A Great Resource for Typical and Atypical Development

I am a big proponent of educating people on movement and development.  I especially try to educate parents and other health professionals because I think, and the literature shows, that the earlier kids and parents get support for delays, the sooner they make progress.  One of the greatest resources out there that I have located is Pathways.org.  They offer handouts for development as well as videos.  Below is a direct copy of an email they sent out talking about their resources.  I wanted to take an opportunity to pass this information along so that more people are educated.

 

Pathways.org videos bring to life subtle differences lost in pictures or words

Pathways.org offers 23 FREE educational videos on our website and YouTube:

·       Topics include motor, sensory, and communication development

·       Comparisons of typical and atypical infant development

·       Videos of children’s progress in therapy sessions

·       FREE downloadable handouts for videos

PLEASE provide these FREE videos and FREE handouts to parents and health professionals

·       Help identify an early motor, communication, or sensory delay

·       Help ensure infants/children receive timely, adequate, and appropriate intervention

Pathways.org Medical Round Table is comprised of leading physicians, clinicians, nurse practitioners,

and lay advisors. These members oversee all Pathways.org projects.

Pathways.org recently presented to:

·       37 pediatric and family medicine, physician assistant, and pediatric nursing residency programs

·       More than 1000 health professionals viewed Pathways.org films and received handouts

·       As a result of presentation:

o   92% of all participants will now refer children earlier for a screening

o   99% would recommend Pathways.org presentation to their colleague

Since 1985, Pathways.org has believed in the right of all children and their parents to the leading knowledge available to maximize all children’s potential.

Getting into Sitting

Babies these days are getting really good at sitting.  The invention of the Bumbo seat has definitely helped with this (although it is a great tool for kids who need extra help with sitting to develop other skills).  Its also a lot easier to pick your baby up and sit them down.  What I am proposing, once they start to develop movement and some trunk control, is to take an extra few seconds and help them get into sitting.  By practicing transitional movements earlier, they develop their motor planning abilities, improve their coordination, and develop the strength they will need to achieve higher level motor skills.  Transitional skills such as learning how to get into sitting will also help your child further develop independent movement which promotes exploration and cognitive skills.  It allows your child a chance to initiate when they want to change their perspective from being on the ground to sitting up.  It gives them a whole new world to explore and can further increase their motivation to move and develop.  This video will show you some ways to help your baby transition from lying on their back to getting into sitting.  As you watch the trunk muscles activate you can also see how it is a great core exercise.  At the last part you see him learning how to modulate his movement so he doesn’t overshoot his target, as well as how to problem solve to accomplish the task.  Transitional movements are a great learning opportunity for your baby.  Check out Developing Sitting Balance for ideas on how to work on sitting balance.

Should I Be Concerned: Gross Motor Edition (up to 15 months)

A lot of times my friends and relatives ask me questions about their child’s gross motor development (especially if they are first time parents and have nothing to compare it to) and if they should be concerned so I decided to writie up a list of items that may be an area of concern for kiddos at 3 month intervals.  This list doesn’t necessarily mean there is a problem but it doesn’t hurt to take a look and see if some of the things you are noticing continue to be a challenge.  Many times I find that if there are some slight challenges with gross motor, the earlier the parents and the kiddo get tips on how to help develop the skills, the quicker the child catches up.  I tried to take a slightly different approach than the typical look at gross motor milestones because there is such a range in milestone acquisition that often parents aren’t sure if their child is behind or not.

General Concerns:

• Very stiff or very floppy
• Torticollis/plagiocephaly (flat spot on the head)
• Prefers standing all the time
• Lack of opportunity for independent motor exploration (time spent out of equipment/carriers/bouncies/etc)
• Profound or significant birth/medical history
• Generally still (not moving) when awake
• Persistent ATNR

Three Months:

• Difficulty lifting head on belly or on back
• Stiff legs with little to no movement on belly or on back
• Pushes back with head
• Tends to keep hands fisted with little to no arm movement on back
• Challenges with bringing hands and/or head to midline on back

Six Months:

