In our house, only I know the answer to this question. Because I hid it. I hid the remote. I’ve also hidden the tablet, the ipad, and the laptop. I’ve taken this drastic measure because I’ve seen what happens when my kids get too much screen time. They become incredibly lethargic and irritable. They are more likely to fight with each other, and less able to make decisions for themselves when they’ve spent too long engrossed in useless programming (watching other people play Minecraft is the absolute worst). So I hide the remote. They are forced to figure out something else to do.
When screens are not an option for kids, an amazing transformation takes place. They play! Children learn, develop, and grow into adulthood through play. Without a screen, they start using their imagination; learning foundational social, motor, cognitive and communication skills in the process. Creativity comes to life, and a paper towel roll is now a sword to slay an imaginary dragon. The floor turns into hot lava, and they problem solve how to move their bodies to get from one room to the other without touching the floor. They play legos with each other, building and creating. They perform shows, coming up with elaborate storylines that build their communication skills. They make up their own games, deciding on their own rules and resolving conflicts when one of them is “out”. Playing with friends from the neighborhood, they learn about empathy, taking turns, and saying “I’m sorry”.
We need these skills as adults. But it all starts with our play in childhood. Too much screen time takes that opportunity away. Physical therapists like myself are always advocating for more playtime. Especially physical play. Children should be running, jumping, climbing, riding their bikes and exploring. When sedentary screen time takes the place of physical play, we see kids who are clumsy and uncoordinated with poor core strength and motor planning. Not many, but some schools even seem to be paying attention to the research that says that increased physical activity goes hand in hand with increased focus and learning in the classroom, leading them to extend recess.
The World Health Organization and American Academy of Pediatrics have slightly different guidelines on screens for kids but the basic message is the same….less screen time and more physical play time. This is no simple feat for parents, myself included. I’m a physical therapist, not a parenting expert. I don’t know the best way to limit screen time, but I do know that it has to be done. In the spirit of putting away our screens, I’ll put mine down right now, so that you can too!
In the world of pediatric physical therapy, there are a couple terms that are used so often by physicians, families, and the general public that they seem to have lost their meaning. “The Core” is a big one. I wonder if people even know what they’re talking about when they say “I need to work my core!” I’m thinking the answer is probably not. “Low Tone” is definitely another one. “My pediatrician says he has low tone” What does that even mean? The term gets thrown around a lot, yet many don’t know what to make of it. The opposite of high tone, it’s become a sort of catch-all to describe muscle weakness or developmental delays. But what is it really? Let’s first look at some quick facts before we jump into characteristics of low tone.
The technical term is hypotonia. It comes with the territory for many syndromes and disorders BUT you do not have to have a syndrome to have low tone. They are not mutually exclusive. For instance, children and adults with Down Syndrome have low tone for sure. BUT just because you have low tone, doesn’t mean you automatically have Down Syndrome. Make sense? It can be just part of who you are. The tone doesn’t change, but it doesn’t always have to be a problem.
Here are a few of the ways I like to talk about muscle tone to parents to help make sense of it. Hopefully, it will help you too!
A Continuum. At one end is very very low tone. This would be someone who has difficulty even maintaining head control and doing any kind of anti-gravity activity. Then at the other end is extremely high tone. With these kids, their muscles are extremely stiff, rigid, and difficult to move. Somewhere in the middle, the rest of us can be found. We could be on the higher or lower end of “normal” resting muscle tone. Maybe a little floppy, but still independently functioning in the world, meeting milestones, and achieving goals. For the record, on this continuum, I trend toward the low end. I can definitely relate to my low tone kiddies!
Resistance to Stretch. If you have high tone, you have a lot of resistance to movement. Your muscles may be tight, and your range of motion restricted. Low tone, on the other hand, shows very little resistance to a stretch. During movement, those joints will just keep going going going going until they can’t go any further. This brings us to…….
Super Flexible. With no tension in the muscle, the joints of someone with low tone are free to keep going until they lock in place or compress against another joint where they can rest. At this point, people with low tone such as myself, rely on the tension of ligaments to hold themselves up rather than using their muscles. (hello back, hip and knee pain!) Those with low tone can hyperextend their knees or elbows, sit in a wide straddle, have really flat feet, and are what some used to call “double jointed”.
Weakness. When your muscles are this flexible, you have to give up some strength. Muscles don’t work so well when they are over elongated and positioned at the end of their range. Plus, when we think of low muscle tone, we can think beyond just the trunk and extremities. If you have low tone, it’s present in all parts of your body. This is why we often see challenges with chewing and communication in kids with low tone….because the weakness can be in the muscles of the jaw well.
Higher Threshold. All muscles need to reach a certain threshold before they’re ready to work. Kids with high muscle tone reach that threshold fast! High tone muscles are always on, always ready to go, and basically say “let’s DO this!” at the mere thought of movement. Kids with low tone though….different story. The threshold for their muscles to work is way higher. So it takes a lot of amping up to get going. These muscles like to rest and there are certain strategies that we can use to tell these muscles “Get up! Let’s get going! Come on!” to get them primed for movement.
