Crossing the Mid-Line .... What does this mean?

**** Please note that I am not a medical professional. The following information is based on our own experiences. 
If you believe that you or your child has difficulty in crossing their mid-line, 
please consult with a trusted medical professional. ****

One topic that I have touched on briefly in a previous post is crossing the mid-line. I was recently asked why this was so important so I thought that I would revisit this topic.

So what is the mid-line?

The term "mid-line" describes the invisible and imaginary line that runs down the centre of our body and divides the body into the left and right. If you like, this line runs down our spine from the base of our skull, through all of our vertebrae to the bottom of our back. Literally.

Crossing our mid-line refers to having the ability to reach across this invisible line in the middle of our body with both of our arms and legs. Being able to cross our mid-line is an important developmental skill that is needed by everyone for many everyday tasks. Reading, writing, reaching to our feet to put on shoes, using a knife and fork, being able to put clothes on and off, hitting a ball with a bat, catching a ball ... all of these tasks and many more require us to be able to cross our mid-lines. Any time that your right (or left hand) crosses over to the opposite side of your body, you are crossing your mid-line.

Having the ability to cross over our mid-line is not an ability that babies are born with. Typically developing children develop the ability to cross their mid-lines through play. Reaching for toys, babies playing with their toes, exploring toys and other objects with their hands. drawing or painting and so on all assist in developing the ability to cross the mid-line.

When we spontaneously cross our mid-line with our dominant hand (in my case, my right hand as I am right handed,) then the dominant hand gets the practice that is needed to develop good fine motor control. If a child struggles to cross their mid-line, then both hands (and feet) will receive equal practice at developing skills. This then means that they will have less skilled hands rather than one more skilled, or dominant, hand.

L was one of those children who struggled to cross his mid-line. His inability to cross his mid-line became evident when he was drawing or painting. When drawing or painting on a piece of paper, if he wanted to draw or paint on the left hand side of the page, he would turn the page on the table to get to the spot that he wanted to decorate rather than move his hand across the paper. L was physically unable to put his hand across his body to the left hand side. It was also evident when he went to reach for toys that were across his body. If a toy was on his left hand side, he would only ever reach for it with his left hand and vice versa on the right hand side of his body. We also noticed that L was neither right or left hand dominant in other words, he'd use both hands (and feet) equally when completing tasks.

L also had difficult in swapping hands mid way through a task such as passing a crayon or toy from one hand to the other. L struggled, and still does, to dress himself. When engaging in fine motor control, L would usually end in a state of extreme frustration as he struggled to complete the task successfully. For a very long time, L would avoid colouring and drawing activities.

L's gross motor skills were well developed but when kicking a ball, he'd often use both feet (but not at the same time) to kick balls around the yard. This indicated that he was neither left or right dominant.

When L was in kindy he was desperate to be able to write his own name, but crossing the mid-line can be a pre-cursor to be being able to write from left to right on a page.

Having a difficulty in crossing the mid-line can also make it difficult for an individual to visually track a moving object from one side to the other of their body. L would move his entire head to track an object rather than just using his eyes.

Once I'd learnt a little more about the mid-line and the importance in being able to cross it, I was a little confused. When O was a new born, I'd learnt about baby massage and moving a babies arms across their bodies during play. O enjoyed this as a baby and L did to some extent. O didn't seem to have any struggles with crossing her mid-line and yet L did. And yet I'd done the same exercises with O and L. 

It wasn't until I was assured by L's Occupational Therapist that it was nothing that we did, or didn't do, as parents. Some children just need extra assistance in learning this skill.

Knowing all this got me thinking - how does crossing the mid-line actually develop?

Having the ability to cross the mid-line is important on a physical level as well as on the brain level. In terms of the brain level, if an individual is unable to cross their mid-line, this may indicate that the left and right sides of their brain (the left and right hemispheres) are not communicating well together. The left and right hemispheres communicate with each other across a mass of tissue called the corpus callosum and because each hemisphere carries out different neurological tasks, the two hemispheres need to work together.

Crossing the mid-line begins to first emerge in the infant years as a child begins to develop their bilateral coordination skills. They do this by using both hands to reach for toys and other objects, pulling and pushing themselves along the floor, crawling and so on.