• Items listed previously
• Back is rounded or slumped
• Unable to lift head up in sitting, supported or unsupported
• Poor head control
• Arches back and stiffens legs
• Holds arms back and up (i.e. high guard)
• Has stiff legs
• Keeps legs in a frog leg position on belly or on back
• Doesn’t like to be on their stomach
• Thrusts into extension for movement (such as rolling or when sitting)
• Not able to roll
• Doesn’t bring feet to mouth or feet to hands on back
• Doesn’t weight bear on arms when on belly
• Doesn’t tolerate or like sitting
• Unable to sit supported
• Doesn’t kick legs
• Unable to lie on side

Nine Months:

• Items listed previously
• Uses one hand predominantly
• Poor use of arms in sitting
• Difficulty crawling
• Only uses one side of the body to move
• Inability to straighten back
• Can’t/won’t take weight through legs
• Prefers lying on back rather than on belly or exploring
• Doesn’t weight bear through upper extremities
• Uses bunny hopping or butt scooting as only means of mobility
• Uses w-sitting as primary method of sitting or a wide based ring sitting
• Inability to weight shift through legs or arms
• Inability to move legs separately from each other
• Difficulty getting onto hands and knees

Twelve Months:

• Items listed previously
• Difficulty getting to stand because of stiff legs and pointed toes
• Relies on arms rather than legs to get into standing
• Sits with weight to one side
• Strongly flexed or stiffly extended arms
• Needs hands to maintain sitting
• No desire or ability to climb onto objects
• Avoids standing
• Trouble transitioning between positions (i.e. sitting to hands and knees, lying down to sitting)
• Difficulty with cruising
• Not attempting to walk with support

Fifteen Months:

• Items listed previously
• Unable to take steps independently
• Trouble maintaining standing balance
• Walks on toes

This is just a guideline for some areas that may be cause for concern and for peace of mind may be worth having a pediatric physical therapist take a look at your kiddo.
References:

Bly, L. (1994). Motor Skills Acquisition in the First Year.  San Antonio, TX: Therapy Skill Builders.

http://pathways.org/awareness/parents/new-parents/monthly-milestones/

Developing Head Control with Pull to Sit

Pulling to sit can work on a baby’s head control as well as develop their core muscles such as their abs.  When they are lying flat on their back this will be the hardest position for them to control their head and neck muscles because they have to work fully against gravity.  In order to make it a little easier for them you can start them on an angle, such as your lap with your knees bent.

When you go to help them sit up using the pull to sit method you want to make sure they engage their whole body to help with the process.  I like to do this by holding their hands and giving a light tug in order to get them to engage their arms so that they will start ‘pulling’ themselves into sit.  Also by engaging their arms and other muscles they are using what I like to call ‘overflow’ to help engage the head and neck muscles. If your baby doesn’t engage their arms to help with the pulling up I would not continue with the motion.

You can tell how their head and neck muscles are developing over time by looking at how their head lag improves.  Head lag is how long it takes them to activate their head and neck muscles to lift their head up while they are pulling to sit.  As they get stronger they can activate their muscles closer and closer to being flat on the ground.  Eventually they will be able to activate immediately and all you are doing is guiding them up into the sitting position!

Another way to help these muscles develop is to do the opposite motion.  Early on it may be easier for them to engage their muscles as you start to lower them down.  They will automatically attempt to prevent themselves from ‘collapsing’ by activating their muscles to maintain their head position.  As you slowly lower them down to the ground it will get harder for them to hold their head up against gravity and it may drop back.  Until you know how long they can hold their head up you either want to have a support (like your legs) ready prior to being flat on the ground or  have a few pillows built up.

After a few repetitions of this your child gets better at it.  They may try to anticipate what they need to do and may stiffen up their whole body in order to try to ‘help’ you but they start to get the hang out of it and their head control gets better with each repeption because their muscles get more efficient at engaging and turning on when needed.

And, you can have fun with it such as playing games of peek-a-boo, or making funny faces or silly sounds.  What a great way for you to engage face to face with your baby while working on their gross motor skills!

For some older kids who are working on head control this can be a good way to help them as well.  You can also go extra slow at various points so they have to work at maintaining their head position as well as activating their muscles.  Another skill you may want to work on is once they reach the sitting position having them be able to hold their head in midline without it dropping forward once they are upright.

What Does Low Tone Mean?

