OT what is it??

OT what is it??
Kids learning through doing!!

Wednesday, September 14, 2011

Back to School Coping Skills and Frequently Asked Questions


How to spot academic issues early.
Is your child is some way “different” from his/her peers and does that difference bother you?  If you have a "feeling" seek an assessment or screening by a registered occupational therapist. HOW  your child does something can be even MORE important than what they are doing!

How to request services.
Simply go into the principal’s office and ask…it is your RIGHT to ask for services.  There is a process, but you can initiate it.

What to ask for and when if you think your child is having concerns.
You can ask for a psycho-educational evaluation.  In fact parents have a lot of power, it is just that the schools are often not very forthcoming about this.
Keep in mind that reports from the  "Student Support Team" are not a legal document. It is basically a "promise" that your child will be given "consideration as to possible needs".
Only an IEP or a 504 Form bind the school to specific actions.

What is the difference between and Occupational Therapy Evaluation and Psychological Evaluation?
A psychological gives an IQ score and assess what the child has learned. An OT evaluation looks at the way a child learns: visual/sensory/motor processing.

Handwriting matters--the answer why it does.
Handwriting is graphic motor skill that uses every sensory/motor pathway in the brain. WSJ article 2011: “Handwriting Trains the Brain”. The WIN™ Write Incredibly NOW™ Program is sensory based and non-repetitive as so many of the standard programs are.  (WIN™ is a registered trademark of Children's Special Services, LLC.  The WIN™ Program is available through YourTHERAPYSource.com).

Homework strategies  AVOID power struggles
“Homework Box” it organizes the “monster” and cleans out the book-bag!~~Ideas from "Learning Re-Enabled" , Elsevier/Mosby Books

Behavior--it's not just about the kids.
Think how are YOU responding to the ups and downs of your child’s school day?  Parents of kids grade 3 and up beware!—relationships turn on a dime—remember to let your kids work things out—coach from a distance.

If you feel your child is "not working up to his potential".
Keep in mind that what you see 1-1 when you are working with your child may be VERY different than what he can do in a class of 20+ children.  The pressures are different.  But if you feel that the teacher is letting your child "slide by" then you may want to think about the following.
Start a "MY BEST" portfolio.  In it DO NOT put HOMEWORK or previous class assignments. Put a drawing and/or a poem, a picture that shows a special interest.  Let your child work on this over time.  Let him (her) know that you want to show the teacher how wonderful they are.
And HIS optimum at school under peer and teacher stress may not be what you see when you are with him at home. But this is the goal he can reach for because it is not a teacher expectation, but something he is already capable of.

Sometimes you need to talk to the teacher--how to handle that.
Go with something written down, think this through at home first. Speak slowly and respectfully, ASK Questions. Do not go in like gang-busters.  But if you do not talk to the teacher first, the principal will not talk to you unless you do.  (State procedures--in most states)
And sometimes the teacher and/or the principal IS NOT RIGHT. Be tactful but clear. (No, his IEP does say...."...."helium and nitrogen do not make a compound"....."You did get a note today. I handed it to you about....."

Report card responses--the child and you.
The Homework Box (see "Learning Re-Enabled")  should take the surprises out and prevent Report Card Shock.  But teachers have email now and you can set up at the start of the year that you want to know immediately if your child is not keeping up, not turning assignments, etc., RIGHT AWAY!!

Most of all this is a temporary marriage between you, your child and the school so hone your negotiating skills, all of life is always give and take and keep your focus on where you want your child to be at the END of this school year.
©Children's Special Services, LLC 2011  All Rights Reserved May not copy without

Saturday, August 27, 2011

Is LIFE stressing your child out??~~Using Media to Quell the Madness

Trying to get your child up in the morning can be a challenge.  Trying to get your health challenged child up in the morning can feel almost impossible.  You wake up 5 minutes before her alarm, and brace yourself for another morning of tears, perhaps yelling, and sibling chaos.

It can be so very troubling when your child who you KNOW wants to be sweet and can be faces every school morning with a loss of control. 

Here is a tip that I suggested to a family with whom I work and I wanted to share it with you.  To do this you will need a video recorder and a private place with just you and your child without the sibling “audience”. 