Through play and exploration, a child will then learn to coordinate their strong hand or foot (or dominant hand or foot) when doing particular skills. They'll also develop their other hand or foot, their assistant or helping hand. For example when using scissors - their dominant hand will hold the scissors and their helping hand will hold the paper. Through play and exploration, they will also spontaneously cross their mid-line. They may be a little clumsy at first, but they will become more skilled at this.

Another factor in being able to cross the mid-line is trunk rotation. If a child has a low core stability, then this may affect their ability in being able to cross their mid-line. This comes back to proximal stability before distal mobility! L was, and still does, sit in a w position. When sitting in a w position, this can affect trunk rotation as the position itself places limitations on how much the individual can rotate their trunk. 

So armed with all of this information we set to work in assisting L to develop the ability to cross his mid-line, with the assistance of his therapists at the early intervention centre that he attended. Through play, L was practising crossing his mid-line on a daily basis but we also incorporated practising this skill into other activities at home.

• Drying dishes - One of L's favourite household chores is drying the dishes - one day, his future partner is going to love me! We used to have a small child's table that we used for various reasons in our house. I would seat L at the table, put the dish towel in his right hand and the wet dishes on the left hand side of the table. Through the action of reaching across the table to the wet dishes he was crossing his mid-line each and every time. I'd also encourage L to then try and use the dish towel in his left hand and the dishes on the right hand side of his body so that both sides had an equal opportunity to practise the skill.

• We'd encourage, and still do, L to dress himself so that both sides of his body could work together.

• Painting - I'd always put the paint on the opposite side of the table and ask L to try and reach the paint without moving his body. Again, every time he reached for the paint, he'd have to cross his mid-line.

• Car letters and numbers - We have created a game board for L to practise his letter and number recognition skills. I have put letter and number stickers on the top of toy cars and have laminated words that L wanted to learn how to spell. L sits directly in front of the board and we put the cars that he needs to his left. Again when he reaches for the cars that he needs, he has to cross his mid-line!

• We have balance boards and gym balls that L will sit on and bounce on, all the while developing his core stability.

• We'd play ball games and we'd encourage L to catch and throw a ball with both hands.

• When we noticed that L was seated in a w-position, we'd encourage him to sit with his legs out in front or with his back up against the furniture or the wall so that we could develop his core stability.

In the beginning of our journey, we would model to L on how to do the skill. This helped tremendously in L being able to successfully complete the skill. And when he became frustrated, we'd offer him reassurance and encouragement! Three years on and we still practise this skill with L. He still becomes frustrated to an extent, but his ability to cross his mid-line in now much stronger.

W-Sitting - What is it?

**** Please note - If you are concerned that your child sits in a w-sitting position on a long term basis, please seek advice from a trusted medical professional. ****

Prior to gaining L's ASD diagnosis, he would regularly sit with his legs in the shape of the letter "w." I'd often seen other children seated in this position as well but didn't really think anything of it, nor was I concerned about it.

L occasionally still sits in this position, especially when he has had a rough day, and I've since learnt that it really isn't the best position for children, or adults for that matter, to be seated in.

O also sits in this position on an occasional basis but not nearly as regularly as L does.

L's sitting position is a regular topic of discussion between ourselves and his Occupational Therapist. Over the past several years we, and his Occupational Therapists, have been doing a lot of work with L on sitting in other positions and on strengthening his core muscles.

So for those that aren't in the know, what is w-sitting?

W-sitting describes when a child is seated on their bottom, with their knees bent and legs splayed out to their sides in what looks like the letter "w." It looks awfully uncomfortable but L prefers this seated position to the more conventional crossed legged position. I've attempted to seat myself in w-sitting to demonstrate what it looks like and have had a lot of difficulty sitting down and getting back up - although this could be due to my age and lack of flexibility!

Children will often prefer a w-sitting position to sit in as opposed to other more challenging and tiring positions. The reason for this is that when seated in a w-sitting position a child does not need to engage their abdominal muscles. When seated in the more conventional cross legged position, a child must engage their abdominal muscles to stay upright.

