Category Archives: Case Study

A True Outlier: Mia Skins the Cat

Dr. Karen Pape wrote the following post on her site in August 2013. Sadly, Dr. Pape died on June 2, 2018. As a tribute to her, I’m reposting it here. Below her post, I share a comment about falling that I wrote in response to her original post. Shortly after Dr. Pape wrote this, I shared my  Reflections on Outliers Post by Dr. Karen Pape which in many ways was the seed for the career transformation that I have undertaken this year.  

In a previous post, I asked people to write me about Outliers…children who were doing more than expected after an early brain or nerve injury. This is Mia, demonstrating a new skill on her 4th birthday.

When you watch her “Skinning the Cat”, it is hard to believe that she had a stroke in the early days of life. The damage was to the left side of her brain, causing a right hemiplegia. Yet holding on to the rings, both hands and arms are working equally hard. Both legs swing up and over. There is no evidence of the hemiplegia. This result is not magic – it is the result of a determined child who has adopted the “I can do it” philosophy taught to her by an equally determined mother. I think both of them qualify as Outliers!

This is the link to the full story of how Mia first learned to swing, then to lift her legs up and finally over the top.

Her mother’s description, still shots and videos, take you step-by-step through Mia’s learning process. First and foremost, Mia expects to be able to accomplish this task and she works hard, through many failures, until she reaches her goal. She is encouraged by her mother and also has the added role model of her older sister. If Zoe can do it, then I can do it! I am quite sure that during the learning process, Mia has taken some falls. She probably had a few bruises as well. Learning a new skill is a series of failures, trying new methodologies and finally success. Mia has the advantage of watching her older sister work through the same sequence of learning and she is up to the challenge.

How many children with an early brain or nerve problem are allowed to fall? When I was in clinical practice, I always checked young children for bruises on the legs. It is a normal finding in growing, exploring children. The absence of bruises often means there is an excess of watchful helpfulness. The cognitive neuroscience experts…and master coaches…understand the simple reality that learning is an experiential process. No able-bodied child has ever learned to walk without a lot of falls. Brain neuroplasticity is activated by a novel challenge. In the absence of challenge, the child’s normal habits dominate. In the past, many therapists had tried to get Mia to extend her arm and grasp. She learned how to do it when she had to…new habits are formed by novel, challenging tasks that have consequences. Read the whole post about Mia’s learning process. Her mother and sister offer some guidance and ensure her safety, but the process of trial and error…by Mia…is the way her brain learns the task.

At the end of the video, Mia says, “I flipped”. Her pride in herself is a precious gift and I am grateful to Mia’s Mom for sharing her story. We need more of them.

August 7, 2013 
Mara commented:

It’s such an honor to have Mia featured here along with Zoe and me. Thank you.

And, you guessed right, she definitely has fallen over and over. She falls all the time and happily proclaims before I can say anything, “I’m okay Mommy!” Then, she hops up and continues doing whatever has captured her attention. And manipulating band-aids for all those little boo-boos is excellent fine-motor practice for both hands, fundamentally a bimanual task.

Just yesterday, we were at a play structure and Mia was playing on a triple trapeze swing, similar to the one in the video above. Just six weeks after first doing skin-the-cat, she continues to take new risks. She can hook her legs with knees bent over the bar and hang head down. She was so bold as to let go with her hands and hang there for a few seconds seeking a thrill. And then, just as I was starting to panic wondering if she’d be able to find her grasp again on the rings she did and she flipped off the bar and had the biggest smile.

It takes some training as the parent to stand by and witness this kind of courage and determination, but the rewards are tremendous and often surprising.

Sisters Pogo Sticking

This morning, I mentioned to my girls that a year ago I had posted about their pogo sticking feats. Zoe reminded me that she led the way and inspired Mia to want to learn this new skill. When I commented that Zoe hasn’t been pogo sticking lately, she said that she has outgrown the one pogo stick we have so it’s time to upgrade.

Here’s Zoe in action with Head-and-Shoulders thrown in for fun in March 2017 at age 10.

