This blog is based on a talk I was asked to give to a group of parents who attend Happy Little Eaters run by the team at Nutripaeds.

I’m going introduce a few different concepts to you and then try tie them all together at the end.

“Don’t Slouch at the dinner table!”

How many of you heard that as a kid? “Sit properly!” “Straighten up!” “Take your elbows off the table?” And who of you now tell your own kids to do that?

Why? Why did your parents ask you to do that? Why do you tell your kids the same thing?

Probably because it looks nicer if a child sits up straight? Its more aesthetically pleasing to an observers eye? It has to do with manners?

But did you know, that eating is actually EASIER if you sit up straight? Or that swallowing is more effortful if you slouch.

Try it for yourself. Go on. Slouch forward. Right forward so your back is rounded and you head is poking out in front like a tortoise. Have a little swallow.

Now to exagerate that posture, sit up but look up at the ceiling. And swallow.

Now sit up straight, head over shoulders, shoulders over hips, look forward and swallow.

Which of the three is easier?

The last one. Am I right?

Sitting posture helps with the ease and coordination of eating. If we sit up straight the area that our stomach has to expand is more. Our lungs have space to move, because the diaphragm has space to move down allowing for the easy flow of air. If we can breathe easier, then coordinating breathing while chewing and swallowing becomes easier.

In addition, bio-mechanically, gravity can assist with taking the food from the back of the throat to the stomach if we sit upright, as your esophagus travels from top to bottom.

When you slough forward, you create a kink in this system. It requires more effort and coordination from a brain and muscle perspective to get the food around the kink, than if gravity was assisting it in a straight line from top down.

Because of this bio-mechanical design, some advise that you need to sit you child at 90/90… 90 deg at the knees, 90deg at the hips, feet supported on a surface, support the head in midline and then the food must come from the front….

But… to throw a spanner in the works…do we always eat or even swallow in this position?

Or as typical,  grown people, are we able to eat an ice cream, walk and talk?

We are able to gulp the last piece of toast in the morning while tying a  shoe lace without choking. We can lounge back and sip a cocktail or cup of tea at the end of a long day. We can ly on our stomachs at a picnic and enjoy a beer or some food. And it’s a pretty good thing I can swallow my saliva while lying on my side or I’d end up with a wet pillow every morning or probably worse my hubby would get drooled on all night.

     

What this means is that, for typical development, to be safe in swallowing, we need to learn to coordinate our bodies in a multitude of ways and be able to swallow safely with our bodies in all different positions.

Any parents knows this; how many of you have kids that as babies and toddlers will put everything in their mouth in all sorts of weird and wonderful positions. It’s part of the developmental process that allows them to swallow safely, so that one day, they too can bend down, swallow their last piece of breakfast and tie a shoelace before dashing out the door.

But, in addition to the importance of us being able to coordinate our bodies in all different ways, what is more important is that the person is able to multi-task. Eating requires us to multi-task incoming sensory information and well as multi-task the outgoing motor plan.

Before you even take a mouthful, your brain needs to;

• Know where your body is in space
• Know where your body is, in relationship to the food, the table, the plate, the spoon etc.
• Know where your head is in relation to the rest of your body.
• Know where your tongue is, in your mouth and where it is in relation to your head and body.
• You need to know where your tongue is, in relationship to your teeth.

Then you put something in your mouth;

• How does your brain pay attention to the taste and smell and size and texture and temperature, without losing the sense of where your tongue is, in relation to the teeth and the head and the body?
• How does your brain tell your jaw, how hard or soft to bite? And chewing the first bite of a crusty baguette is going to be very different to the pressure you use for the last chew, as the consistency of the food changes in your mouth…

And it goes on… the amount of multi-tasking your brain needs to do on a continuous basis, in terms of registration of the sense, process it, give it meaning and feed-forward into creating an action as a result of this information is immense. And that is with only one bite of food!

AND, in addition to that, it needs coordinate the timing of chewing and swallowing with breathing, so you don’t swallow and breath in at the same time.

So, is there a lot going on in the brain! And you know this. If you really want to taste something, why do you close their eyes to focus on the taste?

In summary,

We have the fact that bio-mechanically swallowing is easier if head is on shoulders, facing forwards in a sort of static position.

And we have the fact the swallowing and eating in a typically developed person need to be able to be coordinated in a number of ways and that to be typical we need variability in the way and position we are able to eat and swallow.