Tips on Making a Wake Up Video: Sally to Sally “The Interview”

Ask Sally to make a video in private with just you and your husband and it could be just her on the screen and it could be her "wake up video".  Make it no more than 2-4 minutes in length and let her "write the script" --yelling doesn't feel good for her or anyone else. But when she is calm maybe she could "greet herself" each morning when she gets out of bed Play it on a computer, DVD player, etc. but in her room before she does anything else--
For example it could go something like--
Hi Sally this is Sally
We both know you HATE mornings
And it is your bugaboo time 
We both know that you are really mad about being rushed
It makes "us" nervous and we feel like everything is falling around us
We HATE to be rushed
Breathe deeply--com'on let's hear it really deep now!!
Listen and Hear me say 3 wonderful things about you (us)  1._________2.__________3._________(creative, brave, tries hard for example)
Now close your eyes as I count to 10 breathe in and out
Picture something really fun or pretty
Open your eyes and have a great day!!

Before she talks, before she brushes her teeth she gets to tell herself that the chaos is inside her—it is manageable and all that she has to do is all do-able!

It is the time limits and organization that I believe is stressing your child out.  Other tips include:
§   Setting out clothes the night before
§   Putting the toothbrush out with the toothpaste
§   Shower/bathe at night
§   Put book bag by the door ready to pick up on the way out
§   Set the cereal out the night before so the breakfast choices are made
§   Make lunch the night before and put it in the refrigerator ready to pack
§   Make a checklist that “Sally” can mark off so she gets reinforcement that she is on “track”.
§   Keep morning instructions to a minimum let the routine “do the talking”.

For help with those “Homework Wars” great pointers can be found in “Learning  Re-Enabled” 2nd Edition (Elsevier Books).

But most of all, remember that this is not at you it is in her—step back, breathe deeply, and you both will feel better!!

Thursday, August 25, 2011

Selective Mutism: what does this mean how does this happen?

Selective mutism affects less than 1% of the preschool/early grade children (Selective Mutism foundation website). Most of the children impacted are female.  Although it is hard to diagnose, antidotal reports suggest that the actual numbers are somewhat higher.

This is a psychiatric disorder characterized by a persistent failure to speak in select settings.  These children are usually within normal limits academically, and make their needs known by gestures, nodding their head, pointing, or remaining motionless and expressionless while waiting until someone guesses what they want. The condition is usually not obvious until the child begins school, because at home they are talking to parents, grandparents, etc.   Importantly, time not speaking is paramount in predicting the success of interventions.  By the time school starts, if life without speech has become a “way of life” many of these children find it harder and harder to speak at all outside of specific and distinct situations.

Immediate intervention is crucial. The longer the child is allowed to remain in the non-verbal mode the harder it will be to remediate.  The younger the child, the better prognosis for recovery since the time in specific settings without speech is shorter.  The impact on school and other social situations is also lessened with early interventions. Some primary research suggests that without treatment the disorder can become irreversible.

In that regard, Dr. E. Steven Summit III an advisory board member of the Selective Mutism Foundation states that he has, “…yet to hear of a case …(preschool onset and persistence past the first few months of school) where the disorder remitted spontaneously, i.e. the child “outgrew it” without treatment.”

Description of the Disorder

Selective Mutism is thought to be an anxiety disorder and published research reports much success has been achieved with the use of medications such as Prozac in combination with other behavioral therapies.  The effectiveness of the medication/therapy protocol usually takes 3-6 months to begin to take effect.  The success rate in young children (preschool/kindergarten through first grade) is reported to be as high as 80-90%.  This rate of remission steadily and considerably decreases, as remediation is delayed.

It is important to note that this is not a language disorder, as children can speak fluently and coherently when they are comfortable and in what they perceive to be anxiety-free situations.  Speech disorders are not limited to specific situations (as Selective Mutism is) and are observed globally as the child communicates.

According to the DSM-IV (Diagnostic and Statistical Manual of
 Mental Disorders— DSM) the definition of Selective Mutism is: "the persistent failure to speak in specific social situations, (e.g. school, with playmates) where speaking is expected, despite speaking in other situations."

Secondary characteristics may include: excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, excessive crying, compulsive traits, temper tantrums or other controlling or oppositional behaviors (these may be more prevalent at home or in school/social situations).

Occupational Therapy Treatment Protocol

It is also highly recommended that the treatment protocol be inclusive of families, psychologists, teachers, and related social and behavioral interventions. Progress is usually slow and incremental; patience and understanding are needed for children to overcome this disorder.