Muscle tone is the resting state of your muscles.  When a child has low muscle tone it means that they need to put a lot more energy into getting their muscles to turn on to do what they want them to do.  I often try to explain this to parents by describing that feeling when you finally get to sink into the couch or your favorite arm chair and relax and then someone calls you from the other room and you have to rev up the energy to get up.  Think about having to do that every time you move because that’s what it can be like for kiddos who have low tone.

Generally kiddos with low tone seem to be squishable because they melt right into you when you hug or hold them.  This is great for cuddling but if you are carrying a baby or kiddo around that is melting into you, it means they aren’t able to help support themselves in your arms so it can seem as if you are carrying a heavy weight around.  As their muscles get stronger they get better at activating them so that if you are carrying them, they can hold their own trunk up without having to lean on you.  Its amazing how much lighter this can make them feel!  (Another way to get the idea is if you are holding a kiddo by their hands to help them stand and they just decide to have spaghetti legs and you weren’t expecting it).

When I talk about strength being a challenge for kids with low tone I am talking about not just their ability to generate enough force to move their arm or their leg, but also their endurance and their ability to switch their muscles on and off.  These components all work together to produce movement.

I know that I talk about core strength a lot but for these kiddos its really important.  Just think if your trunk (core) was as stable as a slinky.  Do you think it would be easy to move your arms and legs, to do fine motor activities, to run and jump or even walk, to keep an upright posture in school to help with learning?  It would be challenging to do all of these things and so many more. That’s why when I work with kids with low tone I am often doing activities that will challenge the whole body but also focus on the core.  I also work to increase either how long they can do an activity (such as sitting on a ball for trunk control) or how many times they can do something (such as bridging) because this will help to increase the endurance of their muscles so they can stay working as long as they want them to.

Since it is harder to move and to activate their muscles, a lot of times they may need more practice, help and support, not to mention motivation to get moving! When they are little I do lots of tummy time to develop their butt muscles, anti-gravity trunk extensors, their head and neck muscles and their shoulder muscles.  The more interesting you can make the activity the longer you can get them to want to play in this position.  I do other activities as well, such as pull to sit to work on abs and head control (I make them work both going up and going down).  Going down is often easier (until you get close to the ground) because their muscles are already turned on so they just have to keep them on so they don’t ‘crash’ unlike going up where they have to turn their muscles on and its really hard when you are flat on the ground because you are fully working against gravity. I could go on all day and I might have to do another post just on activities!

Since these kiddos have to put out so much more energy to do things than a person with regular muscle tone, and the fact that we are constantly asking them to do more, don’t be surprised if they get tired easily.  For instance, it may not seem like it is that hard to sit in a chair to do work but if you think about all the energy they have to expend to keep their body up nice and straight its not surprising that they are tired.  When they are little they may need to nap more often, especially if they are doing therapy.  If you are in a mommy and me or a gymboree class you may notice that your kiddo needs to take breaks a little more frequently than the other kiddos.  This is normal for them.  However, you also want to remember the goal of working on their endurance so it doesn’t hurt to challenge them.  Just like when I am training for a race, 3 miles may be in my comfort zone but to get to the marathon I will have to challenge myself to run a little bit further than my comfort zone allows each day.

TheraTogs or the Spio suit or even hip helpers are tools that can be helpful for kids with low tone to give them a little extra support in the core so that they can practice the skills they need to practice.  I also use a lot of tickling to remind a muscle to turn on and stay on.  Sometimes using a slightly unstable surface like a sitting disc or a therapy ball can also be a reminder to keep muscles on.  Since it is unstable its a lot harder to sink into the support like they would be able to in a nice firm chair.  Also using wedges (although I wish I could find these filled with sand in addition to the air filled ones) in a chair (tilted forward) can help to activate a child’s core for improved sitting as well.  What are other tools that have helped either kids you have worked with or your own child – I’m sure I’m leaving out a ton of ones I’ve thought of or used but I always love to hear new ideas!

You can download an informational handout of this information here!

