Therapists Consulting with School & Daycare Staff

It seems this year has been extra crazy and busy, which means I haven't blogged near as much as I did the previous two years...oh well, if life even slows down a bit, then I'll get back to blogging more. Ironically, I don't watch television very often or do other things that you would think should take me away from my blogging, yet somehow the days and evenings fly by!

In addition to me working part-time for an early intervention program in which I work in homes, daycares, and in the community with children ages birth to three years with special needs, I also work part-time for myself. I see a few children on a weekly basis as well as conducting consultations and evaluations for a local school district (not the one I work for ECI or the one my daughter attends). So, this year I have learned a lot about billing insurance companies, facilities, and Medicaid...lots of lessons have been learned! But the biggest thing that I've enjoyed doing this year (besides being a Mom of two children and a wife) is providing consultative services.

Consultations are really important and that is why most school occupational therapists spend most of their time doing that versus direct services. Because the therapist is only around a child a small part of the week (or for some kids even less), and the parents, teachers, or daycare staff are around them for the majority of the time, then doesn't it make sense to teach them a few simple strategies that can make a difference in that child's life. Some of the suggestions can be as simple as putting the child at a table that faces a less "busy" area and therefore is less distracting so the child can remain seated and do his "work". Ideas may also be as simple as rewording requests, keeping instructions short and simple, using a picture schedule system, or making sure the table/chair is at the appropriate height which provides better support for handwriting and focusing.

Consultative services doesn't mean that the child doesn't also need direct therapy, it just means that there may be adaptations to the environment that could make a functional difference. It might also mean that teaching the adults to interact differently with the child could make a difference. For example, for a child who transitions poorly between activities at a daycare one suggestion may be to give him a one minute verbal update of what will be coming next. Predictability often lessens anxiety in children with developmental disabilities, especially the children with sensory processing disorder (SPD) and autism spectrum disorder (ASD).

I've learned through the years to not get all of my "therapy kicks" out of directly interacting or touching the child. When I was first out of college, I wouldn't have dreamed that I could help out a five month old with Down Syndrom so much unless I was literally touching the child helping him to roll over or helping with some other motor or feeding skill. Yet, now I know that if I show the parents a few strategies for "tummy time", positioning while holding/feeding the baby, and diapering that I'm making a big, maybe even bigger difference than I am by directly working with the child. It has been a change for me not to be the one to feed the client, but to be the one guiding the parent either verbally or physically. After all, it's not "all about me"!

So, if your child gets direct services only at a clinic, then ask the therapist if she/he is willing to do a home visit at least once. Insurance may or may not pay for it, so funding could be an issue. If you can't afford to pay for the home therapy visit privately, then videotape the surroundings of your home during the daily routines that are difficult such as toothbrushing or meal times; have the therapist view it and give any suggestions on how to help that routine go smoother. Maybe the therapist will also be fine with you participating in the therapy session at the clinic so you can learn some activities to do with your child in between sessions. At the very least, get a handout individualized to your child on activities or adaptations that would be beneficial.

Making Halloween Fun For All

It's Halloween time! Many of us think it is fun, whereas others are not feeling the same amount of joy as the rest of us! In hopes of making the holiday more pleasant for all, I have provided a link on ideas for adapting this holiday for a child with Autism Spectrum Disorder. I also think these ideas could work well with any disability or young child:

http://www.autismsupport.org/halloween.html

My small family of four likes to dress as a theme. Last year we all dressed up as characters of Toy Story. This year we will be characters from Peter Pan...even the dog is dressing up as a pirate. Since my three year old son gets scared of "spooky" things easily, we probably will be wearing "happy" costumes for a while. Last year, he became very upset with the decorations we had on our front porch, and would only go out the back door until the decorations were taken down the day after Halloween. So, if you have a case like this, some of the ideas in the link may work well for you even with a child who doesn't have a developmental delay or diagnosis of autism.

Enjoy trick-or-treating and HAPPY HALLOWEEN!