Occupational Therapy is valuable here to provide the child with multiple sensory-motor experiences that will increase their self-esteem as well as increase their ability to create expanding realms of confidence and competence.  Such therapy should incorporate play-based situations where the child can lead and increase achievement levels within task demand situations.  Specifically, having the child make and then “speak through” a hand puppet and/or other projective experiences can help with verbalizations.

It is essential to address this condition early as it can interfere with academic, social and/or occupational successes.  Therapy should utilize puzzles, board games, sign language, rhymes, music/songs, within both fine and gross motor activities that can facilitate spontaneous responses. Slowly introducing eye contact and alternating between whispers and “funny voices” can allow the child to interact in and at the same time feel emotionally safe.

Other techniques that can be incorporated into an occupational therapy treatment session are:
  1. Teach the child to sub-vocalize and talk themselves through a sequential task
  2. Acknowledge the anxiety (sadness and/or anger) and help the child deal with it*—do not deny it  (*you cannot kid a kid!)
  3. Increase physical activities
  4. Increase creative experiences (arts and crafts, music etc.)
  5. Increase positive self-talk (one idea is to make a “Positive Tree” and put leaves on the tree each time a skill is achieved)
  6. Help the child anticipate situations that may be stressful and to role play them in advance
  7. Promote the decrease of “startle” (Moro) reflexive responses and other neuro-sensory-motor responses that persist beyond their developmental age criteria.

Research by Sally Goddard, Director of the Institute of Neuro-Physiological Psychology (author “Reflexes, Learning and Behavior”, Fern Ridge Press, 2005) relates Selective Mutism to primitive neuro-reflexes that should have developmentally self-extinguished but have not.  She provides what she calls a “roadmap” of the brain and relates “the inability to speak” to a retained fear paralysis reflex. This is an early reflex that exists in utero. It is eventually transformed into the Moro reflex, but never fully disappears. When we are faced with a sudden shocking situation we may freeze… totally unable to move. (I refer to it as the "frightened deer" reaction. When you come across deer they won’t just run away, they stand there, completely still. It’s not that they are brave … they can’t move. It’s a protective mechanism, because an immobile target is harder to see for a predator.) Also included here in addition to the Moro Reflex, is a sustained symmetrical tonic neck reflex that can posturally place a child so close to the desk (or other writing surface) that no other stimuli can be acknowledged and thus all stimuli becomes “unexpected” eliciting a startle response.

This research has primary implications for treatment within occupational therapy.  By facilitating the child to move and react we are increasing her ability to “defrost” from what Goddard refers to as frozen neuro-developmentally delayed responses.  She goes on to explain that these children cannot speak because they are in constant overload from ferreting out stimuli that other children readily ignore  (i.e., unexpected sounds, movements or situations).


The OTR, by careful application of activity can help these children whose physiological and psychological systems are impeding them from fully participating in the process of growing up. Occupational Therapy teaches the “art” of living, and verbal expression is an essential element of that art.

Tuesday, August 23, 2011

What Principals Do NOT Want YOU to Know

This is going to be short, but I really have to share.

With approval from the main office and support of the PTA my neighborhood elementary school was going to let me rent space for ONE hour to have a meeting for parents and professionals.  Titled ..."Back to School Coping Skills".

The flyer read.....

BACK to SCHOOL coping skills for parents, teachers, Occupational Therapists, Psychologists, Resources Teachers and related support professionals!! 
  •                                How to spot academic issues early.
  •                                How to request services.
  •                                What to ask for and when--
  •                                if you think your child is having concerns.
  •                                What is an Occupational Therapy Evaluation?  
  •                                What is psychological how are the 2 different?
  •                                AND THE BASICS                                                                                                                                                                                                  
  •                                Handwriting matters--the answer why it does.
  •                                Homework strategies.
  •                                Behavior--it's not just about the kids.
  •                                Sometimes you need to talk to the teacher--
  •                                how to handle that.
  •                                Report card responses--the child and you.

                               And more.................

What this principal took offense to was "the list of topics".  To quote, "...I do not want someone in speaking at my school telling parents information that is not approved by the county."  In other words parents should not get information that can help them help their children.

I was floored!!  Not wanting parents to have information is a contradiction to the Parental Rights each school is obligated to share with any parent who asks, and must be shared at all IEP Meetings.

Of course it is in size "5" font and is in a trifold brochure, and at the moment a parent is handed "their rights" leaves little to no time to read them.

