Increasing the Intensity of Sensory Input

A sensory diet is when additional sensory input is added into the child's daily activities. This might include making sure the child runs around or swings at recess as opposed to them just sitting there on a bench. It might also include a child wearing a weighted vest or backpack while on an outing. The list is never ending of how sensory input can be weaved into a child's daily routines: marching between locations, vibrating pen, "heavy work" activities such as cleaning the chalkboard or carrying groceries for parents, or even extra trips to the neighborhood park.

So what is a parent to do when they have tried a sensory diet and the child still needs more? Well, that is when the occupational therapist (or other clinician trained in sensory integration techniques) analyzes the input the child is receiving. They should be asking about intensity, duration, frequency, and mode of sensation.

Intensity levels can be altered with jumping by adding a mini-trampoline versus just jumping on the ground. This can be made even more intense by the child jumping on a large outdoor trampoline. Another way intensity could be increased is to buy special suspended equipment such as swings with bungee cords that allow extra resistance as the child swings. These can be found at:

www.southpawenterprises.com

Some of the families I work with already have the outdoor play gyms that have a swing, slide, ladder, and "rock" wall. Often, suspended equipment could be used with these play gym systems. So a regular sling seat swing could be replaced with the "frog" swing which is also a sling seat, but has bungee rope at the top so the child is bouncing up-down in addition to being able to swing front-to-back.

Intensity could be added to marching by adding 1-2 pound leg weights around the child's ankles as he marches. Other ideas include: Joint compressions, a game of tug-of-war, deep massage vs. light touch, songs with words versus just instrments...and the list is never-ending!

Duration: length of time of sensory input. So, if the family tends to let the child play at the park for 20 minutes, maybe the time should be lengthened to 30 minutes or more. This is especially the case for a child who has sensory modulation disorder with the symptoms of sensory seeking or sensory under-responsiveness.

Frequency: means the amount of times during the day. If the child only gets one "wiggle" break at school/home then maybe the child needs more "wiggle" breaks. The average adult attention span is only 45 minutes of listening, and for children it is even less. So, we know that many special needs children can't focus as long as a typically developing child...so, more "wiggle" breaks are needed! If breaks are not possible, then fidgets for the hands or a cushion for the bottom such as the Movin' Sit (R) could be helpful.

Mode of sensation: is the input tactile? auditory? visual? movement (vestibular and/or proprioceptive)? smell/taste? oral-motor? Changing up a sensory diet with various types of input may be necessary. This can be frustrating to teachers and parents because after a few months of the ideas given by the therapist they aren't getting as good of results. Altering the sensory diet can be a guessing game especially when the child fluctuates from day-to-day or even hour-to-hour!
Maybe if the child tends to like motion that is up-down such as bouncing on a ball or jumping on a trampoline, then a different kind of movement could be added to the sensory diet. Examples of more intense motion include rotary/spinning or upside down movement. Examples of less intense motion include front-to-back or side-to-side motion at a predictable pace.

I hope this article got you thinking! Once a sensory diet is in place, it probably will have to be tweaked here and there...especially if there are lots of changes in that child's life.

Occupational Therapy for Feeding Skills During Family Mealtime

I have a lot of therapy strategies up my sleeve when it comes to pediatric feeding disorders. Some of them include fancy positioning equipment, oral-motor devices, stretches, and textured teething toys. Some of my strategies even require that I become "certified" just to use them. Yet, the most effective strategy that I have found so far is to show up during family meal or snack time for children and during a scheduled bottle feeding for infants. It sounds SO simple, but it works!

For many of the children I work with they can perform a certain skill such as munching a soft diced vegetable if I was to give them just a couple of pieces in between some mouth exercises at a time in which they were not even hungry. They might even be able to hold a spoon if we practiced scooping up toys out of a sand box while we are playing in their room. But that doesn't mean they have the muscular endurance and sensory processing abilities to chew three different foods on the plate while using utensils to feed themselves. It is hard for many children with feeding disorders to handle more than one food due to the various flavors, temperatures, resistances, and textures. Additionally, they may be able to chew the food, swallow the drink, and manipulate the cup and utensils when sitting alone, but can't handle it when there are more people present. Why is that? Well, every child may have a different reason, and I am not going to know "why" unless I directly observe the meal within the natural setting: family meal time. If that isn't possible, then I observe snack time.