Social Stories to Improve Behaviors

I am a big fan of social stories to teach young children and/or children with special needs (any age) when there is a problem with a behavior or the child is anxious about a situation. The concept originated by Carol Gray. Although social stories are often used with children with an autism spectrum disorder, I have found that you can use them with many children with developmental delays or young children with no delays. Here is a link on how to make one:

http://www.ehow.com/how_5135970_use-social-stories.html

This link probably gives ideas for grade school children, and adapting it for the toddlers would mean doing more of the work. I have had my own children help me by coloring some of the pictures in the book.

I have made quite a few for my own children, and they like to read them even after the issue has been solved. Back when my daughter (now 7 years old) was three years old, she was very scared to go to swim lessons. So, through reading the story to her daily she became less anxious. That is because the predictability of the lessons lessened her anxiety. So often, children act up when they do not know what to expect, and through writing an individualized story about what may happen and what is expected of them, their anxiety may lessen.

Some of the stories that I have taught families to write for their child have included: going to the dentist, airplane rides, gymnastics class, swimming lessons, birthday parties, Christmas day, potty training, the choir singing at church, and the list goes on. Remember, when writing a social story to stay as positive as possible and emphasize the behavior you want from the child and don't say a bunch of "no" and "don't". For example, if the child has a problem with running in the hallways at school you may say in the book "we walk in the hallway quietly and slowly while listening to the teacher" as opposed to "we don't run in the hallway and disobey the teacher".

I would love to hear stories about some of your favorite social stories that you have helped write!

Is your child ready for preschool?

Since most children are going back to school over the next couple of weeks, I thought I'd post a link on preschool readiness. Preschool is important for many children, especially those with learning disorders or developmental disabilities. If they go to preschool, then they may perform better in kindergarten. ..they may even have fun in kindergarten!

First 5 | California

I have a friend who used to be a kindergarten teacher. She once told me that the best thing a parent can do for any child to prepare them for kindergarten is to send them to preschool or another part-time program such as Mother's Day Out or daycare the year or two before starting kindergarten. It is hard to learn in kindergarten if the first part of the school year is full of separation anxiety... get that out of the way in preschool!

Halliwick Method to Teach Swimming

It's that time of year when most everyone wants to cool off in a pool, especially if you live in the southern USA like I do...too many days where it is 100 degrees F or above! For many of us, we want our kids to feel comfortable around the water, have safety awareness, and also learn how to swim. Some kids are harder to teach swimming to than others, and especially if the child has a medical or mental disability. Here is a link about the Halliwick method that can be used to teach swimming, it was created by a physical therapist who is an aquatic specialist. He has techniques for a variety of special needs including pediatric and orthopedic disabilities.

Halliwick

So go ahead, gather up your intertube, rubber duckies, and towel and head off to the swimming pool!

ZERO TO THREE: Self-Control 24 - 36 Months

Although my son turned 3 years old earlier this month, I do not expect him to never have tantrums or meltdowns. Yet, I already noticed over the past couple of months that they occur WAY less. Here is a link on the behavior and self-control of a two year old and some strategies to use:.

ZERO TO THREE: Self-Control 24 - 36 Months

Toddlers are SO much fun, but they are also unpredictable! So, it's always nice to have a better understanding of why they behave the way they do.

Simply Thick Lawsuit: Free Consultation with Attorney necrotizing enterocolitis NEC

Please spread the word about this important information regarding a recall on Simply Thick and a possible link to NEC:

Simply Thick Lawsuit: Free Consultation with Attorney necrotizing enterocolitis NEC

Animal Assisted Therapy for Special Needs Children

In honor of my family getting a puppy 2 weeks ago, I thought I'd post this link on how animals can help children with special needs:

Animal Assisted Therapy for Special Needs Children

When I worked at a rehab hospital for adults with neurological injuries I really enjoyed seeing the trained dogs come in and mingle with the patients. So many of the adults were so happy to see the dogs, and it was amazing how some of them tried to move an injured arm or speak more around the pet! I've also seen this same effect with children with special needs. Even children with only developmental delays do well with dogs. A few years ago I was working with a 16 month old boy who wasn't walking; he had mild sensory modulation problems, but other than that just a delay with walking and talking. His mother adopted a 2 year old dog, and guess what, the boy began walking and talking within 3 weeks of the family getting the dog. These two were best buddies, and it was so amazing to see how this gentle dog helped this boy. The little boy was motivated to walk so he could keep up with his best friend! I have many stories about how dogs, cats, and horses have helped the children I work with. I would love to hear your stories too!