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Encouraging Rolling – From Back to Stomach

I’ve already addressed rolling in a previous post, as well as if you should be concerned if your child isn’t rolling yet, but I wanted to provide a video for some visuals on ways to encourage rolling in your child.  This video addresses helping your child to roll from their back onto their stomach.  Its important that your child learn to activate their flexor muscles (abs) to assist with rolling as opposed to throwing their head back to use extension to initiate rolling.  Using a toy or object that your child is interested and engaged in will encourage them to track it visually which they will follow with their eyes, head and then body as you move it to just over their head.  They will also try to reach for it which will further bring their abs into it as well continue the motion in the direction of the roll.  They also need to bring their leg and hip over which can complete the motion onto their belly.  In the beginning they usually need some extra help at the hip to guide them towards their belly, as well as to prevent them from falling right back onto their backs.  Don’t help too much at the hip because they need to start figuring out how much muscle activity they need as well as how far to continue the action (so they don’t fall back) and how to stabilize.  All of the trial and error is great opportunities for them to develop motor planning and work on movement exploration.  Once they are on their belly often their arm can get stuck under their body. If you tickle at their pecs (front of the shoulder) sometimes you can encourage them to pull their arm out.  Often they will figure out ways to maneuver their body until they can get the arm out from underneath them.

One final thing, make sure you help them practice rolling to both the left and the right so that they can maximize their mobility as well as develop their strength equally on both sides.

When all things aren’t equal – Legs

I recently had a parent ask about ideas to help her child who has weakness on one side of her body more than the other side.  I figured I would write about some of the ideas that I use although please be aware that there are a ton of ideas and it depends on the developmental stage your child is at and specifically what skills they are working on.  For this case I am going to give ideas for kids that are working on skills such as walking or stair climbing.  I’m going to look at ideas for encouraging the use of both legs more equally. (In order to differentiate the legs I will talk about them as the weaker and stronger leg, hopefully this does not offend anyone)

Climbing – I love having kids crawl up and down steps.  This is a great way to work on both sides of the body together but still encourage them to activate the side that is weaker.  It works on developing reciprocal activity (which is needed for walking and crawling) as well as motor planning, coordination and leg strength (especially the butt muscles).  Make sure your kiddo is switching legs as they try to crawl up, using one knee on the next step up and then shifting their weight onto that leg as they bring the other leg up.  Make sure they are shifting their weight onto the leg that is leading so that they are practicing weight shifting as well as taking maximal advantage of the opportunity to develop leg strength.  They may need a little help especially if it is the weaker side.  Make it motivating by putting a favorite toy a few steps above them or using a toy with multiple pieces that they need to go up and down to get all the pieces (i.e. puzzles).

Up and Down Hill – Walking up and down inclines can also work to help your kiddo develop strength equally on both sides.  Especially on the way up they have to engage their butt muscles in order to keep their balance and on the way down they need to maintain control so they don’t crash.  You can have them walk or crawl up and down the hills.

Step Ups and Downs – If your child is standing and walking already then working on step ups and downs is a great activity.  I like to use smaller stairs and encourage the kiddo to go up leading with their weaker leg and come down leading with their stronger leg.  This way the leg that isn’t as strong gets to develop strength and power as it lifts the kiddo up to the next step and it develops control as it lowers the kiddo down onto the next step.  If your kiddo can ‘cheat’ while on the stairs then find a few phone books you can tape together or a step stool that is at a height that is challenging but they can have success (usually with a little support).  When I work on these kind of skills I pretend we are going over a mountain and usually I have bean bag animals or puzzle pieces on one side and their ‘home’ on the other side so that they think they have a purpose in going over the step over and over.  Same rules apply, stepping up you put the weaker leg on the step and going down you leave the weaker leg on the step.

Single Leg Stance – Now this can be challenging if your kiddo can’t fully stand or balance on one leg by themselves yet.  Here are some ideas to help that skill evolve as well as work on keeping their weight on the weaker leg.  You can have your kiddo stand with the stronger leg up on a slight height like a phone book or a step stool and play with them.  If they have challenged balance you may need to stand close by.  You could have them stand like this while playing with magnets on the refrigerator, drawing at an easel, playing games on an ipad, etc.  Just make sure they aren’t leaning on the support surface too much!  Another way to encourage single leg stance and shifting onto their weaker leg is to use a stomp rocket.  The stomp rocket is a toy that is so much fun!  Have them use their stronger leg to stomp on it which makes them have to stand on their weaker leg.  As they get better at this you can have them hold their foot up for a count of (1,2,3,etc) before they are allowed to stomp.  Depending on how good their balance is you may have to give them a slight hand (not too much support) while they balance before stomping.