Not all parents have sat on the other "side" of the table like I have, professionally.  So when it came time to advocate for my own children I knew what to do.  But still I was intimidated. Are these people going to be mean if I push the issues? ETC.

But when I was told to "just trust them" I flipped off the fear and said .."that in 10 years I will not remember their names but in 10 years I will still know my child.  So trust aside, let's get to the purpose of this meeting which is to create a happy and successful learner!"

So it is threatening to give this information to families??

Parents, BEFORE you have an IEP, 504 or any meeting with your child's school READ your parental rights in advance.  http://www.parentalrights.org is a good place to start, and also look them up for your specific state.

Has protection of educational domain replaced the mission of education?  At least it seems at my local elementary school it has.

The law is on the side of the child and the parent--invoking it appears to be at the discretion of the principals, take back the power you were given no one will protect your child like you will.

Thursday, July 14, 2011

Cycles of conversation the role of Social Skills Groups with young children

“Talk to me: Practicing the art of conversation -- what preschool experts call "cycles of conversation" -- is another goal for the year. Taking turns to talk is about a growing sense of respect for others -- an important piece of the school-preparation puzzle. Same goes for asking for permission before taking that red crayon.” (www.brainhealthandpuzzles.com/preschool_brain_development.html)

In the clinic setting I often encounter children who sad to say seem, to have a sense of entitlement.  “I see it, I want it, I’ll take it” without regard to who might be using the item or the consequences of what taking the said item might produce.

These kids come from “good homes” and go to “good schools”.  What is the issue? Why haven’t they learned the basic concepts of respect for self and others?

It would be too easy to say that indulgence is the answer but it is certainly part of the answer.  The other is that we have in many cases allowed for technology to speak to our children more than we do.

Nothing can replace human touch and interaction for teaching.  It is important to learn through experimenting what is appropriate and binding and what is coarse and rejecting in our daily interactions.  Speaking to our children is primary source of how children learn to speak to others.

And they learn by observing.  If one parent is routinely putting another parent “down” verbally, than the child may naturally assume that it is OK to talk to the chastised parent in the same manner.  This is often although not always translated into the way and manner that child interacts with other adults such as teacher, caregivers, etc.

On the other hand, allowing the child to “explain himself away” instead of owning his or her behavior is just as detrimental to the development of positive social skills.  Teaching a child to accept “no” as answer is a life skill that will stand well in both home and school situations.

When a child sees aggression as power and he sees him or herself as not so powerful, the urge to mimic the bossy behaviors seen in close adults (such as parents) can result in what is seen as aggressive or bullying behaviors in children by teachers etc.

A child learns respect for others by seeing the significant adults in his or her life showing respect for each other.  A child learns self-respect by living in a culture of respect and feeling secure in the limits of his immediate world (home and school).

Difficulties seem to arise when there is more than one message being delivered.  When children get to be the unwilling shuttle puck in a game of “who is the better parent”? Or “listen to me not __(mom/dad)__”; or any other similar ying yang game that leave the child making the choice of who to listen to and when.  These children then go to school and the rules are so confusing that they often unwittingly get into trouble for not following rules they saw as “optional”.

Young children learn respect by what they see.  Respecting self comes form respecting others first.  Respecting self in young children is manifested by effort in school work, pride in the results, polite responses to not only adults but peers and intuitively understanding that “first’ and “best” are not interchangeable terms.

If a child is getting into repeated trouble in peer situations, favors one parent over another (with the exception of abuse cases), is modeling adult behaviors not appropriate for young children, then clearly this child is in social difficulty.  He or she is obviously trying to create behavioral patterns that he sees as working for “__dad/mom__” and is confused as to why it is not working for them.

This goes back to the structure and boundaries discussed earlier. Clearly adults are not children, children are not adults.  The differences create different behavioral expectations. It is not a “one size fits all”. 

While “do it because I say so” is not the universal best option sometimes it is necessary.  At other times negotiations and or expanded explanations are needed.  But these explanations are not “owed” they are “offered” to explain a circumstance and it is incumbent upon the child to accept without confrontation these situations especially those with parents and teachers.

So the ART of Conversation is a cycle of give and take, talk and listen, taking turns, respecting others and ultimately maturing into a healthy respect of self.

Saturday, April 30, 2011

Finding the best way to be the best parent …is it possible?