Zoe’s tricks on the pogo stick motivated Mia to master her own tricks. A year prior to this, Mia had a hard time making the pogo stick go down.  Here is Mia “one handed” with her tongue out to help focus! Variety is one ingredient in healthy movement development so part of what I am sharing this month are many of the different activities Mia tries. Pogo sticking requires balance, timing, and comfort with falling. Here’s Mia in 2017 at age 7.

And, here is Mia this year in 2018 at 8 years old.

Triple Trapeze Stunts – Age 8

While Mia is more drawn to team sports than gymnastics, she continues to challenge herself on our backyard play structure and on similar challenges at larger playgrounds.

She’s come so far from five years ago when she first managed to skin-the-cat, as the flip over is called on this triple trapeze bar with two rings.

I love her inventiveness, how she does the movement to get her feet to flip over and then reverses it, then she starts from the midpoint, to flip back, again and again. As you watch the videos, notice how she is patient with herself, giving her right hand time to find its way into the ring, to grip, how she leads with her left hand but waits until both hands are participating to flip herself over. She uses her eyes to help make sure her right hand is where she wants it to be as her sensation in righty is reduced.

Mia had a stroke at birth and has right hemiplegia, affecting her right arm and hand.

Mia loves playing goalie

In the final weekends of the hockey season, Mia got to play goalie for both of her hockey teams, the highlight of her season! As her mom and one of the assistant coaches for her over the past five seasons, it’s been a joy to witness her development, focus, self advocacy, and passion for this position as goalie. While I played hockey through college, I was not a goalie and was never drawn to the position.
Mia started to play hockey when she was four, see Preparing for First Hockey Season. The previous winter, she had skating lessons. Mia’s Skating, Play Detective with Me shows her early skating progress. Pretty early on, in her first season of house league hockey when she was five, Mia started to ask to play goalie whenever she could. Since she’s left handed with a smaller and less functional right hand due to a stroke at birth, we figured out that she needed to hold the goalie stick in her left hand. There was not any beginner equipment in the league locker for this opposite side glove/blocker, “full right”, or if we found it, it was way too big. So, Mia played goalie in her regular hockey gloves.
Mia is incredibly persistent when she wants something so she started to ask for me to buy goalie gloves for her. By December 2015, she was successful in persuading me. I still had my doubts but didn’t voice them to her. Instead, I delighted in that grin, got out some tennis balls and started tossing them at  her.
Pretty soon, she got a chance to wear the new gloves on the ice
The following season, when Mia was seven, she had an opportunity to play on a 10-and-under girts team that actually had players ranging in age from 7 to 12. Mia was the youngest. They played full-ice hockey, 6 vs. 6, including a goalie. Undaunted, when the regular goalie was away, Mia volunteered to play in net. She attended a few goalie clinics that the league offered throughout the season.
Mia kept working on her glove skills for goalie, off-ice. When she attended a week-long constraint therapy camp where they cast her left arm and she focuses on improving functioning with her right arm, her chosen goal was to improve her catching ability with that glove.

Around this time, she also got fitted for a neoprene hand brace to wear on her right hand. We tried having her wear it under her goalie catching glove and it worked for a while to keep it on more consistently, but she eventually said it was not as comfortable with the hand brace so she stopped wearing it.