Kicking a ball – Have them practice kicking a ball.  You can have the ball be standing still or it can be rolling towards them (depending on their level).  In order to pick their foot up to kick the ball they will need to balance on their weaker leg.

The above ideas all can help with stability and strength on their weaker leg.  If you are looking to have them work on lifting their foot more with things like walking then you can reverse some of the activities I listed or you can also try some of the ideas I talked about for improving foot clearance.

Please share other ideas!

Motor Tips for Parents – Part 3

   

I thought I might stop at Motor Tips for Parents – Part 2 but after hanging out with my friend and her five month old baby the other day I was hit with inspiration (well actually she pointed out that what I told her might be helpful to other parents to know too).

• Development isn’t always linear – My friend was commenting that every time she would start to get concerned about the fact that her baby wasn’t reaching a skill/milestone (and didn’t appear to be even close to reaching that milestone) it was as if the next day all of a sudden they were performing the very same skill that she was concerned about.  I have seen with a lot of the kids that I work with (for both developmental milestones and for more challenging motor skills) that often times the child is working on the pieces of a skill.  For instance, if your child isn’t rolling over yet or even looking like they are attempting to, but they are on their belly and turning their head or lifting their bottom or trying to maneuver their arms, they are moving their body to try to figure out how their muscles work.  They could be practicing different components such as weight shifting from side to side or activating their flexor muscles (abs) all of which are key ingredients for rolling over.  After practicing the components all of a sudden (it seems like) they are able to put them together and perform the whole skill!  So what I explained to my friend is that sometimes development can look like a series of steps as opposed to a smooth line.  On the flat part of the step is when they are practicing the pieces and then all of a sudden they put it together and move up to the next step.
• Provide opportunities – I’m going to relate this one to tummy time but it can be related to almost any area of development such as drinking out of a cup, feeding, potty training, etc.  When my friend first started doing tummy time with her baby he hated it (a common theme from parents) and someone told her not to worry about it because kids do things in their own time.  I agree with this statement however kids need to be given the opportunity to try out and practice the skill.  So in the case of tummy time, your child is never going to learn to love it or get the benefits of it unless they are given the opportunity to be on their belly.  This can look like having them on their belly for brief periods of time on different surfaces such as a big exercise ball or on your chest (while you are lying down) or on a piece of kid safe mirror (they love looking at their reflection).  If you give them short experiences of tummy time in different ways so that they are getting a new experience and they are distracted from the fact that they ‘don’t like’ tummy time, they can eventually get the hang of it and in the meantime they get to work on all the skills that tummy time supports so that they can better develop their gross motor abilities.  By continually providing opportunities for a skill you are also more likely to figure out when ‘their own time’ is.
  

More Great Songs for Therapy

After my last post on fun songs to use in therapy my coworkers suddenly started remembering songs that they frequently use in therapy so I thought I’d share some more ideas.

If You’re Happy and You Know It

This is a great song because you get to insert your own action.  You could pick skills that you are working on such as: jump up and down, stand on one foot, stand on tip tiptoes, jumping jacks, etc.  I also use it when we are on the ball and I am trying to keep the kiddo from using their hands to stabilize so I will often insert actions like:  clap your hands, reach to the ceiling, touch your ears, touch your head, reach to the sides, wiggle your fingers, touch your shoulders, say hooray (and reaching arms up overhead).

Hokey Pokey

Just by following the words of the song the kiddos get to work on motor planning and balance (and single leg stance for left and right foot).  To spice it up a bit you can have them jump (or hop on one foot) at the end instead of clapping.  You can also use the words ‘Touch the ground, stand back up, touch the ground and shake it all about’ to work on squats.  You could have the kids pretend they are dogs or cats and they can put their ‘paws’ and ‘tails’ in to work on crawling and balance in quadraped.  You can also just change animals for every turn so if they are frogs they hop in and hop out, or butterflies tip toe in and tip toe out.

I’m a Little Tea Pot

This is another fun song to use on the ball.  You can work on postural control while singing the song and then when you get to the ‘tip me over’ part you tip the kiddo backwards so they have to do a sit-up to get back up.