When L sits in the w-sitting position we can see that his body appears to sag onto the floor. Now that we know what to look for, we can see that he doesn't engage his abdominal muscles at all. And he can sit in this position for longer periods of time with ease than other positions. When seated in the more conventional cross legged position, L tires easily as he has to engage muscles to stay upright. When seated in a cross legged position he needs to move around on a regular basis to offset the uncomfortable feeling that he gets from his tiring muscles.

Sitting in a w-sitting position provides a very stable base for the child's trunk and hips and therefore allows a child to move easily to play on the floor. However the movement is generally in a forward and backward motion as opposed to moving and turning from side to side. 

The tricky thing about the w-sitting position is that many typically developing children will, at some stage, sit in this position. What most parents, myself included prior to L's ASD diagnosis, do not realise is that excessive use of this position during a child's growing years may lead to future orthopedic problems.

One of the issues with the w-sitting position is that it does not allow or permit a child to perform trunk rotation, or twisting and turning, and lateral weight shifts, side to side motion, to reach toys on either side of the body.

The development of trunk rotation and weight shifts over to one side and to the other is vital in children as both assist in maintaining one's balance while running and walking as well as when climbing and playing on play equipment. It is also necessary for being able to cross our mid-line when writing, drawing, turning pages on books, dressing oneself and other similar skills.

Sitting in a w-position on a long term basis may cause orthopedic issues in a child's hips, knees and feet as well as tightness in the leg and hip muscles. I'd never made this connection until speaking with L's OT but it does make a lot of sense as the w-sitting position itself doesn't look like a natural position to sit in as the joints are bent in unnatural ways. Although in saying that L makes it look very natural!

If a child sits in a w-sitting position once in a blue moon, there is really nothing to be concerned about. However when it occurs on an ongoing basis, the child really should be re-directed to sit in a different position so that any potential issues with their joints and muscles are avoided.

So what alternatives are there I hear you ask and what are the benefits of other sitting positions?

Side sitting - This is when the child sits with bent knees and both legs are out to one side, one leg will be tucked under the child's bottom. If seated in this position, the child should really be encouraged to swap legs from side to side occasionally so that the muscles don't become tight on one side of their body. This position allows a child to maintain flexibility in their hips but it also forces a child to engage their trunk muscles!

Cross Legged sitting - This is the more conventional sitting position used by most children. They are seated on their bottom with their legs crossed in front of them. It is often referred to as "sitting with butterfly legs" or "criss cross apple sauce" legs! This is an ideal sitting position as it assists in stretching the muscles in the hips that can become tight with persistent w-sitting. It also assists in strengthening a child's abdominal muscles.

Circle Sitting - This is very similar to cross legged sitting however in this position the legs are not crossed but instead they form a ring in front of the body. Sitting in this position increases a child's base of support and therefore provides them with greater stability. This is a more stable position than cross legged sitting and is great for children when first learning to sit. Babies will often sit in this position to begin with as it is quite a natural way to sit.

Long Legged Sitting - This describes when a child sits with their legs straight out in front of them and slightly spread apart. Seated in this position can help in stretching a child's ham strings. It takes a lot of energy for a child to sit in this position if they are not used to it and if the child struggles to sit up tall or they need to lean back on their hands for support, it can be an indication that their hamstrings are tight.

Sitting against a wall - This position looks exactly like it is called. The child sits against a wall, or furniture, with their legs straight out in front of them. This position provides a child with the extra stability that they may need but also assists in stretching their ham strings.

We also encourage L to sit on a wobble cushion as he can move about if he needs to but he also needs to engage his abdominal muscles as he wiggles about on the cushion. He actually prefers to sit on the cushion as he sees it as a game! The wobble cushion is a win-win option - L has fun but he's engaging and strengthening his core muscles at the same time. Make therapy fun and children will want to participate!

As mentioned earlier, L's Occupational Therapists have been a god send in suggesting other options for L to sit in as well as other activities for L to engage in. We do still allow L to w-sit as he is incredibly comfortable in that position but it isn't on a long term basis. L is now at the point that when he does sit in a w-sitting position, he will often self correct.