This 2017-2018 season, Mia played on two teams, a coed Mite A team with just two girls, and an all-girls 8-and-under team. She asked to play goalie whenever she could, though both teams rotated the goalie position among all teammates. In a recent tournament, Mia was picked to play goalie for her girls’ team. And, they got into the playoff round of the tournament due to her lower goals-against total.
Our local hockey program offers to pay half of the cost for private goalie lessons, 30 minute lessons once a week for 20 weeks, and so I signed Mia up for that. The first goalie coach suggested a new helmet and a bigger stick so we went shopping again. Mia’s chest protector is a hand-me-down and her leg pads are on loan from our hockey program. I’ve done surgery on the catching glove multiple times to help Mia get a better fit. Still, several times each practice or game, she comes over to ask me to help put it back on which is a two-person job since she has less strength and dexterity with righty. She’s learned a decent butterfly move.
Initially, the coach we were assigned was a poor fit. He yelled at the Mia and coached 8-year-olds as if they were at a much higher level. He was not making any accommodations for Mia’s limited use of her right hand. It took me a while to sort this out as Mia was getting a ride to these afternoon lessons mostly with our au pair. Then, I went to a lesson and saw Mia in tears. She said she didn’t want to do the private goalie lessons anymore. With her permission, I wrote to the head goalie coach to express my concerns, and we took a break before trying again with a new goalie coach who was thankfully a much better fit. He immediately saw what Mia could and could not do, and gave her homework to watch YouTube videos of Connor Hellebuyck, an NHL player who catches in a nontraditional way. Mia learned a new way to catch, and continues to refine this. She has been so thrilled to catch pucks in games.

Here is Mia in action in some games. She ended the season loving goalie more than ever and tried out for next season to play goalie full time. I’ll still make sure she practices her skating without all the pads but her heart is in goal. She’ll play on a U10 all-girls team, seeing time in net every game.

Case Study: Ponytails and Folding Socks

Zoe is a great inspiration to Mia. Just this morning, Zoe put her hair in pigtails, and before I knew it, Mia had too. Zoe is seven. Mia will be four years and nine months old tomorrow. Zoe wasn’t even aware of the idea of doing her own ponytail or pigtails until she was in kindergarten last year and saw a classmate doing it. Mia has the good fortune of watching Zoe do everything day after day so she gets the idea that she can too.


I don’t always see it coming with these new challenges that Mia defines for herself. A couple of weeks ago at bedtime, I noticed that Mia was brushing her hair a ton with leave-in-conditioner and getting frustrated with the tangles. I thought her frustration was related to hairbrushing. It wasn’t until the next morning, when I was sitting on the couch reading to them and Mia was attempting a ponytail and getting frustrated and then going into the extensive brushing routine again that I realized her quest to give herself a ponytail.

Mia is very dominantly left handed and she can do a lot with her right hand, especially in bimanual (two-handed) activities, but learning a new skill behind her head seemed pretty daunting to me as the observer.

So, here’s what I observed in an e-mail I sent to her occupational therapist. “Mia has embarked on teaching herself to do a ponytail on her own hair. She has many of the concepts and steps but not all so is getting frustrated. I am looking for ideas and ways to support her. She puts the elastic on her left hand, uses both hands to gather the hair into her right hand to hold it there. She uses her teeth to get the elastic from her left wrist onto her left hand, and then manages to get it around the bunch of hair somehow but gets frustrated and stuck after that. She then claims her hair is tangled and embarks on a lot of spraying of leave-in-conditioner and brushing with her left hand which migrates her part further to the right. Can you help Mia work on this, break it down, etc?”

Then, I went online and searched for “one-handed ponytail” and posted to ask other families with stroke survivors for their experience with kids learning to do ponytails. One replied that her daughter had learned at age eight. Another told me how ambitious Mia is to be attempting this so young.

I thought about putting out elastics of various size and texture to let Mia experiment. But, life is busy, and I haven’t done much to support her, and still she’s learning, very much on her own initiative and with the ongoing model of Zoe.

At Mia’s weekly occupational therapy, that first week of March, they talked about how frustration comes with learning something challenging. They experimented with doing things in front of Mia so she could see and feel to get the concepts more solid. The therapist even offered that Mia could try on her hair. Instead, they made a bunch of yarn to use for practice. And, in that way, Mia learned the concept of twisting and doubling over the elastic to loop it through a second time.

I’ve seen Mia successfully make a ponytail in her hair once. Even doubled over, the elastic was too loose and fell out after about half an hour. I had no idea she could do pigtails, and since I didn’t see her doing them, I don’t know exactly how she managed, except that she must have reached over around her head to do the major work with lefty.

