Head Banging

When a young child bangs his head repeatedly, it can be scary to us parents. My 15 month old son recently went through a stage in which he wanted to bang his head on the stroller and high-chair. I don't think he was doing it for any particular reason; he did it once and seemed to like it, so he kept doing it. I nipped this behavior in the bud by completely reclining the back of the stroller and the high-chair. This meant if he was to throw himself back, nothing was immediately there to bang his head on. He tried it once, and realized it made him lay down. So, he quit trying it.

It is not considered abnormal to head bang, however, many children with special needs bang their head and do so excessively. Some kids do it to the point that you are left wondering how they aren't in excruciating pain. More than one book on raising infants and toddlers reports that up to 10% of typically developing young children head bang in order to fall asleep. This statistic sounds a bit high to me, but maybe it included children in the statistics who were similar to my son where they just tried it for a month or so. Yet, many of the kids I work with are chronic head bangers. I try to put my thinking cap on and help the parents come up with solutions to diminish the head banging. Often, we are successful, but sometimes not. Many of those kids eventually outgrow the behavior when they were ready. Listed below are some tips that have worked for some kids that I have worked with over the years. Consider why the child is head banging:

• Is the child frustrated with a toy or person? If so, help him come up with other ways to appropriately release anger. One idea includes a place to retreat to when he is upset such as a tent. Within this tent provide toys or music that are typically calming and/or fun for him. For some kids, don't place anything in the tent other than a pillow or bean bag because they may need only minimal input.
• Is he upset that you don't understand his wants and needs? If he is completely non-verbal, then PECS, sign-language, augmentative communication devices, or other strategies taught by a speech-language pathologist, ABA therapist, or other special educ. staff may need to be implemented. If he is verbal, but just can't express himself when upset, then give a couple of choices. This makes him feel validated as well as helping him express his wants and needs. The choices can be with words, sign language, gestures, or pictures.
• Is the child just bored? Many kids, especially those with sensory processing disorder (SPD) or an autism spectrum disorder (ASD), need lots of movement opportunities or they get bored. Indoor activities may include: trampoline, tunnel, rocking horse, help clean and do chores, and obstacle course. Outdoor activities include: playground equipment with swings, slides, and climbing structures; swimming, walking/running, bikeriding, wagon rides, and yard work. Even a toddler can "help" dig weeds or water the flowers. Maybe the child is bored because he doesn't know how to play with toys or by himself. Get suggestions from your special education staff (OT, PT, SLP, ABA, developmental teacher, EIS, etc.) on toys and activities that may be easier for the child to learn to play.
• Is the child a sensory seeker and needs that deep input head banging provides? Try lots of "rough housing" (supervised), jumping, and the other activities listed in the previous question-answer. Head massage or vibration may be helpful too.
• Does he have seizures or migraines on a regular basis? Even if he is on medications that doesn't mean these problems are under control. I have had numerous kids over the years head bang, eye poke, & nose poke during, before, or after a seizure. Some kids have mixed types and although they may usually stare off, that may not always be the case.
• Does the child have a visual impairment or functional visual deficit? For children with some vision (low vision) or who see double (diplopia), they may get eye aches and think it feels good to bang their head. In this case, darken the room and minimize the work the eyes must do. If the child is head banging as you are having them work on puzzles or other fine-motor activities, then give frequent breaks or cut the session short. If the child should be wearing glasses, then insist they do. Build up to all day starting with 30 minute increments; but don't skip a whole day or play with toys up close without the child wearing the prescription glasses.
• Is he dependent upon head banging to rock himself to sleep because he has no other strategies? If so, help teach self-reglation and self-calming activities. Some kids suck their thumbs until they fall asleep whereas others hum, sing, or hold a soft toy. For this child, provide lots of motion activities throughout the day which may shorten the length of time the child head bangs in the evening. Some kids do well with compression such as tightly tucked in sheets, large heavy pillows placed around their bed, and tight pajamas.
• If the head banging is so severe that the walls or furniture are getting damaged, then this is excessive force. Consider having the child wear a soft helmet to protect his own head as well as the surfaces he hits. Try using lots of pillows too.
• Is the child head banging for attention or avoidance? If so, behavioral strategies may be needed to stop this behavior. If it is for attention, then quit being the audience and try your best to ignore it. Now, everyone in the family and at school (preschool) must be on board, or the child thinks he just has to head bang harder or longer in order to gain your attention. Try to give attention to him when he is not head banging...save the computer, TV, and phone talking that you do for another time, and give the child lots of positive attention during his waking hours.
• Does the child have a reason to have an itchy head? Lice, eczema, dandruff, scabbs, etc. should be considered. If you do not know what lice or their eggs look like, then search the Web and I'm sure you can find loads of information. Discuss treatment for lice with your child's physician. If eczema is a possibility, then discuss this with your child's physician; the child may need prescription shampoo and lotion for his head.