Lastly, eating is not just about swallowing, it’s about the multi-tasking of a multitude of sensory inputs and then multi-tasking a multitude of motor outputs, and this is a continuous feedback, feed-forward loop.

Where can it go wrong?

1. A child with poor core coordination is not going to be able to physically hold their body upright. Or if the demands of sitting upright and not falling over are too much on the body, eating and swallowing will be difficult.
2. A child who has missed out on opportunity to mouth toys in all different positions, sit and eat in different position, will don’t have developed adequate safe swallowing skills.
3. A child with difficulties in sensory processing, specifically the multi-tasking of sensory information will struggle to focus on sitting upright, as well as the eating process.

So as parents, what can you do to help?

1) You can keep telling them to sit up straight… but did that ever work for you? I didn’t think so.

2) Understand which area your child may be struggling.

If you can understand where the difficulty lies you can target intervention more specifically.

3) Create a space where bio-mechanically sitting and eating is easy.

a) Some advise, 90/90 with head and trunk supported with cushions and feet resting gently… But I feel that no toddler is actually going to stay like that and your cushions will be a mess.

b) From sitting point of view, make sure your child is not working hard to be in sitting. Balancing on a stack of cushions, perched at the end of a dining chair with your feet dangling, make it very difficult to sit. Make sure your child has adequate foot support, and if need be a back rest.

– Use high chairs but make sure there is a foot support

– Toddler chairs are great. make sure the child feels safe and that they don’t feel they will fall off the sides. Ensure foot support.

– Buy specific foot rests, like the Footsi or from places like GoodWiz . 

-OR Make your own. Like This DIY for dining chairs for this  DIY Foot rest for High Chairs

4) Allow opportunity for oral sensory and oral motor experience in different positions, that isn’t necessarily nutritional. (i.e. not at the dinner table). Allow babies and toddlers opportunity to mouth toys and have sensory play that involves the mouth where they don’t have to be sitting upright, but exploring all different possibilities of body positions.

5) Realise that from a sensory processing point of view eating may be difficult.

a) Prepare for eating. Some people find that some big sensory input, just before dinner can help the brain maintain a sense of where the body is in space. Time spent on the trampoline or jumping on a bed, or swinging back and forth, or sitting in a laundry basket and being dragged around the house can help give “Loud” info to the brain about the body so that it can maintain a better posture for food.

b) However some people find that too much excitement before dinner, stimulates the sympathetic nervous system which means the child itsn’t going to feel hungry, even if they are. Then some down time with a book or craft before dinner may help them realise that they are hungry.

c) Allow for time between mouthfuls for them to readjust body, and become aware of their body again. Between mouthfuls, if they are sagging, you can give their backs a firm little rub, or a tap on the shoulders as a sense reminder to the brain of where the body is in space.

d) Minimise other sensory distractions during eating times, such as loud noise, TV etc. For children that find sensory processing very difficult, even a loud clock can be distracting.

e) Be aware of what food textures may be less or more difficult for you child to manage. And this will have an effect of posture and vice versa

6) To me, this point is most important. Create opportunity away from the dinner-table for children to have activities that develop a better sense of their body in space, that helps with improving core coordination and strength and assists with improving skills of multi-tasking sensory information. The principle for these kind of activities is to use the 3D environment that we have and that  our bodies have the capacity to exploring and play in a 3D environment at different levels, on different types of surfaces and different ways to use the body. Principles of up, down, over under, in, out, backwards, forwards, sideways, turning, twisting etc. Some ideas include;

• Climbing: Jungle gyms, rocks, trees, tree trunks
• Obstacle courses in the passage, by crawling over pillows, climbing on and off couches and beds. What are all the different ways you can get off? Climb off, slide down on your bottom, on your tummy, hands first, head first etc.
• Rough and tumble with mom or dad… using people as jungle gyms.
• Activities where you move forwards, backwards, sideways, turning etc.
• Wheelbarrow walking, cartwheels, handstands (head down activities).
• Swimming, playing in the pool with mom/dad. Moving different ways in the pool.

So Learn to play with your kids, get out, get up, get down, get in, get messy, have fun!

This is an article I wrote and was published as a requirement of my MSc Med in Child Health. The full article can be found here.