Since I don’t have good video of her working on this new skill, I thought I’d share another recent clip of a different self-defined fine-motor task. I got the girls new socks and Mia set herself the task of folding them all into balls. Enjoy and look to see how she uses her two hands differently. And, if you listen, you’ll hear Zoe in the background, alternately vying for attention and cheering Mia on as she folds socks. That’s our normal. Zoe said just this morning, “Mia’s learning early with the pigtails and ponytails!” Mia’s persistence, determination and inner drive are all quite remarkable, even more so because she’s not yet five.

Update from March 21, 2014

I managed to capture a video of Mia making a pigtail. Notice how she gives each of her hands different jobs at every stage of the process. And, you can see her moment of pride as she accomplishes what she set out to do. Enjoy!

Preparing for First Hockey Season

My girls think it’s hysterical that my first hockey shin guards were improvised, soccer shin guards paired with foam knee pads. That didn’t hold me back. I played one year with boys, starting when I was eight, and then joined the girls’ league. I went on to play Division I hockey at Brown University, just as the game was shifting to a more competitive level.

Two weeks ago, I signed the girls up for hockey and myself up to coach. The season has already started, but soccer still fills our Saturdays for another couple weeks. After figuring out that their skates still fit, and Zoe had a helmet, but Mia did not, we went shopping. I bought full sets of equipment the first weekend we decided the girls want to play but we hadn’t had time to touch it since. Sunday, they tried it all on, I showed them how to tape their sticks, we labeled it all with their names and color-coded tape (green for Mia, pink for Zoe), and the girls got so excited that they wanted to go to public skating.

October 2013 – Mia 4.25 years old, Zoe 6.75 years old

It was not crowded, skating was fun and leisurely. Both girls wore their hockey gloves. Mia brought me her right one and asked for help to find spots for each finger. She kept it on easily throughout the hour of skating.

Both girls picked up where they had left off with their skating after a season of lessons last winter. Zoe was too fast to capture well on video in the low light. She progressed a great deal last winter, which was the first year when it was feasible for me to take both girls skating regularly, both to open skate and to weekly lessons for four months.

Here’s a moment when Zoe wanted to skate with Mia. For me, it was so lovely to be on the ice with them both. They needed much less help from me than last year, or any prior year, and I can glimpse ahead that in a few years, they’ll be skating circles around me. Zoe told me that she feels lucky that I know all about the equipment and about hockey. She has noticed that most of the soccer coaches are men and it already makes a difference to her to have me there on the ice with her.

In this tiny clip, I captured Mia falling and getting up quickly and easily. Anyone familiar with hockey knows this is the first and most important skill. The notable moment of this video for me is that to stand up, Mia first stands her right foot. Last winter, she used her left foot exclusively. Her right side is the side affected by her stroke. I’m so happy to see her using both sides now to fall and get up. And, I was also happy that she was able to manage her glove on her right hand.

The girls wanted to stay to watch the Zamboni clear the ice but there had been so few skaters that they didn’t need the Zamboni. I promised many more opportunities to watch the Zamboni.

Just to show our history of attempting to skate each winter, here’s a photo log. We missed one winter when Mia was an infant.

January 2008 – Zoe, 1 year old

January 2009 – Zoe, 2 years old, with Mara (pregnant with Mia)

January 2011 – Mara helping Mia get her skates on

January 2011 – Mia, 18 months, with Mara

January 2011 – Mia, 18 months

January 2011 – Zoe, 4 years old

Thanksgiving 2011 – Zoe, almost 5 years old, with cousin Alex

Thanksgiving 2011 – Mia, 2-and-a-half

Thanksgiving 2012 – Mia, 3-and-a-half

Thanksgiving 2012 – Zoe, almost 6 years old

October 2013 – Mia 4.25 years old, Zoe 6.75 years old

Case Study: Skin-the-Cat

Mia taught herself to do skin-the-cat the weekend of her birthday party, days before turning four. This is one of many seemingly amazing milestones she’s hit this spring and summer. I’ve been celebrating them along with her and Zoe. In fact, the first time she did it I was not watching and Zoe helped her. Mia came to tell me and repeatedly told me, “I’m so proud of myself!” And, she was, she owned her new accomplishment.