First off let’s start by saying that there is no such thing as the best method, the best protocol, the best book to read on how to be the best parent.  Whether or not your child has special needs or not, there just simply isn’t a method that is the one to use.

Every snowflake is different and so is every child.  Every family is different too. So those “experts” who espouse to know just how YOU should be doing something as important as raising your child are way off the mark!!

Now that is not to say that there are not real theories and ideas out there about how to handle specific situations—the oppositional child, the one who refuses to eat, the overly shy child, etc.  Yes, there are suggestions out there on how to handle these situations, but remember that is what they are suggestions, not dogma.  (And I say this as an author of book about special needs children!)

All too often I have seen well meaning parents read a book, go to a lecture or seminar and come back and “swallow the system whole”.  They structure their lives around doing the “recipe” totally unaware that there is no tried and true path for raising children.

However there are a few things that can help:
  1. Start with common sense
  2. What you do has to fit in with your family and ALL the family members
  3. Mom and Dad MUST be on the same page and be a team together
  4. Do not try to be your child’s friend—you are the parent
  5. Parent is both a noun and a verb
  6. Your real job is to become obsolete—not needed—eventually
  7. Children only really need three things:
    1. Love
    2. Structure/security
    3. Boundaries

There are a lot of “cookbooks” out there.  The advice overflow can be confusing and overwhelming. Starting the with gold standard of Dr. Spock, all of them promise that if you follow their method you will have the happiest, most well behaved, adjusted children ever.

If it were only that easy, first there would be only ONE book everyone used, and second it would imply that we are all the same.  But, alas we are not all the same and the plethora of books substantiates that.

What does happen when parents “marry” a system is that is stymies the parents’ creativity.  If “Jimmy” is acting out and he is not stopped because the “book” says to let him “figure it out” that may work at home, but at school when the teacher says “stop” she means  “stop and now”.  Not used to that “Jimmy” can be unjustly labeled a “trouble-maker” when in truth he is only doing what is acceptable at home.

If you “Google” parenting you come up with 1,000+ entries and if you try “best parenting” you get even more!

When my daughter, now 36, was graduating high school she wrote a song who’s opening lines were….”Kids don’t come with instruction books and they don’t come with guarantees, I’d like to thank you Mom and Dad for taking care of me…”

I saw a greeting card recently that listed the “Top 10 Reasons” someone was the ‘best parent and #1 was “ You Love Me”.  Forget about being embarrassing, you will be; being “hated”, absolutely but only temporarily; not being “cool”, hardly ever and the list goes on.

Don’t be afraid to parent your child.  Your child wants you to be the parent. They have peers at school. They need you to be the steady force that guides them—reliable, constant and loving.

Saying no is part of the program—boundaries are everywhere and they might as well learn that starting at home.  We live with red lights, schedules to meet, and behavioral constraints.  Children need to learn that boundaries can also be guiding and protective.

Letting a child learn from “natural consequences” may be OK some of the time, but left solely to a world of “consequences” without limitations other than those self-imposed can lead to chaos and confusion.

Because something “worked” at your friend’s home with “Jill” does not mean it will work with your “John”.  Because something looks good in a book, does not mean it will work in your home.  Because the video at the seminar was motivating, does not mean that you can reproduce that within your family.

Use COMMON SENSE, and just provide love, security, structure, boundaries and patience—for both you and your child. 

Saturday, March 19, 2011

Feeding Issues and Sensory-Motor and Emotional Development

Tommy is 4-years old and he won’t eat.  He can eat.  He can swallow.  He can chew. He just refuses. It is difficult at home during mealtimes, and it is impossible to go to restaurants.

Sound familiar?  If it does, read on.

Children with feeding issues often present with a complex array of issues that impact the entire developmental scheme. It involves physical, emotional, sensory, social and cognitive skills.

In many cases, by the time the child enters therapy, the problem has been on going for many years.  Therapy often requires an intensive multi-disciplinary approach in order to accomplish long-term goals and long lasting changes.

Before treatment begins with occupational and speech therapists, it is essential to rule out any associated medical problems such as reflux, slow stomach emptying, constipation, respiratory or cardiac issues, etc.

Left untreated feeding issues can have far reaching impacts on the child well into adulthood, giving rise to physical, mental and behavioral concerns.

Eating is basically a suck-swallow-breathe pattern that is repeated over and over.  Most children learn this automatically, but for some it must be taught.  For this a speech therapist is often engaged to treat this along with any other oral motor associated concerns.