Prevalence of Disability in HIV-Infected Children Attending an Urban Paediatric HIV Clinic in Johannesburg, South Africa.

Abstract

With the success of evolving cART, HIV has become a chronic condition, however, children vertically infected with HIV have been shown to have developmental difficulties and disabilities. This study aimed to investigate the prevalence of disabilities among a group of HIV infected children in South Africa and whether they are being referred and accessing support services.

A cross-sectional study was conducted at a paediatric HIV clinic in Johannesburg. Parents were interviewed about their child using the Ten Question Screen for Disability questionnaire along with a follow up questionnaire. Data from the child’s clinic file were recorded.

Of the 200 children whose parents were interviewed, 50.5% experienced disabilities, where 58.4% of those had more than one co-existing disability. The most commonly reported disabilities were, developmental delay (27%), cognitive and behaviour difficulties (21%), communication difficulties (17%) and physical disabilities (13%).  Of the children who reported disability only 46% had been referred to one or more of the following support services; Audiologist, Occupational Therapist, Physiotherapist, Psychologist and/or Speech and Language Therapist. A history of low birth-weight, tuberculosis, lower respiratory tract infections and low pre-ART CD4% were found to be factors associated with the presence of developmental difficulty and/or delay.

The prevalence of disability in children infected with HIV is high and these children are not being referred and/or accessing the appropriate support services. Government policy and clinic practice need to shift focus of management of children with HIV, to integrate services that can assist with developmental potential and quality-of-life.

Keywords: word; paediatric, HIV, disability, development, child

Developmental coordination disorder (DCD) what it says it is… a disorder of the development of coordination. There have been many definitions between the scientific and clinical communities which are discussed in depth and at length!

However I like to think of DCD as a deficit in coordination, resulting in delays and difficulties with motor skill development, associated with deficits in sensory processing, psychosocial and language development as well as difficulties with academic performance.

WHAT CAUSES DCD?

Until recently DCD was seen as an idiopathic disorder (meaning no-one knew what caused it!). Historically research has focused on associated risk factors for DCD which include genetic factors, prematurity, increased (fetal) toxin exposure (e.g. cigarette, alcohol, drugs) and maternal stress and depression. Many of these factors can be associated with poor socioeconomic status and as a result poor socioeconomic status is also often linked with DCD.

With the advent of functional magnetic resonance imaging (fMRI) more researchers have explored the aetiology (cause) of DCD, and have recently developed two main theories. The first is “Micro-structural damage to various brain areas and spinal cord” (Zwicker et al 2012 as cited in Ferguson et al 2014, McLeod et al 2014).  The second theory is that of “intrinsic maturational problems of the developing brain and insufficient stimulation of the delayed brain” (Zwicker et al 2012 as cited in Ferguson et al 2014)). It is universally accepted that the Central Nervous System (CNS) (brain & spinal cord) is what controls and coordinates the body, then logically as a disorder of the development of coordination, DCD must be a result of atypical development of the CNS.

By applying the Movement Analysis and Education Strategies approach (Maes 2015) which is supported by Leonard HC (2016) we can deepen our understanding of how a child with DCD develops.

Let’s look at typical development. In typical development, the ability to move in a coordinated manner is the consequence of a number of events that have their foundation on preceding events. The CNS continually coordinates movement from conception to death. As a baby and toddler, the ability of the CNS to coordinate movement allows for the child to explore. By exploring different movement patterns and receiving sensory feedback from these movements; a child develops a repertoire of postural and movement skills. The more skills (increased repertoire) you develop the more options you have of combining these skills to achieve a task. The more combinations you can make, the more tasks you can do and the better and more refined task execution becomes.

In other words; to be able to look typical while doing a task or activity one must have adequate posture and movement skills available which will depend on the coordination ability which in turn depends on an intact CNS. It is a balancing act, where one block depends on the block below and the block above it to maintain stability.

If a typically developing child has not developed an adequate skill set (foundation) for a particular task or activity they can look atypical, until they have developed more complex skills, increased their skill repertoire and refined their selectivity of skills in order to master the task. This concept continues into adulthood. For example have you watched someone trying to learn to ski or snowboard for the first time?