Here she is, the morning of her birthday party in full action.

I have a series of posts in mind that I’d like to write over time to show and tell how I think it’s been possible for Mia to master so much. I happen to have a lot of photos and videos of her development. This is the first such post. Mia is incredibly determined and courageous and always has been. I’m quite attuned to her needs and goals and have focused a lot of attention on providing an environment where she can continue to thrive and learn, sometimes in surprising ways. Mia has been pretty persistent at mastering her world since infancy and that continues. Her repeated practice in different settings allows her many “successive approximations” until she masters a new skill. This notion of “successive approximations” is one that Feldenkrais wrote and spoke of often.

At four years old, Mia definitely owns her “I can” attitude. She has many experiences of watching her older sister, Zoe, master one thing after another. And, Mia comes along finding her own way to do many of the same things in her own time. Just this week, she surprised me in the lake where we swim. She’s swimming farther each day than the last without assistance or floatation and now she’s asking to dive under my legs, just like Zoe. And, she surfaces with rocks in her clenched fists asking me to guess which one has the rock and which one has just sand.

This story goes way back to when Zoe was an infant and some friends lent us this baby hammock for her to sleep in. Zoe was so mobile that she only lasted a couple of months in this hammock because I was afraid she’d end up on her belly in the soft hammock and obstruct her breathing.


Those friends needed it to lend to another family so we gave it back but I asked to borrow it again when I was expecting my second child. I had it set up days before Mia was born, and Zoe discovered that it worked pretty well as a place to swing like a monkey. Zoe was nearly 2.5 at the time.


Mia did sleep in it too for a few months. By the time she was done with it as a sleeping hammock, Zoe’s habit of swinging from it was so established that I put the hammock away and left the frame in my bedroom for daily gymnastics practice.


Mia started to swing from it a couple months after turning two.

Zoe taught herself to do skin-the-cat on the hammock frame when she was 4 years, 8 months.

When Mia was nearly 3, she could swing from rings like these. Soon after this picture, we got our own set for our outdoor playset.


At Zoe’s, sixth birthday party, when Mia was 3.5, Mia was able to support herself well on the bar and pull her knees to her chest.


So, Mia’s seemingly sudden mastery of skin-the-cat on the triple trapeze swing featured at the top of this post really can be traced all the way back to Zoe discovering what a wonderful piece of equipment that baby hammock could be, without the hammock of course.

The frame remains in my bedroom. I’ll close with a video clip of Mia working and working to get her feet on the frame of it. She had done it several times before I started trying to capture it on video so by this time she was tired. But, you can still see her determination, intense persistent efforts and  good attitude. Note how she experiments with placing her hands in many different spots to see how that feels and works. Allowing all of these attempts is what ultimately helps Mia build strength to master these skills and many others. And, she can transfer the same skills to doing the monkey bars.


This post on bicycling is part of my streak in the month of May to spread awareness about pediatric stroke. Please consider donating to support Children’s Hemiplegia and Stroke Association, an organization that has helped our family tremendously with support and information.

Both my girls started riding balance bikes (2 wheels, no pedals) when they were two years old.


In late March, Zoe asked me to go to the bike store to look at bikes. She’d been outgrowing her 16″ bike which she rides well. I had raised the seat but then the handlebars were too low. Of course, Mia also chimed in with, “I want a new bike too!” That wasn’t part of my original plan. She was on track to stay on the balance bike a while longer and then get Zoe’s 16″ hand-me-down.

For historical reference, Zoe could ride her Skuut balance bike the mile to their daycare before I got her the 16″ “pedal bike” which was in the spring after she turned 4. We skipped training wheels. The 16″ bike was a little too big. She could pedal right away and balance and steer but it took her a while to be able to start and stop with confidence and she went back and forth between the balance bike and the pedal bike for more than a year before things clicked on the pedal bike.