Path of Least Resistance. Here’s a pic of my low tone self as I sit to write this article. According to my muscles, they work smarter, not harder. If there’s a chair, I’m gonna sink and curve all the way into it. I’ll slump all the way forward, rest my arms on my knee, and head on my hands. Here, I’m even using my laptop to hold me up! And as for babies with low tone, if there’s a lap, they will take it! It can be hard to resist because little ones with low tone just melt into you and love to cuddle, taking advantage of all the postural support you provide. It is important to note that these kids are NOT lazy!! Please stop telling kids with low muscle tone that they are lazy!! I’m one of the hardest working people I know. My muscles on the other hand……..
All or Nothing. Kids with low tone love living in end ranges. Either standing fully extended, hips and knees locked out, putting a ton of strain on those poor ligaments OR completely flexed into a little ball with a massive amount of compression on the joints. There is no strength in the middle of the range…..all or nothing. This becomes a problem because it makes transitions in and out of positions difficult. These are the babies who sit when you sit them, stand at the couch when you stand them, but can’t do any of the in-between movements, so they are completely reliant on others to move in any kind of dynamic way.
Just when you thought you understood low muscle tone, let me end with this: Don’t put those of us with low tone in a box. You can have low tone but be stiff. You can have high tone but be very weak. Kids with low tone can look like a puddle on the floor, staying in the same spot you left them for way too long. Or they could be flitting around non-stop spinning themselves in circles, always the “wild child”. Low tone manifests itself in many different ways, and no two are the same. An experienced physical therapist can help you connect the dots and figure out how function relates to tone for your little one!
Walk into any daycare classroom and you’ll see it. My hips start to ache at the mere sight of it. It’s on every pediatric PT’s shortlist of cringe-worthy things to never ever do. Right up there with skipping crawling and using baby walkers. The notorious “W Sit”!!
“W Sitting” is a position in which you sit on the floor with both knees bent and your feet splayed out behind you to either side. Taking a bird’s eye view, the legs make the shape of a “W”. I can barely get into this position myself, but why do some kids LOVE it, yet PT’s HATE it so much?
When kids learn the “W”, their bodies have figured out, “Woah this works really great for me!! This is by far the easiest way for me to sit and play”. Think of the pelvis as a large bowl. To “W” is to passively drop your trunk into this really stable bowl that will do the work of keeping the body upright with minimal effort. In this position, you can literally hang out and your muscles will do zero work. This is why little ones, especially kids with low muscle tone and related postural weakness, REALLLLLY love this position. It’s the path of least resistance and who can blame them? Who wouldn’t want to work less to make play easier? But here’s why it’s on the PT cringe list….
Feeds into postural weakness. There is really no opportunity to use your trunk muscles in the “W ” position. They don’t have to do any work here. But we need strong trunk muscles for crawling, standing, walking, moving in and out of positions, breathing, digesting……ok let’s just say everything. You need them for everything!
Dreadful posture. The spine curves and the pelvis rounds under.
Ugh. Look at that rounded posture! 😩
Discourages exploration: It’s impossible to shift your weight while in the “W”. Every single movement we perform in life starts with a shift in weight. If you’re sitting on the floor, you see a toy, you shift your weight, reach (hopefully across your body) for it, and move to get it. In the “W”, you are stuck. You can only reach what is within arm’s length. And you can only use your right hand on your right side of your body and the left hand for the left side. You aren’t moving. You aren’t exploring your environment at all. At least not efficiently and not while moving your head and body dynamically through space. This leads to a ton of other issues, not the least of which is vestibular (Side note: this is the system that informs you about where your head and body are in space. When it’s impaired I hear things like “I don’t know why but my son really hates the swing at the playground”).
Dreadful hip & knee positioning. The “W” puts your hips at the extremes of internal rotation putting them at risk for dislocation. Same with the knees. The femur above the knee is rotated all the way in while the tibia below the knee is rotated all the way out. That’s some serious stress on the knee joint!
Dreadful foot positioning. Especially for kids with really flat feet, I find that the “W” feeds into the pronation and makes a flat foot even flatter. It also contributes to in-toeing or what’s commonly called “pigeon-toed” with both feet directed inward instead of straight ahead.
Ok, so we all agree we don’t like the “W” position. What do we do?
Givereminders. One of my absolute biggest pedi PT pet peeves of all time is when I hear adults tell kids who are “W” sitting to “Fix your feet”. Ugh! I am NOT a fan of sending the message to kids that there is any part of them that is wrong and needs to be “fixed”. It’s the worst. I much prefer “Feet in front!” or “Where are your feet? Put them in front so I can see them!” and then delight in how cute their bare feet, shoes or socks are!
Alternatives. Kneeling or sitting on heels are both fabulous alternatives. I like to make the “W” disappear by scooping the feet right under the bottom for a safer and more dynamic way to sit. Crisscross applesauce, circle sit, side sit with both feet directed to either the right or the left, in a chair or step stool, on the belly, in a long sit with both legs straight out in front. These are a few different options.
