does your child w-sit?
A somewhat 'normal' position used among children can lead to abnormal development
By Donna Greco, MPT
Chatting with the parents of children in a playgroup, one mother began watching the toddlers closely. She noticed that her 12-month-old daughter, Jessica, sat differently than the other children in the playgroup. She also noticed that as the children explored the environment, each child used different methods of mobility to get from one place to the next. Suddenly intrigued by the diversity of physical development, the mother took a break from the adult conversation. Although close in age, the children's skills varied considerably. Some walked upright, others crept around on all four limbs to reach their destinations.
The mother observed closely as the children interacted with one another, moving into and out of several different play positions. The adult conversation blurred to a hum as she changed the full focus of her attention to the playing children.
She was particularly interested in the children's sitting positions. Some children sat with both legs to one side, propping themselves up on one arm, using the opposite hand to grasp and reach for toys. Others sat cross-legged, freeing both hands for play. She eyed Jessica intensely, suddenly aware that her child made no attempt to move about. Jessica maintained the same position; her bottom planted firmly behind her, each foot rested against the corresponding hip.
The position, appeared awkward to the mother, as she thought hard: Had she heard somewhere that this sitting position was unusual? Possibly abnormal? She did not recall, but Jessica seemed comfortable, and, even though she did not attempt to change position or move across the floor as the other children did, the child was playing contently. The mother continued to keep an eye on the children as she dismissed the thought, sighed and returned to the adults. Tuning in on the conversation, she quickly began laughing and chatting with the other mothers, comparing notes about toddlerhood.
Should the mother have been more concerned about the use of this unusual sitting position? Pediatric physical therapists unanimously say, yes! This position, where the child's bottom is firmly planted between the feet, is commonly referred to as W-sitting. Observing the W-shape formed by the child's legs, one can easily see how the term was coined. Many children frequently choose this position during play, and whenever observed it should be corrected immediately. If you know a child who W-sits you should be concerned, and here are the reasons why.
In a W-sitting position, the hips are placed at the extreme limits of internal rotation, predisposing the child to future orthopedic problems. In the abnormal position, the risk of hip dislocation becomes a concern. If the child has hip dysplasia, which commonly goes undetected in youngsters, sitting in the W-position increases the risk of dislocation tremendously. Pre-existing orthopedic conditions can worsen when major muscle groups are placed in shortened positions and begin to tighten. These shortened muscles are at risk to form contractures, and a permanent shortening of the muscle--especially prone are the hamstrings, adductors and Achilles tendon.
And That's Not All
W-sitting compromises balance development. A child who frequently W-sits does not need to use his trunk muscles. Because W-sitting allows the child to balance himself in a straight-aligned position, the trunk muscles are not challenged and balance reactions are not needed. As a result, trunk control and balance are slower to develop and delays due to nonuse are likely. Frequent W- sitters typically lack stability in their trunk and pelvis and will commonly rely on this abnormal sitting position to hold their balance against gravity. It is much eas- ier for children who have not yet developed mature balance reactions to W-sit during play because the hips and trunk are fixed and do not have to do much work. This static positional stability means that the child no longer has to be concerned with holding himself up. The child does not need to use trunk rotation or side-to-side weight shifting, as the position itself offers the child stability not found in other more developmentally acceptable positions.
It Gets Worse
Because trunk rotation does not occur during W-sitting, midline orientation is avoided. Children naturally begin to bring their hands together at midline to manipulate objects, but a child who regularly W-sits is discouraged from engaging in this important milestone. Instead, the child tends to use the right hand on the right side of the body and the left hand on the left side, disrupting bilateral hand use and the development of future hand preference. The W-position discourages the child from crossing over midline, which involves shifting the weight of the upper torso onto the opposite arm and using the trunk muscles to rotate in order to retrieve a toy. Midline crossing, bilateral hand use and hand dominance are important developmental milestones that pave the way for the development of more advanced motor skills.
What to Do
Prevention is the best method if you catch the problem early. When you see a child about to W-sit, immediately prevent it from happening. If you are too late to prevent the child from sitting between his feet, change the position immediately. Place the child in an acceptable position (see photos), and keep and eye on the problem. Let the child know what positions you prefer by encouraging alternative sitting. Be consistent. Each time you see the child W-sitting or attempting to do so, correct it. Children often assume this position when transitioning from creeping on hands and knees to sitting on the floor. From all fours, the child simply parts the knees and plops his bottom down between them, resulting in the W-position. To prevent this, keep the child's knees and feet close together when either creeping on hands and knees to sitting on the floor. With the knees and feet in close proximity, it will be impossible for the child to sit between them. Assist the child into an appropriate sitting position by gently guiding the legs out in front to promote a "long-sitting" position. If you choose side sit, be sure to alternate sides so that the child will develop trunk control and balance in both directions.
Observe the Child Closely
Does the child use other sitting positions or does he consistently assume the W-position? If he uses W-sit exclusively, it may be an indication that the child is having balance problems. If it hasn't already been done, suggest a referral to a qualified pediatric physical therapist. Frequent W-sitting can be a sign of developmental delay and a qualified physical therapist who specializes in pediatrics can determine whether there is a problem and give helpful hints for prevention.
No W-Sitting Allowed
I often teach parents and teachers of developmentally delayed children about the problems with W-sitting. A child with Down syndrome in our early childhood program has been a chronic W-sitter for all the reasons given above. He continues to W-sit because he finds it easier to play and interact with others if he does not have to worry about balancing himself while seated. His proximal stability is compromised by hypotonicity frequently present in Down syndrome, which makes him a prime candidate for W-sitting.
His therapy focused on discouraging W-sitting, encouraging normal sitting postures and developing balance by promoting trunk and pelvis strength. He has recently learned that we prefer he sit in a side-sit position. Everyone involved with this child's care has been trained to correct his chronic W-sitting habit. When the child is seen W-sitting in the classroom he is immediately told, "Fix your leg!" He quickly responds by moving one leg out and placing it to the other side. At 4 years of age, the child has just begun to walk, and if allowed to continue W-sitting, it is likely that his trunk and pelvis would not have developed enough to begin unsupported standing and independent ambulation skills this year. As with most developmentally delayed children, W-sitting is not the only problem, but continued use of this position can exacerbate existing delays.
W-sitting can have long-term effects if left unnoticed and uncorrected. So whenever possible, discourage this unnatural position. No child should W-sit, regardless of whether developmental delays are present. See photos for examples of acceptable alternative sitting positions. If a child cannot sit independently in other acceptable positions, it is important that he be assessed for modified sitting and positioning. Supported sitting along with other positions such as prone prop or side-lying may be among the recommended suggestions.
Jessica no longer W-sits and has moved forward in her physical development. Her mother is now aware of the problems of W-sitting and is the first to admit that continued use of the position may have been the reason why the child's balance and ambulation skills were delayed. Although physical development varies from one child to the next, a simple problem like W-sitting can be the culprit behind problems in children with otherwise normal development. *
Questions or comments are encouraged by the author, and may be used in her column appearing in local publications. Write to Donna Greco at 5014 Boetzberg, Christiansted, USVI 00820, or e-mail creative- firstname.lastname@example.org.
Donna Greco is a pediatric physical therapist who works with children with developmental delays in the Virgin Islands.