allow children to learn how to express their feelings without judgement, and teach parents to set limits and place consequences on behavior without crushing a child’s spirit.  Isn’t that what we all want for our children?  Check out Stretch Your Toddler’s Patience, Starting Today! even if your child is not a toddler.  It turns out that Dr. Karp’s easy technique for handling demands works on impatient people at almost any age.  You just alter your presentation to fit their emotional state and communication level!

Research suggests that the way a gifted brain functions is always going to be different than the typical child.  I believe that therapy for gifted children effects change in a very similar manner to therapy for the autistic child; therapy can make daily life easier, and it can help a child learn to handle their thoughts and experiences with greater comfort and ease.  Brain function changes as it learns to adapt and make better connections, but the structure remains unique.  Occupational therapists support gifted children and their families in exactly the same way we support people in the special needs community:  without judgement or dismissing problems that arise in living.

If you are the parent of a very young gifted child, and you would like more support, take a look at some of my previous posts:Supporting The Gifted Toddler at Preschool   and Your Bossy Baby or Toddler May Be Gifted. Really. Here Are The Signs You Are Missing! You can use these strategies today to help your gifted child!

Want more personalized support?  Visit my website tranquil babies and purchase a phone consultation.  You will have a chance to ask questions and get answers that directly give you more calm and more joy in your home…today! 

Should Your Child Use A Pencil Grip?

I will be asked about pencil grips every time I teach a workshop or lecture on handwriting.  My popular post, The Pencil Grip That Strengthens Your Child’s Fingers As They Write. , partially explains when and why I would recommend the use of this excellent pencil grip with older kids.  I have a message for preschool teachers that see awkward or clumsy pencil grasp in their 4 -year-olds:  don’t use a grip until you have worked on grasp!  The reason?  The other grips will not develop better grasp, and pencil grips are too frequently lost or used improperly with young children.

Pencil grips can be a huge help for older children or children with specific muscular or neurological issues.  Kids with low muscle tone or too much joint mobility in their fingers can really benefit from their use.  Children with mild cerebral palsy and muscular dystrophy can also benefit from the use of a good grip and the correctly-sized writing tool.

For typical kids who aren’t using a tripod or quadruped grasp but are writing letters, the better choice is to get creative with crayon and marker dimensions.  Short crayon pieces, Flip crayons from Handwriting Without Tears (HWT), and writing with a tablet stylus from iCreate can strengthen muscles and increase tactile and proprioceptive awareness.  Finally, teach grasp actively.  HWT does a fabulous job in their teacher guides.  These books, especially  the pre-K book, are underutilized.  They are fantastic resources for any preschool teacher and pediatric occupational therapist.

Pencil grips can help some children, but don’t jump into a grip until you have addressed the reasons you were thinking of using a grip in the first place!

Teach Your Kindergartener How To Erase Like a Big Kid

Does it matter how a child erases their mistake?  You are probably thinking that I ran out of topics for my blog this week.  Not exactly.

I was thinking about what makes my handwriting posts different than other bloggers that publish posts on early writing skills.  I like to look at all the details when I work with struggling writers.  I search for every way I can build a child’s skills and confidence.   Knowing how to control an eraser is a simple but important skill for children in kindergarten to master, and can save a homework assignment from the trash bin.

Controlled erasing prevents removal of well-written characters.  This means more work and more time to complete an assignment.  It prevents paper destruction.  If your child struggles to write, imagine how he would feel if he accidentally tore the paper and had to start over.

Why would children struggle to control an eraser?  Kids with limited hand strength and stability often press too softly or use too much force.  Children with sensory discrimination difficulties do the same.  Kids who have difficulty focusing, are impulsive or are defiant can make the same erasing mistakes.  Finally, kids with motor or orthopedic issues can have the same difficulty controlling the eraser that they experience with their pencil.

What can you do to help?

  • Select the right eraser.  Although pencils usually come with erasers, some children do much better with a larger eraser or one that is shaped for easier grasp.  A larger eraser can also have more textured edges and even more weight, giving children more sensory input with use.  My favorite eraser is the Pentel Hi-Polymer latex-free eraser.  Super at cleanly erasing, and easy to grasp.  Beats every pencil eraser I have ever used.  Here it is:Problems With Handwriting? You Need The Best Eraser.
  • Demonstrate how to hold the eraser for control.  If a child uses a fisted grasp, they are erasing with elbow or shoulder movements.  These large movements are likely to be harder and less controlled.  Demonstrate that using a mature tripod pencil grasp will result in more control and faster erasing.
  • Make eraser practice fun.  Write awful letters, your worst products, in between good examples on a page.  Have your child erase your mistakes.  Draw mean faces and have them get rid of the “bad guys”.  Draw “coins” and see who has the most money left.  Bonus round:  have them write in the amount on the coins.  Larger number, more money!!