Old MacDonald

Great song for getting repetition of activities in.  If you are using an animal puzzle or play animals it works even better and the kids get to work on animal recognition because they get to select the animal that is on Old MacDonald’s Farm!  Usually we use this type of song for working on things like walking on a balance beam or going up and down the stairs.  Activities where they need lots and lots of repetition for mastery but may not be that exciting to do over and over again.

Winnie the Pooh

I only use the first lines from this song when it says ‘When I up,down,touch the ground it puts me in the mood.  Up, down, touch the ground in the mood for _____‘.  This can be a fun one to get a kiddo ready to do something.  You can have them squat up and down and then change what they are in the mood for.  It could be jumping, walking, running, crawling, spinning, etc.  (You just have to be okay if the rhyming is off!)  And it works even better if you do a big dramatic pause before you give the action!

More of Our Own!

• Mr. Helper (to the tune of Frere Jacques) – Mr. Helper, Mr. Helper, – Hold, Hold, Hold, – Hold, Hold, Hold, – Hold the paper steady, – Hold the paper steady, – Helping hand, Helping hand.  Great Song to use when trying to teach a kiddo to use their secondary hand for stabilization or to ‘help’ with the task.
• This is the Way We Wash Our Hands – I’ve adapted this one to go with gross motor tasks such as This is the way we (climb the stairs, jump around, skip along, stomp our feet, crawl away, run around, cross the bridge [for balance beam walking], bend our knees [squatting], walk on our toes, walk on our heels, etc).  Also lets the kids work on changing tasks because they have to switch what they are doing as the words in the song change!

Autism and Gross Motor Skills

In the most recent issue of Pediatric Physical Therapy there are three articles regarding autism/autism spectrum disorder and gross motor skills.  I was actually really excited to see this because I sometimes feel that gross motor skills get put on the lower end of the priority scale for kids who are diagnosed with autism, autism spectrum disorder, or PDD-NOS.  Now don’t get me wrong, I understand that there are only so many hours in a day and there are so many areas that you need to prioritize for your child’s development.  Gross motor is easy to overlook especially if they are walking and able to get around independently.

I just thought I would take a moment to highlight some of the benefits of working on gross motor skills with children who are diagnosed on the autistic spectrum.

• Strength and posture – Generally kids with this diagnosis have lower muscle tone.  This low muscle tone can cause them to fatigue quicker, have challenges with postural control, and make learning new tasks more demanding (which can make it harder).  Working on activities to develop core strength and overall muscle strength will help with these challenges which can aid them in paying attention in school because of improved posture, trying out new skills, playing longer with their peers during active play.  In addition, fine motor skills and speech skills can improve as a result of improved strength and muscular endurance as well as opportunities for active play.
• Coordination – Learning new skills can be challenging because of weakness and low muscle tone as mentioned above, however it can also be challenging if it is hard to organize all the pieces that make up a skill.  For example, jumping jacks involve jumping, arm movements, leg movements and timing/rhythm.  Just one of these components may be challenging so being able to practice breaking down the pieces of the task and then as they master the pieces putting them back together for the whole motion can help your child to achieve the skill in a more timely manner and with less frustration.
• Social skills – I have worked with several kiddos who are diagnosed as being on the autistic spectrum and concerns with families are often around their ability to interact with their peers and play.  Because learning new skills may be challenging that can make it harder to keep up with peers as they continually evolve their play and gross motor skills.  For example, jumping is a skill that kids love to do when they figure it out.  If your kiddo is having trouble jumping they may be missing out on valuable opportunities to relate to their peers in a play based way.  Same with bike riding or even being able to participate in PE or recess.
• Sensory – Depending on your child’s sensory needs, adding in gross motor play will allow your child the opportunity to get a variety of sensory experiences such as proprioceptive feedback to their joints (which can also help to keep low tone muscles ‘awake’), vestibular input to their inner ear from moving up, down and around, as well as tactile input from the various surfaces they may come in contact with during play.  Let’s Play and Get Messy! touches on some of the sensory aspects of play.

I am definitely not writing this to tell you to add one more thing onto your already busy and probably completely scheduled days, but just to help you look for opportunities to add gross motor practice into your day.  If your child is working with other professionals you can ask them to include some gross motor into their activities.  Or maybe find out from their teacher what their peers are doing on the playground or in PE so you can have ideas for active play in your household