Behavioral issues with feeding are sometimes referred to as “conditioned dysphagia”.  Conditioned dysphagia is a learned disorder that holds onto a “habit” long after the physiological need for such a behavior has ceased to be needed.

All feeding programs should have as its primary and most important goal nutrition.

Justine Joan Sheppard, SLP from Columbia University suggests that mealtime be the place to present the child with foods that they are already successful with instead of unfamiliar new experiences.  However Heather K. Adams, in an article from the North Dakota Newspaper suggests a compromise.  Have the child’s preferred foods, but then have a “tasting spot” at the table with new foods. The child can then try small tastes, does not have to have them on his/her plate but has had the opportunity to sample something new.  The child should not be pressured, and should be allowed to reject a food after a small taste has been made.

The Kennedy Kreiger Institute has a program for children with food aversions that focus on weight gain, food by mouth intake, mealtime appropriate behaviors and self-feeding abilities.  Their multi-disciplinary program is part of a continual assessment and re-assessment of measurable goals that both the child and the family can work on together.

Irene Chatoor of the Children’s National Medical Center specifically notes these issues as “Sensory Food Aversions”.  She states that children have aversions to particular tastes, smells, textures, and temperatures of foods.  She goes on to state that these children often have other sensory issues as well.

There is a difference between “picky eaters” and children with real food aversions.  In an article by Dovey, Staples, Halford and Gibson (2007), “picky eaters” are defined as children who “consume an inadequate variety of foods through rejection of substantial amounts of foods that are familiar (and/or unfamiliar) to them.  “Food neophobia” on the other hand is the avoidance of new foods.  While the “picky eater” and the “food neophobic” are related, but have theoretical and behavioral differences.  These authors saw that “Food Neophobia” was part of picky/fussy eating but without many of the associated behaviors.

Within these (above) categories are the “selective eater” who will only eat certain foods, and the “choosy eaters” who generally show a disinterest in eating.  Sensory food aversions generally appear about age three when children are being transitioned to self-feeding.  At this age children are expected to become more autonomous and less dependent. This transition for some children maybe more traumatic and therefore food issues sometimes arise.

In order to successfully address these concerns it is imperative to distinguish between children with minor food aversions and those with more serious concerns where their reluctance to eat can evolve into serious eating problems.

Treatment generally follows a basic three-step system:
  1. Acquisition—the child learns a new behavior relating to food i.e., chewing, orienting to food, etc.
  2. Fluency –the child practices the behavior to become faster at it and for it to be automatic
  3. Generalization—the child utilizes the learned behavior with different items in different settings.

Imbedded into these steps is the reinforcement of appropriate mealtime behaviors and the extinguishing of non-appropriate ones.  This can include a reward system where an activity is offered that the child would not have access to otherwise, etc.

§ So if your child only eats burgers and pizza, try some of these suggestions:**
Introduce a grilled cheese sandwich
§ Let them use their fingers—try introducing edamame!! (full of protein!)
§ If texture is a problem puree foods to start and slowly increase the consistency
§ Use toast as it has texture and cannot easily be lost as a bolus in their mouths
§ Use dips—toast into tomato soup for example
§ Disguise protein as a dip—put it in familiar sauces and mix it in your food processor
§ Tempt them with foods they love and let them know that you want a meal the whole family can love
§ Serve veggies with ketchup—green beans can become “green fries” with ketchup
§ Teach fine motor skills with “chop sticks” using pealed carrot sticks instead of the wooden ones—if they bite down they get some nourishment instead of splinters!!
§ Gross-em-OUT—works great for some little boys—one mother reports that her son wouldn’t eat beans until she told him they made him fart!!
§ Create a “Tasting Spot” with the rule that the picky eater has to at least try a little; if they like it they can finish it, if not they can leave it.
**from various Internet sources

And remember
§ DO NOT get into power plays this is NOT about the caregiver it is about Nutrition
§ Children use food in many cases as a stress “reactor” so adding stress is counter-productive
§ Food aversions are often associated with co-existing diagnoses such as Autism, Depression, reactions to life situations, etc.
§ The goal of diet therapy is to gradually increase in-take
§ Progress is slow
§ There are often set backs
§ Eating is a major social event –it is “family time” and not being able to participate may impact the child’s self-esteem

Occupational therapy with its extensive training and research into the area of sensory integration, and speech therapy with its focus on oral motor development are ideal interventions to help the child address these sensory concerns as well as helping the family construct a positive home program.