And as mentioned earlier, if w-sitting occurs once in a blue moon there really isn't anything to worry about. It is a behaviour often seen in typically developing children. But as with other ASD traits, when it is an ongoing behaviour or action, that is when we need to be on the look out for options to redirect the child to use.

Child's Play. Therapy at Home!

I have mentioned several times in various posts that I am able to turn almost any household chore or child's game into a therapy activity.

In my experience with working with children in early learning settings, through my previous jobs as an Education Officer and even with my own two little superheroes, I have found that children learn best when they are playing.

Children, including my two little superheroes, seem to be more willing to take part in an activity when the activity is fun and enjoyable. They seem to learn best when they think that they are just having fun! If only they knew the truth that, shock horror, they were actually learning and practising new skills!

When an activity is fun and it is purposeful, this can be a huge factor in determining how successful the activity will be and how long a child will willingly participate in the activity.

When L started in his early intervention therapy last year, we wanted to give him the best opportunity possible of succeeding with the new skills that he was being taught.

So Daddy superhero and I decided that we would attempt to turn everyday household activities and chores into therapy activities.

Home really is filled with endless opportunities to teach our children new skills and to allow them to practise new skills.

So here is my list of the how, and the why, to turn household chores into learning opportunities.

But, and there is always a but, before I go on ALL of the following activities are based on our families experience and should NOT be considered medical advice. If you feel that your child lacks in any of the areas that are included in this piece, please consult your GP or paediatrician.

Crossing the Mid-line.

First up, what is the mid-line?

The mid-line is an invisible line that runs down the centre of our body and divides the body into the left and right. The ability of being able to cross the mid-line is not something that babies are born with. Children develop the ability through "normal" childhood development. But it is an ability that babies and children practise every day through play - reaching for toys, playing with their toes, exploring objects with their hands and so on.

Being able to cross the mid-line is an important skill to develop - we use it when writing, reading a book, tying our show laces, sitting cross legged on the floor, doing puzzles, hitting a ball with a bat, catching a ball and the list goes on. Any time your right (or left hand) crosses over to the opposite side of your body, you are crossing your mid-line.

Some children struggle to cross the mid-line and L was one of these children. His lack of being able to cross his mid-line was evident when he was drawing or painting. When drawing or painting on a piece of paper, if he wanted to draw or paint on the left hand side of the page, he would turn the page on the table to get to the spot that he wanted to decorate. L was physically unable to put his hand across his body to the left hand side.

When L was in kindy he was desperate to be able to write his own name, but crossing the mid-line can be a pre-cursor to be being able to write from left to right on a page. Mmmm, what to do.

He was practising crossing his mid-line at the early intervention centre through play, and at home through the following activities.

• Drying dishes - One of L's favourite household chores is drying the dishes - one day, his future partner is going to love me! We have a small child's table that we use for various reasons in our house. I seat L at the table, put the dish towel in his right hand and the wet dishes on the left hand side of the table. Through the action of reaching across the table to the wet dishes he was crossing his mid-line each and every time. 
• Painting - I'd always put the paint on the opposite side of the table and ask L to try and reach the paint without moving his body. Again, every time he reached for the paint, he'd have to cross his mid-line.

• Car letters and numbers - We have created a game board for L to practise his letter and number recognition skills. I have put letter and number stickers on the top of toy cars and have laminated words that L wanted to learn how to spell. L sits directly in front of the board and we put the cars that he needs to his left. Again when he reaches for the cars that he needs, he has to cross his mid-line!

Every time we were assisting L to practise these skills, either myself or Daddy superhero would model to him how to do the skill. This helped tremendously in L being able to successfully complete the skill. And when he became frustrated, we'd offer him reassurance and encouragement!

Proprioception Input.

Earlier this year I published a post on Sensory Proprioception. Put simply, the sense of proprioception is little known but it is very important as it is responsible for our body awareness and position. The proprioception sense tells us where our body parts are in relation to each other, it gives us information on how much force we need to exert in certain activities, like when hugging someone.

Prior to L starting early intervention, I can honestly say that I had no idea what this little known sense was responsible for. When one of his therapists explained the sense, it was a "aha moment."