On that shopping day, I ended up getting Zoe a 20″ bike with hand brakes and gears. It seems like she is a really big kid all of a sudden. She can ride it well and independently. I even let her go up and down the street by herself. She’s good about going to the side of the road when a car is coming.

Mia fell in love with a little red 12″ pedal bike so I indulged her too. Mia could pedal, balance, and steer on day 1. She still needed help to get started over and over again, but she mastered her 12″ 2-wheeler faster than Zoe did the 16″ just because it’s more her size. Bicycling is an excellent skill and activity for Mia with her right-side challenges as it requires that she use her whole self in a balanced way. The grip on the handlebars and the pressure up through the arms is good for her. On her first day, she seemed to need to look at her feet to make sure they are on the pedals and some of that could be that she’s learning but some could be that she uses her eyes on the right foot particularly since her sensation is less developed there. I kept reminding her to look up at Zoe who was off in front most of the time.

Here’s Mia after just three weeks on her new pedal bike. She can pedal, steer, turn around to come back, and stop in a controlled way. You may notice that she does let go first with her right hand when stopping at the end of this video. Since that video, she has taught herself how to start on her own, all before turning 4 in June!

My lessons from this experiment in supporting two children in learning to ride bicycles:

  • Balance bikes are awesome! Kids learn to balance and steer and go fast without also dealing with pedals.
  • It’s possible and faster to skip training wheels.
  • The right size bike makes learning much easier. I don’t mind that Mia will outgrow her 12″ bike after a season if she has used that season to master the skills.

Monkey Mia

There is a place on the west coast of Australia called Monkey Mia. It’s famous for the dolphins that come ashore. I was there in about 1995 after a research cruise that ended in Perth. But, we never saw any dolphins.

“Monkey Mia” is a good nickname for my Mia now who seems utterly determined to master the monkey bars as soon as she can.

This evening, we went to the park. Zoe is a pro at the monkey bars, so fast that I couldn’t get any pictures of her on them. I was also trying to help spot Mia. Little did I know that Mia had moved on and no longer wanted my help.

Zoe is trying to master her next challenge with climbing trees  with branches that are kind of hard to reach.


So, here’s Mia in a series of action shots. Her focus and motor planning are palpable. She makes the riskier big reach with lefty as she knows that’s safer for her and then she’s able to reach and extend her fingers to grasp with righty.



Every occupational therapist who has worked with Mia has focused on helping her extend her right arm, hand, and wrist. This shot below is an incredibly clear view of how well she has to do that to succeed in her goal of mastering the monkey bars.





And, here’s a video of Mia putting it all together on the monkey bars.

Earlier this week, Mia figured out how to get started on her bike on her own. She’s been riding it well for a few weeks but still needed a tiny push to get going. No longer. It’s almost as if each new motor skill she masters drives her to find the next challenge. In the last picture above, she’s reaching for the fifth bar. There are only two or three after that. And, she wants to go back to the park to practice so she can go all the way across. She did the monkey bars so many times this evening, dropping to the ground each time her arms gave out. She’d get up and say, “I need to try again.” I started to worry that her determination was so intense she might keep trying past the point of fatigue and injure herself. I gave my 5 minute warning and we biked home for bedtime snack.

This post is part of my streak of posts in the month of May to spread awareness about pediatric stroke. Please consider donating to support Children’s Hemiplegia and Stroke Association, an organization that has helped our family with support and information.

Update on September 3, 2013

Here’s Mia yesterday at 4 years 2 months old (four months after her early forays shown above) showing me that she has been practicing and can go all the way across the monkey bars. Note how confident and nonchalant she is. She just knows she can do it and she does. You might also notice that she consistently reaches first with her left arm (unaffected) and then with her right arm (affected by stroke). She does this for every one of the seven bars, reaching first with lefty, then with righty. She happens to be wearing the same lucky butterfly shirt she wore in May when I first captured her learning to swing on the monkey bars in the still and video images above.