In DCD, as a consequence of this minor damage to the developing central nervous system the child’s brain is unable to coordinate typical patterns of movement. This impacts the way the child learns to develop postural and movement skills, resulting in a poor foundation of skills (e.g. decreased repertoire of movement and postural skills). The particular set of skills that the child develops/learns will in turn affect the way they interact with the environment and engage in tasks/activity/play. As discussed previously, if the child does not have the skill set for environmental interaction and/or the task/activity required they will appear atypical compared with their peers. The way the child engages in tasks will affect how they engage in further, more difficult tasks. As tasks become more challenging (requiring more/different/complex skills), the child will look more atypical because they haven’t developed the correct skill set due to atypical coordination. In other words; the foundation of coordination (CNS) is not working as well as it could resulting in atypical coordination resulting in the child learning atypical movement skill and the child looking atypical during a task or activity as a consequence. If the foundation is unbalanced it will unbalance the whole tower.

The way a child engages in a more difficult tasks depends on how they have engaged in previous tasks (their foundation). As a result, the fall-out of children with DCD is only noticed once the child reaches school-going age as the complexity of tasks a child is expected to perform increases. The more complex the task, the more the deficit becomes more obvious.

In summary, if a developing infant struggles to coordinate their bodies, it will affect the exploration of their bodies and their environment. In turn it will affect how they experience sensory input which will impact their feedback and feedforward systems. If your sensory processing is atypical then the development of motor learning and further skill acquisition is affected (Leonard 2016). Skills could include any form of function from, vision, perception, gross motor skills, fine motor skills, executive function, attention to working memory etc.

REFERENCES
American Psychiatric Association (2013) The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5). Arlington, VA. Available at: www.dsm5.org (accessed 21/03/16).Anon ( (n.d.))

Astronaut Training: A Sound Activated Vestibular-Visual Protocol. Vital Links. Available at: http://www.vitallinks.net/pages/Astronaut-Training-A-Sound-Activated-Vestibular-Visual-Protocol.php (accessed 29/03/16).

Blank R, Smits-Engelsman B, Polatajko H and Wilson P (2012) European Academy for Childhood Disability. European Academy for Childhood Disability (EACD): recommendations on the definition, diagnosis and intervention of developmental coordination disorder (long version). Developmental Medicine & Child Neurology 54(1): 54–93.

Ferguson GD, Jelsma J, Versfeld P and Smits-Engelsman BCM (2014) Using the ICF Framework to Explore the Multiple Interacting Factors Associated with Developmental Coordination Disorder. ResearchGate 1(2). Available at: https://www.researchgate.net/publication/261409477_Using_the_ICF_Framework_to_Explore_the_Multiple_Interacting_Factors_Associated_with_Developmental_Coordination_Disorder (accessed 28/03/16).

Hamer E, Bos A and Hadders-Algra M (2016) Specific characteristics of abnormal general movements are associated with functional outcome at school age. – PubMed – NCBI. . Available at: http://www.ncbi.nlm.nih.gov/pubmed/26896696 (accessed 29/03/16).

Harris SR, Mickelson ECR and Zwicker JG (2015) Diagnosis and management of developmental coordination disorder. CMAJ: Canadian Medical Association journal = journal de l’Association medicale canadienne 187(9): 659–665.

van den Heuvel M, Jansen DEMC, Reijneveld SA, Flapper BCT and Smits-Engelsman BCM (2016) Identification of emotional and behavioral problems by teachers in children with developmental coordination disorder in the school community. Research in Developmental Disabilities 51-52: 40–48.

Leonard HC (2016) The Impact of Poor Motor Skills on Perceptual, Social and Cognitive Development: The Case of Developmental Coordination Disorder. Frontiers in Psychology 7. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4779971/ (accessed 28/03/16).

van der Linde BW, van Netten JJ, Otten BE, Postema K, Geuze RH and Schoemaker MM (2014) Psychometric properties of the DCDDaily-Q: a new parental questionnaire on children’s performance in activities of daily living. Research in Developmental Disabilities 35(7): 1711–1719.

Maes J-P (2015) Movement Analysis and Education Strategies for the treatment of children wth Cerebral Palsy and similar neurological conditions – Course Notes . Available at: www.maestherapy.com.

McLeod KR, Langevin LM, Goodyear BG and Dewey D (2014) Functional connectivity of neural motor networks is disrupted in children with developmental coordination disorder and attention-deficit/hyperactivity disorder. NeuroImage. Clinical 4: 566–575.