To those kiddos who love it so much, we hear you! We get it! But we also want you to grow strong, explore, and play without boundaries! We promise you’ll thank us later and your joints will thank us too! “W” sit no more!!
To be fair, toe walking is a normal stage of development. I see it a lot when babies are learning to cruise along furniture for instance. Brand new walkers lead with their toe to take steps. But after about 18 months, toe walking is not cute and should be addressed by a physical therapist. Here’s why:
Inefficiency: If you are walking on your toes, you are taking twice as many steps as the typical toddler. This is exhausting! Not only physically exhausting but mentally challenging as well. You really can’t concentrate if all you’re thinking about is not falling over.
Skeletal changes: When we’re young, bones are susceptible to molding. They grow in relation to the force applied to them. Your heel is meant to be a shock absorber during walking, but if you’re pounding away on the ball of your foot instead (ouch!) over time you will see a funky looking foot. This means a wide foot where the arch is very flat (or there is no arch at all) with a skinny heel. Good luck finding shoes! After about age 3, these bones are set and you’ve got what you’ve got. So early intervention is key!
Muscle Shortening: If kept up long term, toe walking leads to muscles in the lower extremities that are so tight from overuse that you couldn’t get that heel down on the floor if you tried. Again, ouch! Plus how will you wear shoes?!?
Unstable: Walking on your toes is very unstable! Not just at the ankle but it makes the knee unstable too, leading to injuries. Of course, this leads to hip and back pain too.
Can’t stop!: Kids who walk on their toes have muscles that are long where they should be short and vice versa. This means the muscles can’t work well, and they can’t put on the brakes. Toe walkers are in constant motion, resulting in more falls and more crashing into things.
Here’s the confusing part: Toe walking isn’t ever about the toe walking. It is instead a sign of a bigger problem. In other words, walking on your toes is fulfilling a greater need. And it’s a need that is worth risking everything mentioned above. That’s gotta be big! So our job as PT’s is to figure out what that need is. If we treat only the foot, we won’t see improvement because that underlying need will still be there. Toe walking is very highly correlated to vision impairment and vestibular dysfunction so the “need” could be sensory based. Or it could be orthopedic or neurological….a skilled PT can help figure it out with you.
Bottom line: If your little one is toe walking past the age of 18 months, please please please don’t “wait and see”. He won’t outgrow it and the potential for change is less the longer you wait.
I love these chalkboards! I wish they were a thing when my kids were babies. Each month flies by and it’s an adorable way to look back. Especially when you’re looking at sweet Bea here! They do remind me of a question I’m asked all the time though….”What should my baby be doing now?”
It can be confusing for parents to know what skills their baby should have at any given month. This is because:
There is a huge range of what is considered “normal”. In fact, the range is often so huge, that I don’t even use the word “normal” anymore. Throw in some mom (or dad) guilt and comparing your baby to the skills of others you really know nothing about, and you have a recipe for serious stress and confusion!
There is a lot of variation between babies depending on their special circumstances. Was the baby born prematurely, or does he have a syndrome or neuromuscular disorder? This really matters!!
As more and more babies show delayed gross motor skills (thanks a lot Back to Sleep Campaign circa 1994!) the new “normal” seems to have shifted to later and later in the infant’s first year and into toddlerhood. For instance, the average age for walking is 12 months, but there’s a range of up to 14 months. When more and more babies start walking around 14 months, the worry zone gets pushed back to 16 months, then 18 months (which is definitely late by the way) and on and on. But PT’s don’t like this, or at least I don’t. I like sticking to the good ole traditional milestones, and for good reason. But which is it?!? 12, 14, 16, 18 months?!? It totally makes sense to me why parents are confused.
So…..here’s a mega simplified month by month breakdown of targeted skills to look for. Of course, there are lots of other little things that happen in between, but these are the biggies. Here we go!
NEWBORN: FLEXION! Your baby should be curled up in a ball in any position you put him in.
2 MONTHS: When you pull your baby up to sit, she should be able to bring her head with her.
4 MONTHS: SYMMETRY! Head in the middle and not tilting to one side. Using right and left sides of body equally. On back: Reaching for both knees at the same time On belly: Propping up with elbows directly under shoulders.
5 MONTHS: Rolling to belly and back smoothly. On back: Reaching for both feet at the same time On belly: Pushing up with both hands
6 MONTHS: Sitting independently!! On back: Putting feet in mouth On belly: Pushing up and reaching for toys
7 MONTHS: Commando crawling!
8 MONTHS: Hands and knees crawling!
9 MONTHS: Pulling up to stand
10 MONTHS: Standing by himself!
12 MONTHS: Walking!
When it comes to infant development, the old adage “everything happens for a reason” actually holds true. One milestone is prepping you for the next, starting at birth and believe it or not, even before that! Delays can really snowball if you don’t know what to look for. If you suspect your baby may be delayed or at risk for being behind with gross motor skills, it’s always a good idea to have a pediatric physical therapist check her out. We are here to help make sense of it all and promote happy, healthy, milestone-reaching babies!