ZERO TO THREE: Sleep Challenges in Infants and Toddlers: Why It Happens, What to Do

Whether it be from my friends or parents of children I work with, I get asked a lot of questions about how to help babies and young children sleep better. Here are some good ideas on the challenges of sleep:

ZERO TO THREE: Sleep Challenges in Infants and Toddlers: Why It Happens, What to Do

I've been lucky that my son slept through the night (7 hours or more) by 6 weeks of age and my daughter slept through the night by 8 weeks of age. Unless they were sick or teething, they have been excellent sleepers. Of course, there has been the occasional night mare or delay tactics in going up to bed, but overall I've been lucky in the area of "sleep". My husband and I put the children down at the predictable time of 7:30 for my son (he'll be 3 years old in June) and 8:00 on school nights for my 7 year old daughter. They have the potential to get 11 hours of sleep at night on a weekday, and then my son may or may not also take a nap at preschool or home (depends on if it is a day I work). For that age group children need 10-14 hours of sleep in a 24 hour period, and my children get that. So often, a child's behavior problems or school difficulties can be lessened by making sure they have a proper amount of sleep...notice I didn't say the problems vanish, just maybe lessen depending upon the child.

Feel free to post sleep problems and solutions that you have had with your child or a child you work with!

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.

Indwelling Thumbs in Children with Spasticity

It has been a BUSY month so far, so this is my first post of the month... the longest I've ever went without writing an entry! Oh well, Happy Spring (almost)!

Lately, I've been working with quite a few children of all ages who have spastic quadriplegia; this is when both legs and arms have extreme tightness due to neurological impairments, and typically the upper body is less functional than the lower body for these children. For the younger children such as infants and toddlers, I often suggest "Joe Cool" or "Benik" splints (sometimes with a harder material inserted between the thumb and index finger) in order to help the thumb not stay tucked in the hand. Some children require night-time splints (e.g. from orthoplast) as well, but I am simultaneously encouraging as much active movement as possible. But unfortunately, active movement isn't always possible; this is especially the case for a child who has suffered a near drowning, CMV, PLV, or a TBI. In that case if a splint isn't tolerated due to too much tightness and orthopedic mal-alignment of the fingers (wrists, IPs and MCPs), then I suggest rolling up a small washcloth within their hand. This gives the web-space a small amount of support without an excessive, painful stretch. If the thumb and fingers continue to be tight over numerous years, then the creases within the palm can become "stuck" to each other which makes it pretty much impossible to open the hand to full passive range of motion, and if it does occur the skin may rip and/or bleed. Even for the kids who may never actively move their hands due to severe physical and cognitive involvement, getting the thumb to not tuck is important... dislocated bones or "windswept" deformities can be painful!

Of course, I always promote massage, stretch, weight-bearing through an open hand, and active use of the muscles when possible. Also, some children need a customized splint created from an orthotist or occupational therapist. Some "ready made" dynamic splints may even work. In these cases, I have to investigate funding ideas if insurance doesn't reimburse for it and if the family doesn't have the financial means to pay for it.

I would love to hear other strategies for helping reduce indwelling thumbs in children with neurological damage. If you have any, send them my way!

ZERO TO THREE: Steps Toward Crawling

Here is a great article on what happens right before a child typically learns how to crawl and the various styles of crawlers:

ZERO TO THREE: Steps Toward Crawling

The only thing I would add to this article is some other types of atypical crawling:
-segmented: the child crawls but it appears slow, and not fluid as if every movement of the arms or legs have to be thought out. This can be a sign of a variety of problems including neurological
-bunny hop: the child crawls with the hands and then hops forward with both feet simultaneously coming up under him, just like a rabbit does. This can be a sign of neurological, muscular, or orthopedic problems
-bear crawls and can't bend knees- this is when the knees are extended vs. bent, it can be nothing to worry about unless that is all the child can do. It could be due to muscular tightness, orthopedic, or neurological problems

These atypical patterns in addition to the ones listed in the article (e.g. using one side only) may resolve after the child has been crawling for a couple of months. If they do not, this should be discussed with the child's pediatrician to consider a referral for therapy and/or a specialist (neuro or ortho)..