O’Brien JC, Williams HG, Bundy A, Lyons J and Mittal A (2008) Mechanisms that underlie coordination in children with developmental coordination disorder. Journal of Motor Behavior 40(1): 43–61.

Rosenblum S and Regev N (2013) Timing abilities among children with developmental coordination disorders (DCD) in comparison to children with typical development. Research in Developmental Disabilities 34(1): 218–227.
Schoemaker MM and Smits-Engelsman BCM (2015) Is Treating Motor Problems in DCD Just a Matter of Practice and More Practice? ResearchGate 2(2). Available at: https://www.researchgate.net/publication/274633943_Is_Treating_Motor_Problems_in_DCD_Just_a_Matter_of_Practice_and_More_Practice (accessed 19/03/16).

Schoemaker MM, Smits-Engelsman BCM, Sugden D and Chambers M (2005) Neuromotor task training: a new approach to treat children with DCD. ResearchGate. Available at: https://www.researchgate.net/publication/30491534_Neuromotor_task_training_a_new_approach_to_treat_children_with_DCD (accessed 19/03/16).

Smits-Engelsman BCM, Blank R, Kaay A-CVD, Meijs RM-VD, Brand EV-VD, Polatajko HJ and Wilson PH (2012) Efficacy of interventions to improve motor performance in children with developmental coordination disorder: A combined systematic review and meta-analysis. Developmental Medicine & Child Neurology 55(3). Available at: https://www.researchgate.net/publication/232736455_Efficacy_of_interventions_to_improve_motor_performance_in_children_with_developmental_coordination_disorder_A_combined_systematic_review_and_meta-analysis (accessed 19/03/16).

Smits-Engelsman B and Jelsma D (2011) Development Co-ordination Disorder – Course Notes. University of Cape Town, Department of Health and Rehabilitation Science Division of Physiotherapy.

Smits-Engelsman B, Schoemaker M, Delabastita T, Hoskens J and Geuze R (2015) Diagnostic criteria for DCD: Past and future. Human movement science 42. Available at: https://www.researchgate.net/publication/274571746_Diagnostic_criteria_for_DCD_Past_and_future (accessed 19/03/16).

Snapp-Childs W, Mon-Williams M and Bingham GP (2013) A SENSORIMOTOR APPROACH TO THE TRAINING OF MANUAL ACTIONS IN CHILDREN WITH DCD. Journal of child neurology 28(2): 204–212.

Thornton A, Licari M, Reid S, Armstrong J, Fallows R and Elliott C (2016) Cognitive Orientation to (Daily) Occupational Performance intervention leads to improvements in impairments, activity and participation in children with Developmental Coordination Disorder. Disability and Rehabilitation 38(10): 979–986.

 

Hi Cape Town!

My name is Shane, I’m a qualified physiotherapist and I have just moved back to Cape Town for a new (if not dryer) adventure.

I started my journey towards being a paediatric physio when I was a child and was packed off to physio by a teacher for “low tone”. Physio was pretty fun and I figured if you could help someone and they had fun at the same time, then that is pretty cool!

I studied at UCT, completed my community service in northern Kwazulu-Natal and found my way back to Cape Town, where I was very happily employed at Paarl School for Children with Disabilities for five years. I loved working there and it helped grow a passion for treating all children, but particularly those who had been diagnosed with cerebral palsy. My knowledge base grew and I was afforded plenty of time by the school to attend courses and improve my skills.

However, I love learning new things and felt I needed to improve my knowledge base. I went to Johannesburg to complete a Masters in Medicine in child neuro-developmental health and worked part time in a private practice there. At the same time, I become very involved in learning more about an approach to treating children called Movement Analysis and Education Strategies (MAES).

As a physiotherapist, I have spent a lot of time analysing HOW children and adults move. The MAES approach was the first approach I have come across that not only looks at how a child moves but delves deeper into WHY they move the way they do. It is an approach that analyses movement, from the mover’s point of view and not as an outside observer.  It deepens the understanding of movement and is more about the psychology of movement than the actual movements itself. This approach has helped me individualise my assessments and treatment to each child taking into account every child’s own specific needs.

After completing the Masters (which took at least a year longer than I anticipated), I have returned to Cape Town to start a new chapter. I am looking forward to the adventure that is PhysioKids: Shane Brassell Phsyiotherapy!