Teaching Toddlers How to Play with Toys

Shouldn't all kids just know how to play? Not necessarily. Some kids can fiddle around with a toy and figure out what to do with it. Others learn by watching another child and then imitating what that other child did. For some children, especially those with developmental disabilities, they don't learn by either one of those ways. They must be taught, and even then the lessons need to be broken down into simple steps. These steps may need to be repeated an hour later or the next day. For children with muscle tone or orthopedic abnormalities, the difficulties in learning may be due to fatigue and mechanics. But eventually, with repetition and patience, the child can learn how to play.



Quite often when I am asked to "come look at a toddler" at work and give my advice to why this child is behind in his development or he has destructive behaviors such as breaking toys, throwing things, or tearing apart other household items, I realize that the child doesn't know how to play. So much of a typically developing toddler's time is spent in play. But some of the toddlers with a delay in development are running around wild, just sitting there doing nothing, watching TV, or "getting into trouble". If they do play it may be limited such as only playing with certain toys and being perseverative in the way they play. An example of perseverative or controlling play is when a child insists on stacking blocks and doing nothing else with the blocks. If someone tries to help them make a house or train with the blocks, they get upset. This is because they have such a limited repertoire of how to play. When some of these toddlers get bored with the same old toys or not knowing how to play, they may become destructive. These behaviors the toddler has would be diminished if he just knew how to play.

That is when I come in to the picture. This means I need to be an investigator and figure out why this toddler is acting up. Is he bad because he is evil? Most likely not. I find that very rarely is there not a reason for a behavior problem. Reasons include: seizures, developmental delays (especially language- receptive and expressive), food allergies, and plain ole' not knowing how to play with toys.



Before parents are able to say "Go play with your toys" to their toddler, there are some things to consider:

• What is the child's physcial and cognitive abilities? Figure out is it really reasonable or not to expect this child to do such a thing. Does the child have the manipulation skills, muscular endurance, and problem solving abilities to play with the toys that are there.
• Can the child make choices? If he can't make choices when you verbally ask a question such as "Do you want to play with the puzzles or the trains?", then he isn't going to say this to himself and go choose an activity unaided when you go ask him to play.
• Is he motivated to play with the toys he has? If he is 2 years old and still has baby toys as opposed to "big boy" toys, then he isn't likely to go play with the toys.
• How long of an attention span does this toddler have? Do the toys require a longer attention span than he has (e.g. game boards, intricate puzzles)?
• Is there some structure to how his toys are kept and organized? If the toys are just dumped and scattered around, some toddlers are too overwhelmed by this to figure out what to go play. However, if they had toys kept in containers, shelves, baskets, or a toy box they may be more likely to know which toy to play with, especially if the adult guides them to a certain container.
• Has the parents, caregivers, or other adults in the chld's life spent enough time getting down on the floor and playing with the child? If not, then why? If it is because the adults don't have time, then make it. If it is because the adults don't remember how to play, then go get one of the many books out there on toddler games and toddler activities and read it. Just think back to things you would have liked when you were young. For example, I always wanted a sit-n-spin (R) but never had one. I played on one at a friend's house when I had the chance. So, I bought one for my daughter when she was 2 1/2, and sure enough she loved it! She didn't play with it daily, but she did enjoyed it. Browse the toy catalogs or toy aisles at the store if you are unsure of what to play. Just have fun playing!

Remember that many kids need to be shown how to play. If you show them that a toy car doesn't just get rolled back and forth but can be crashing into blocks, racing off of a table or couch, and driving under furniture as you make car noises "beep, beep" then they may then have more ideas on how to play. For toddlers and other children who tend to be rigid and controlling in their play skills, you may only be able to show them one more way to use a doll, blocks, or cars. But if you show them one new way to play per week, then within a month, they learned 4 new ways to play with toys. Before you know it, the child will have many choices of what to play when Mom hollers out "Go play in your room!".