And lastly, avoid labeling.  If asked, simply respond “Tommy is not eating now, but he is trying and we are working on it with him.”  Things are so much easier when done with an understanding friend.  And a child’s best friend is often found in the family.

Susan N. Schriber Orloff, OTR/L, is the author of the book Learning RE-Enabled, a guide for parents, teachers, and therapists (and a National Education Association featured book), and the Handwriting on the Wall Program. Children's Special Services, LLC is the exclusive provider of P.O.P.tm Personal Options and Preferences, tm social skills programs. She was the 2006 Georgia OT of the Year and the CEO/executive director of Children’s Special Services, LLC, which provides occupational therapy services for children with developmental and learning delays in Atlanta. She can be reached through her Web site at www.childrens-services.com or at susanorloff@childrens-services.com.

Thursday, March 3, 2011

Sensory Interventions with the Autistic Child

Many of the characteristics of a child with autism also mirror those of a child with sensory processing disorder.  Autism as a sensory issue is very tricky, so many things over lap and intertwine. The classic indicators seem to almost be the same. However, it is important to differentiate between the two. The following lists help to illustrate the similarities and the differences between the two conditions.
Sensory Integrative issues may be characterized by:*

1.     Either be in constant motion or fatigue easily or go back and forth between the two.
2.     Withdraws when being touched.
3.     Refuse to eat certain foods because of how the foods feel when chewed.
4.     Be oversensitive to odors.
5.     Be hypersensitive to certain fabrics and only wear clothes that are soft or those they find pleasing.
6.     Dislikes getting his or her hands dirty.
7.     Is uncomfortable with some movements, such as swinging, sliding, or going down ramps or other inclines. Your young child may have trouble learning to climb, go down stairs, or ride an escalator.
8.     Have difficulty calming him or her after exercise or after becoming upset.
9.     Jumps, swings, spins excessively.
10.  Appears clumsy, trips easily, poor balance; odd posture
11.  Social skill issues/authority issues.
12.  Tantrums
13.  Overly sensitive to criticism
14.  Either always on the go or very sedentary
15.  Memory difficulties and/or problems following directions
16.  Has difficulty with buttons or snaps.
17.  Is overly sensitive to sound. Vacuum cleaners, lawn mowers, leaf blowers, or sirens, etc.
  1. Lacks creativity/variety in play; plays with the same toys in the same manner over and over etc.

While Autism and or PDD issues may be characterized by:

1.     Insistence on sameness; resistance to change
2.     Difficulty in expressing needs; uses gestures or pointing instead of words
3.     Repeating words or phrases in place of normal, responsive language
4.     Laughing, crying, showing distress for reasons not apparent to others
5.     Prefers to be alone; aloof manner
6.     Tantrums
7.     Difficulty interacting with others
8.     May not want to cuddle or be cuddled
9.     Little or no eye contact
10.  Unresponsive to normal teaching methods
11.  Sustained odd play
12.  Spins objects
13.  Inappropriate attachments to objects
14.  Apparent over-sensitivity or under-sensitivity to pain
15.  No fear of danger 
16.  Noticeable physical over-activity or extreme under-activity
17.  Uneven gross/fine motor skills
  1. Not responsive to verbal cues; acts as if deaf although hearing tests in normal range.
(*complied from various sources)

Not every child on the spectrum will exhibit all of these issues.  However there will be areas of relatedness and it is in these similarities an understanding of unique interventions can be found.

For example let’s look at “Patrick”:
              Five-year old Patrick is always on the 'go'. His teachers do not know what to do about him.  He has few friends and those he makes he cannot keep.  He cannot sit in circle time. Lining up to go out to recess is unpredictable.  And even worse, he talks about not liking himself and how he hates everyone and "everyone" hates him.
           He has his favorite toys and his favorite clothes and that is what he plays with and wears,  with little to no deviation.
          School is a challenge. He seems to either escalate or get so lethargic that he cannot move. He seems unable to “reset” himself, he stays “on guard” and anxious.  He does not like to go to PE or to lunch because he says that the other kids  "pick on him and hit him”.  On the playground he plays mainly with girls, and the boys seem to ignore him.  When he runs he does so with abandon bumping into people and things and barely noticing. His gait is awkward and when he runs his arms are up and sometimes he runs on his tip toes. He does not seem to respond to facial expressions or to be able to register empathy for others. He complains that things "hurt" him even when there is no evidence of that.
         Making eye contact and following a slow moving object is impossible for him without accompanied very cues. Hyper sensitive to smells, he complains about odors in art class, the lunchroom and on the school bus.
         Recall of academic information is difficult and varied repetition seems to be the best learning path at this time.
       Easily upset and emotionally labile, he seems uncomfortable in his own "skin".