It is important that children crawl, but not mandatory. I have a 16 year old niece who skipped crawling and began walking at 8 months. She climbed furniture by 10 months, and went on to be a high level competitive gymnast. She takes advanced classes at high school. So, although she has no gross motor or learning problems, skipping crawling can be an indicator for that...not always, but can be sometimes. Crawling helps the brain learn to use the two sides of the brain together, develop arches within the hand muscles for fine motor control, and promote depth perception (eyes). Maybe this is why my niece's handwriting isn't exactly the best...not awful, but not great either!

Study of Early Child Care and Youth Development (SECCYD)

A common suggestion that I make for toddlers with a developmental delay, particularly with language skills, is to go to daycare, preschool, or Mother's Day Out (MDO) for at least 2 days a week. I make this suggestion especially for children who don't have siblings or who are the oldest child. Children need to be around other children their age which helps them learn how to play, talk, and share. Having said that, there is a difference between how kids thrive in good child care and low quality child care. Here is a link to an interesting study that evaluated how children progressed with development in different types of daycare:

Study of Early Child Care and Youth Development (SECCYD)

I realize that not everyone wants to send their child to a facility such as MDO or daycare, or maybe they want to but can't afford it. In that case, I help the parents brainstorm other ways to be around children, such as play groups, library story time/ craft time (FREE!!!), church activities, neighborhood groups, and other public places that may have free admission at least once per week such as an interactive children's museum. My subdivision has a monthly newsletter and within it, dates/times are identified for Mom's groups, play groups, and special events. It may not be the same teacher and peers each time like a daycare or preschool would be, but at least there is socialization among the children.

Autism Speaks, Community, Family Services,

I came across an amazing website "Autism Speaks" recently. I was so impressed with how they had very detailed videos displaying what a typically developing child would look like for a particular play or language skill, and how a child with autism may look like doing the same task. Also on this site was a huge data base of different types of treatment in the various cities in each state. What a great source for a parent of a newly diagnosed child or for a family that will be moving to a new town! Here is the link with the names and numbers to some facilities in Texas:

Autism Speaks, Community, Family Services, Texas: Categories

Even though this link is for Texas, the other states are represented also. Some of the links include: ABA, early intervnetion (birth to three years), preschools, OT/PT/Speech therapy, biomedical interventions, doctors, and community support. I will definately be sharing information from this site with the families that I work with!

iPod | iPhone | iPad Apps for Special Needs Children

I was just fiddling around with my iPhone and downloading some applications today. My search was on a variety of pediatric diagnoses seen in OT, PT, and speech, and not too many came up, which surprises me. But once I read how much has to go into creating an app I figured out why there aren't many! There are over 200,000 apps. available so maybe I just couldn't find the right ones. I have MANY ideas on some possible apps, and maybe one day I will actually get around to creating one...too bad I am not good friends or relatives with a computer programmer! One app that I came across that I did like was one specifically for children with autism:

iPod | iPhone | iPad Apps for Autism

Another one was for identifying a baby's various cries. So many of the parents have problems with deciphering the cries, which means the baby may get over-fed, put down for sleep too often, or over-stimulated. This app looked like it could be beneficial to new parents: http://www.crytranslator.com/

I would love to hear of some of the other good apps out there. Please, send info. on them!

Helping Children Play Within an Organized Space

My daughter and I went through all of her toys yesterday to make room for all of the toys she got for Christmas last month. I had her make various piles: one for toys to keep, one for missing pieces, another for toys to donate, and of course the trash can! Within the donate pile, I started to think of who I could give each item to such as a particular child on my caseload, her younger 2 year old brother, a daycare, or the Goodwill.