We then had to start incorporating activities into our day to day routines so that L's sensory proprioception input was increased which in turn assisted in further developing his sense of proprioception.

We did this by:

• Getting L to assist in carrying the shopping into the house from the car. By carrying bags of differing weights he was able to get a feel for what different weights felt like.
• We'd get L and O to help with "heavy work" activities around the house - helping to pack away toys in the house, helping to put the washing into and out of the washing machine, watering the vegetable garden with a full 3L bottle of water, moving child's furniture around the house. The possibilities are endless!
• We'd do some deep tissue massage by squeezing L's arms and legs when he was agitated.
• We'd encourage L and O to play with different fidget spinners, playdoh and other sensory toys so that they could work out what level of force they needed to manipulate the tools.
• We have an endless supply of different types of pillows and blankets that the little superheroes can stack, climb on and hide under.

The possibilities for increasing a child's proprioception input really are endless!

Fine Motor Control.

Fine motor control really is a no brainer - we need this skill every day to tie shoe laces, to do up buttons and zips, to write, to read and so on.

Fine motor control is defined as the coordination of our small muscles usually in synchronization with our hands, fingers and eyes.

There are many ways in which a child can practise these skills.

• L loves to help hang the washing out and take the washing in - in particular he just loves playing with the pegs! I'll put the peg basket down at his level and let him play with the pegs, but the deal is that he has to pass me pegs when I need them. We have a game going where he pegs them onto the side of the basket and I take them from there. When we first started playing this game, hanging the washing out dragged on and on as L struggled to clip the pegs onto the basket. He would usually end up needing to use both hands to manipulate the pegs. Now, he manipulates the pegs with one hand with ease.

• Prior to going on a family holiday to Queensland in 2016, I created a pencil case of different letter recognition games. L loved "playing" with each and every one of these games. From my point of view, every one of the games helped with his fine motor control - he had to use pegs to clip onto the correct number on some games, he had to pull velcro pieces on and off of other games and all of the games assisted with his number recognition skills.
• Drawing and painting - we'd encourage L to use the pencil grip to hold whatever he was using to draw or paint with.

• We have a puzzle board with various clips on it. L loves playing with this and as every clip on the board is different he uses varying degrees of fine motor control to open and close the clips and puzzle pieces.

Again the possibilities for fine motor control activities are endless around the house.

Emotional Regulation

Put simply emotional regulation is the ability to recognise and respond to our own emotions as well as the emotions of others.

Emotional regulation is an important skill for ALL children to learn as it assists them to not only recognise and respond appropriately to their own and others emotions, it can also assist with their overall behaviour. It is thought that emotional regulation is linked to how well children manage other tasks during childhood. Through successful emotional regulation, children are more able to manage difficult and stressful times that occur as part of life. And as a child learns how to self regulate their own emotions, their concentration ability, turn taking and sharing skills are also improved. 

L has always struggled with his own emotional regulation - it was one of the big tell tale signs of his autism from an early age. L rarely responded appropriately to the emotions of others.

We try to incorporate emotional regulation into our daily routine, especially when reading books with L and O.

While reading, we talk about how L and O think the characters are feeling during the story. We talk about why the characters might be feeling that way - what is happening in the story to make them feel that way. We talk about how the story makes O and L feel.

We read books on emotional regulation, such as The Monsters Inside, during which the story gives L and O ways in which they are able to self regulate their own emotions.

Talking about how different characters are feeling also assists in developing my little superheroes theory of mind skills - but that is another blog post!

When deciding on what area of therapy an activity or game would slot into, I think outside of the box. I take a good look at the how and why of an activity. 

Do you have any activities that you do regularly to assist your child's development? I'd love to hear all about your ideas.

*** Theory of Mind - You may have seen this written as ToM. Theory of Mind is the ability to attribute your own mental states (beliefs, intents, desires, emotions and so on) not only to yourself but also to others. It is the ability to place your self in the place of others to try and work out how they may be feeling at any particular moment in time. It is also the ability to understand that others may have different perspectives than your own. Quite often theory of mind has not fully developed in individuals who have autism and as such they will struggle to understand how others are feeling.