 Children on the spectrum often have pronounced sensory issues. To understand Johnny’s primary areas of concern, how therapy helps, and what can parents do at home, please refer to the following chart.
Presenting Issue
Behavioral Manifestation
Sensory Processing Concern
Treatment Approach*
Anticipated Outcomes
Auditory Concerns:
Easily startled by unexpected noises

Easily Distracted

Screams and yells and has temper tantrums
Not hearing sounds with auditory figure ground discrimination or with sound/activity relationships

Attention floats and does not stay on topic
The Listening Program ™
Games that incorporate unexpected noises with the “warnings” of noises decreasing as tolerance increases
Increased noise tolerance

Increase attention to task with diminishing supports
Visual Concerns:
Does not seem to see objects in his immediate visual field

Bumps into people and things and falls a lot
Visual figure ground and visual constancy issues

Does not use visual motor ideation to plan movements
Obstacle courses

Use of weight appropriate free weights during gross motor games to increase sense of body in space
Increased motor planning in familiar situations—translating this into less familiar tasks as tolerated
Always on the go

Takes risks during play

Seeks movement
Does not know how to slow self down and he just builds momentum until outside forces slow him (teacher, etc.)
Perseverative quality to his movements

Skewed motor planning

Depressed vestibular processing
Quick change activities where increasingly the sequence or order of things changes and he has to make movement, planning and/or postural adjustments
Slow it down!  Have the child make a “plan” keep it to a maximum of 4 things—1st do____
2nd , 3rd and 4th ___
stick to the plan and make choices for the next time
Habituates wearing the same clothes

Expresses discomfort when touched

Demonstrates exaggerated responses to touch
Tantrums if “right” clothes not available

Will not try to put on anything new even if pre-washed

Gets into fights when he is trying to make friends
Tactile defensive behaviors

This causes adverse emotional reactions both in school and home
Timed trials for adjusting to new fabrics: i.e. “you only have to wear this for 3 minutes” or only while you are brushing your teeth and increase time tolerances

Provide “expected” unexpected touch and rate with child the reactions
Increased ability to tolerate new fabrics and to try new pieces of clothing

Modulated reactions to touch
Smell in lunchroom, art class, etc. are noxious to him
Nutrition issues and he becomes lethargic in the afternoons due to lack of food and this impacts his school work
Textures in mouth may be a negative trigger and over-sensitivity to smell is operating here
Make a dinner “Tapas” bar where he gets to eat whatever he usually chooses but must also take a taste and intentionally smell a new food
Increase repertoire of tolerated foods

Will eat in the lunchroom with support—first place him near the door and then slowly move him into the room
Easily upset

Difficult for him to self-regulate

Labile mood swings

Few friends

Hard for him to enter into group play

Uncomfortable with who he is
Unpredictable behaviors make it hard to anticipate his needs

Peers see him as “weird” so he is often not asked to play and when he asks he is often rejected

Isolated from others in classroom group time due to behaviors
Almost absent self-regulation skills

Chaotic responses not always fitting the circumstance

Social isolation

Organizational deficits

Make a game together where he is in charge of making the rules (but you are in charge of making it reasonable) and “rig” it so (gently) he is not always “winning”.  Warn him of this in advance and talk about reactions and choices make a “reaction box”©***

Use gross motor games to create simulated social and motor planning actions and activities and get him into a new comfort zone!
*Treatment Approaches are suggested ones there are many ways to address these issues
**The Listening Program ™--available commercially
***The “reaction box”—exclusive to Children's Special Services, LLC  Get a heavy cardboard man’s shoe box; decorate it with paint, contact paper, etc. put in it on separate slips of paper good behavior choices ONLY. When he is upset let him pound on the box for a while and then he picks a choice out of the box and you help him achieve that “choice”.

So what do you treat first?  Everything! That is Occupational Therapy, changing the context in which one lives so that life can be lived with greater ease.