I go through the kids' rooms at least twice a year and it helps our whole home to not be taken over by toys! I plan to do my son's room tomorrow...but without his help! He is like the average two year old who doesn't want to part with toys even when they are broken. This is why he has a couple of injured Barbie dolls that were previously his sister's, you know, the one's that have a missing foot or received a "haircut" that wasn't so attractive!

This event got me to thinking that as an occupational therapist working in the homes of families with special needs children I am able to help families go through their toys and organize them. I can help find the toys that are appropriate for the child (and siblings) to play with as well as box up toys that are too young for them developmentally. So often the children I work with that have developmental delays get over-whelmed by too many toys in a space; so I find that removing toys not used anymore really helps them focus better on the toys that are still left. Something so simple can help a child to have a longer attention span or even less sensory defensiveness. For kids with poor motor planning, it helps them to make better choices of what to play with as opposed to choosing a "baby" toy. For example, if all of the rattles are put away, then maybe the child will reach for blocks, books, or dolls.

For children with delayed language, make sure you leave some musical toys and other items that promote language such as a tape player they can carry around, "microphone", megaphone, whistles, and books.

For children who are sensory seeking/ hyper-active, you may need to make sure you have some action toys in the room such as a mini-trampoline, tunnel, or balls.

For children with poor motor planning, low muscle tone, and/or sensory under-responsiveness (low registration), make sure you have toys setting out visibly and not all of them stored away in closed containers high up on a shelf. These children will most likely not seek those toys out when asked to "go play in your room". I recommend a few toys put in a couple of baskets within their reach. Too many toys in one basket can be over-whelming, so don't over do it! Also, have toys that they would be successful with and some that are for the next developmental milestone. Cars, balls, and dolls are simple toys, whereas a kitchen with plastic food, a race track, and Mr. Potato Head are more challenging. If all of the toys are too difficult for them then the child will just get frustrated and depending upon the diagnosis may choose to sel-stim.

A child with abnormal muscle tone who tends to slump or w-sit could benefit from a kiddy table and chair to offer support and an alternative to just playing on the floor; make sure the table and chairs are at the proper height. If the chair is too low then the child will lean and hunch over the table. If the chair is too high, then the child's feet will dangle which offers less stability for the posture muscles. If the chair is a good height but the table is too high, then the child will have his elbows too high for good fine-motor skills including legible handwriting for homework (older kids) or scribbling (younger kids). Some children will give up when a task is too hard and may even walk away whereas others will start to "act up".

Of course, one of the most important things is teaching the child to clean up. If he/she is not physically or mentally capable of cleaning the entire space, then think of at least one thing they could do. For some kids it may even be that you have to offer hand-over-hand assist through each step. For children with a poor ability to transition, then this is a nice transition helper, especially if it is done in a predictable way. Predictability could include singing the "Clean Up" song each time, or it could include watching a video for 10 minutes after the room is cleaned. There isn't a magic routine, yet structure and predictability help so many children (with or without special needs!).

The list goes on and on about all of the ways you could organize toys and alter a play space. Hopefully, the ones I've listed get you to thinking of how you could help your own child or a client!

CTV Toronto - Sibling spacing may be tied to autism risk: study - CTV News

An interesting study about siblings age and the incidence of autism:

CTV Toronto - Sibling spacing may be tied to autism risk: study - CTV News

I hope they keep finding more clues to the causes ( or possibilities) so they can work on prevention and cures for autism!

TheraSuit- Suit Therapy for Kids with Cerebral Palsy

I worked recently with a child (diagnosed with cerebral palsy) who made many gains with the Suit Therapy using the TheraSuit. Here is a link:

Therapists Use New Methods For Children with Cerebral Palsy | OT Pediatrics News

I've had many kids over the years try alternative therapies, and some of them with good results. The kids have traveled to other facilities for weeks to months receiving various therapies in hopes of getting better motion, balance, and functional skills. All of the ones that have made significant improvements have been the ones who recieved intensive therapy of multiple hours a day: Suit Therapy, Constraint Induced Therapy, hyperbarric oxygen, and many other therapies that aimed at integrating reflexes and providing lots of proprioceptive input. This makes me wonder if NDT and some of the other popular therapies used by most therapists would get similar results if we provided multiple hours of therapy a day....food for thought!