W-Sitting

Every picture my parents took of me sitting on the floor below the age of 4 years shows me "w-sitting". What is w-sitting? It is when the child sits on the floor with his knees bent and his ankles are right next to his bottom...as if he had been kneeling and then just relaxed the feet out to each side. It is termed w-sitting, because looking at the child from a "bird's eye" view, the legs look like the letter "W". It is not good on the knees, hips, or feet. In fact I have awful knees probably because I was a big time w-sitter! They squeak when I bend over or walk up the stairs. If I go to aerobics class or walk a far distance, my knees ache for the next 3 days to the point that I can't sleep without pain medicine. So, I am not a fan of letting a child remain in a w-sitting posture for long lengths of time. I am now in my 30s but was told back in my 20s to quit jogging and aerobics classes or my need for a knee replacement would be sped up. So, I stick to biking, pilates, and yoga....wow, do I miss the adrenaline rush of a nice jog!



W-sitting is a posture that babies and toddlers use briefly as they move in and out of various postures. Little ones move so quickly, you will often see them transition from crawling, to sitting, to kneeling, to standing, back down to the floor, etc. So, w-sitting is not bad in and of itself. It is only not a good position if the child remains in that posture for long lengths of time, such as while playing with puzzles or watching television for 10 minutes. It puts unnecessary pressure on the knee joints and contributes to pronated feet (caving in at the ankles and collapsing at the arch). It can alter a child's balance and even make their gait look funny, especially while they run. My daughter tended to want to w-sit as a baby and toddler, and I had to redirect her quite often. I took her to a co-worker (at the time) who was a physical therapist and she gave us stretches and used kinesiotape to help with leg alignment.



Why do children w-sit? Most of the children use this posture because it is easy...it is less work for the trunk muscles because it widens their base of support. Some kids just prefer it just because. But many kids prefer it because they have low muscle tone (AKA hypotonia) or muscle weakness. It is common to see children with developmental disabilities such as cerebral palsy and down syndrome w-sit. I think that my daughter and I have mildly low muscle tone so that is why we have both been w-sitters. It is not uncommon for me to walk into a daycare (I do early intervention OT in natural environments) and see typically developing children using this posture. It does make me cringe, and oh how I want to correct the child. But I can't if the child is not my client. I can however educate the daycare staff about how w-sitting is not a posture that benefits children's gross motor development.



The following are some suggestions that I have found beneficial in reducing w-sitting in a baby, toddler, or older kid.

• For a baby, just correct their posture by placing them in kneeling, criss-cross (AKA Indian style for those of us raised in the 1970s & 80s), or a side-sitting posture
• For toddlers and children, encourage them to sit at a kiddy table and chair while performing fine motor activities such as coloring and puzzles. It is almost impossible to w-sit in a chair
• While the child (not baby) is playing on the floor, have a stool, bench, or tray (like a "breakfast in bed" tray) available. Have the child slide his legs under the device. Because these devices have "legs" or sides, then it increases the chances that the child will sit with his legs out straight to the front of him.
• If the child is in the "terrible twos" stage or is the type who likes control, then give him choices. When you see him w-sit, say "Would you like to fix your legs by sitting criss-cross or legs to the front?"
• Make up a silly song as a reminder. I made up a song titled "Legs in Front" to the tune of Frere Jacque. Then, as I only hummed the tune, my daughter was reminded of correcting her legs out of w-sitting
• Place toys to the side of the child so he will need to reach out of his base of support. This typically encourages a child to side in a side-sit posture (both knees are pointed towards one side or criss-cross style.
• Try not to nag the child by constantly saying "fix your legs" or picking them up and placing them in another posture. I find it best to set up the environment for success by using some of the above-mentioned ideas. Don't redirect the child if he will only be in the w-sit position briefly...if you do, he will tune you out everytime you redirect him...not good!
• There are probably many other ways to help with w-sitting but these are some common ones that I use
• If it is severe enough of a problem, then the child probably needs a physical therapy evaluation. The PT may suggest certain stretches, therapy techniques, furniture, or shoes to help the child
• If the child has sensory processing delays in addition to the low muscle tone, then the child may benefit from an occupational therapy evaluation. At http://www.sense-ablebaby.com/ there is loads of information on sensory processing problems seen in babies and some ideas to help.