What does family meal time look like? It is different for everyone. I tell the families to set everything up as if I wasn't there. The meal may occur in front of the TV on the couch with one of the three siblings next to the child I am working with or it may occur at the dining room table with every household member present. I just want to see what naturally occurs during the meal time routine...there is no right or wrong. For some children they may not be able to participate in family meal time because of the noise level. For others it might be that they are sitting too close to a sibling that keeps inadvertently touching them. Even after I observe family meal time, I may still not know why the child is having difficulty with eating. That is when I watch the child eat a variety of foods while he is alone. If I figure it out, then we may work on specific skills separate from meal time, but even then the intention is to include the child in family meal time. Some children may need some 1:1 work with oral motor exercises, fine motor play, a "sensory diet", and other strategies immediately prior to family meal.

For those kids who can't handle eating with their family, maybe they could at least sit and socialize or just "be" there, even if they have to eat before or after everyone else. Just "being" with everyone else at the table might be the only way a medically-involved or tube-fed child can participate, and that is okay.

It breaks my heart when I find out that the child with the feeding disorder is not included in any form or fashion just because he has a feeding disorder. If the child's sensory processing abilities don't allow him to be with the rest of the family, then maybe he could help with meal preparation or setting the table.

For babies with feeding disorders, I show up for occupational therapy at one of their scheduled feedings and watch the parent (or caregiver) feed the child. I offer suggestions if needed. I may follow up with stretches and ideas for pacing, positioning, burping, and nipple/bottle changes. If the child is having alot of problems, then I may feed the child. But the problem with that is that babies that are oral feeders get usually 6-8 bottles a day and I am not going to be present for all of those feedings! So, the natural routine of the meal is going to be the adult holding the baby (or placing them in a device) while feeding him. Sometimes I do the first half of the feeding process for training purposes, and then after the baby has burped I will have the parent try to do the same things I did. After all, feeding your baby is the most basic thing that every parent wants to do successfully!

I guess my biggest "take home point" from this blog entry today is try to work with the child within the natural routines. If the strategies given to the family aren't meaningful to them and feel like extra work, then they will not work on them between the therapy visits. On the other hand, if the strategies are purposeful and occur within routines they already have, then the family is more likely to use the therapist's ideas.

Heart Defects in Babies Contribute to Feeding Problems

So often, I work with babies that have various heart defects and more often than not, the babies have feeding problems too. Even after the heart problems have been resolved through surgery or the child "growing out of it", the feeding problems linger into toddlerhood. Why? The number one reason: if you can't breathe well, it is really hard to chew and swallow! This may initially be a poor latch on to the breast or bottle and failure to thrive, because not getting enough ounces during a feeding and burning lots of calories during the feed don't exactly help the infant gain weight. Then, medical staff decide to switch to a high calorie formula that unfortunately has an "yuck" taste, or at least I think that is what the babies are revealing to me. Then, there is feeding tube discussion. Because if the baby can't consume enough calories orally, then an NG (nasal gastric) or (G) gastric tube may be necessary. What a mess! It is a vicious cycle of trying to get the baby to gain weight, especially if surgery is in the future. Then, parents get anxious and the baby "feels" it, which impairs the feeding session even more...uggh! So, then I or another occupational therapist steps in and works with nursing, GI doctors, the pediatrician, and any other person that can help. Often, within a few months things do improve and the baby gets on the right track of gaining weight...yeah! I often recommend strategies to calm the baby so that the suck-swallow-breathe during a feeding is more organized, check out www.sense-ablebaby.com for strategies on calming a baby and the environment.

Once the baby is learning to chew and eat table food, it is often easier for the child to just swallow the food whole than it is to take the time to chew. Many of these children become picky eaters because they know that it is way easier to consume yogurt than it is to chew string cheese! I start out helping the baby learn to use the proper mouth muscles and eat small pieces of food. If you don't work on feeding, you risk a child with an extremely limited diet that may need a feeding tube! Double uggh! However, if a tube is necessary, then so it is. But, feeding skills go backwards unless it is worked on hard! Also, often a swallow study is necessary to make sure the baby doesn't have reflux or doesn't have mechanical problems that would cause the infant to aspirate.

I think that anyone who has a baby that fits the description above, really needs a well-trained occupational therapist (OT), or maybe a speech-language pathologist, to work with the child. OTs can address the other motor delays as well such as not rolling or sitting up on time. So often, babies who have had heart surgery aren't able to lay on their tummy for awhile which impairs rolling and crawling skills. The therapist really needs to communicate with the physician on the plan of care! During therapy sessions, it is a must for the parents to be trained and replicate to the best of their ability what the therapist shows them to do during a feeding. If the baby is medically fragile, a home health nurse may be assigned; in this case, it is a great idea for the OT (or SLP) to work closely with the nurse. Depending upon the nurse's experience with feeding babies, they may need ideas on nipples, positioning, etc.