Saturday, October 20, 2012
Transitions are particularly hard for some children and extremely difficult for most children with sensory issues. It isn’t just the air and the leaves that are changing it are the clothes that the children are wearing changes too.
They entered school in August when the weather was still warm and clothes were soft and light, are suddenly wearing heavier clothes. Clothes with waistbands, shirts with cuffs, bulky sweaters, all contribute to sensory changes. And they are getting unpredictably warm and then cold. For some children with sensory issues this produces a kind of “sensory chaos” and the changes in behavior mirror this confusion.
In addition there is the shortening of the days and it gets darker earlier and children with light sensitive sleep-wake cycles find themselves tired more easily or curiously awake at odd times.
Children who were “doing fine” in August and early September are now distracted and not finishing work. Discomfort in their own skin can translate into discomfort with their personal space causing them to “bump into friends”, have difficulty lining up, or squirming in their chairs, etc.
These issues do not quickly resolve and take time as the child adjusts to the changes in the weather and related changes of dressing and sleeping.
Occupational therapists are uniquely qualified to help both parents and teachers with helping these children better tolerate these changes.
Here is some home and school suggestions that can help these children transition better.
1. Take all the summer clothes out of the room; (your child may “fight” you at first but just explain that you need room for the more bulky fall and winter clothes), once the clothes are in a box and out of the room replace them with familiar winter sweaters (if they still fit) and have your child participate in the placement of the clothes in drawers and closets.
2. Be aware of fall allergies and if needed take your child to the pediatrician for help with this.
3. Transitioning from shorts to long pants where their legs are being “touched” all day long can be a real problem. Try those pants with zippers at the knees that transfer into ‘shorts’ so if the children get really “itchy” they can take off the longer part of the pants while they are in class. Be sure to discuss with your child that they will have to put them back on for recess, going home etc.
4. Use schedules that show when they go to sleep, when they get up, eat, do homework. This will help they have a sense of order and time so that they can meet the task expectations.
1. Believe it or not light bulbs do make a difference. Using lamps in the room with (for example) Eco-Vantage light bulbs (Phillips) is a great way to keep “summer” in the room a little longer and can help with light sensitivity adjustments.
2. Sounds are now different for these children. In the summer there were outdoor sounds at the pool, on the street, and now they are in a classroom in a place where sound is confined; the teacher is talking, kids are talking, chairs are moving. To most children this is not a problem, but to sensory kids this can be as if megaphones were blaring at them. Have soft classical music playing in the room to create non-distracting ‘white noise’, let some children wear headphones, put carpet squares under the chairs. Tampering down the noise level for ambient noise can help a lot.
3. For the children that crave multiple sounds let them wear headphones that have music playing but not too loud so they can still cue into the classroom as needed.
4. “Go to Australia” Have a sensory pup tent in the room set up for kids that need some personal space adjustments. Inside the tent can be different textures (pillows with different coverings) carpet and maybe a beanbag chair, CD player. Children get a “passport” and a “Visa” for a specific time limit (5-10-15 minutes) at which time a timer rings and they know they have to come back to America. For young children show them how far away Australia really is so it will be more fun for them to ask to go!
Change is never easy and change for sensory disordered children is often akin to placing them on another planet. Everything becomes novel, even familiar tasks. Lack of familiarity fosters fear and fear fosters chaos. Containing the chaos and converting it into function is the challenge. Occupational Therapy can be a valuable resource for parents, children and teachers in learning these and other sensory controlling techniques.
Sunday, August 26, 2012
OT’s role with the Autistic Adult—
Susan N. Schriber Orloff, OTR/L
I frequent my local Office Depot often. Dave works there, and over time I have gotten to know him fairly well. He is an expert in all things electronic. To ask Dave a question is to expect a very long detailed response. It is almost impossible to interrupt him once he starts his explanations and takes offense if you do.
Ritualistic and unfailingly consistent in all his behaviors, Dave is tolerated by his co-workers, but is never seen in casual conversation. When not with a customer, Dave is known to spend his time dusting and caring for the equipment in his department. In one of our conversations, Dave asked me what I did and when I told him, he shared that he “used to be autistic, but now he was cured”. All of sudden, everything seemed to make sense.
As OT’s we see a lot of autistic children, but what happens when these kids grow up? At least by my observation, aside from low wage jobs in grocery stores, autistic adults almost seem absent from usual daily encounters. So when Dave shared with me this very personal piece of information, I began to investigate services for autistic adults in my community. Sadly, there seemed to be very few choices compared to the opportunities for individuals in the 18 months to 22 years. It seems that when public school services end so do the opportunities.
There are private post secondary schools, but many of these are expensive making participation not a viable option for many families particularly in this economy. Vocational training centers seem to be even scarcer.
This is not to discount the existing day programs, the independent living options or state vocational centers. But often these resources come with long waiting lists and in many cases are significantly under-funded.
What does all this mean and what is the impact on occupational therapy within the role of services for the autistic adult? I propose that OT be an integral part of the high school curriculum for autistic children in grades 9-12. And that the services include but not be limited to testing for community skills, vocational training, community “fieldwork employment”, and supervised simulated independent living skills.
The impact of not being proactive with these emerging adults has multiple negative consequences not only for families but the greater community as well. Children generally outlive their parents, so without good community living resources many of these adults find themselves (if lucky) being cared for by siblings or extended family, but in some cases, homeless. Living “unprotected” carries with it the potential for becoming easy prey and possible involvement in drugs, crime, etc.
Dave appears to be one of the lucky adults on the spectrum. Employed by a major retailer who obviously knows both his strengths and limitations. We need to educate the community in order to create more opportunities that promote independence and dignity for the autistic adult.
Occupational therapy has its roots in what historically is known as “Curative Workshops”. Maybe it is time to remake that concept updated for the 21st century providing services for all autistic individuals—children and adults.
This rare but potentially devastating condition affects girls born to older mothers. And as we as OT’s working in schools and preschools have already observed, many of our “first time moms” are often in their late thirties and early forties.
It is not a given that all older moms give birth to children with issues. But in the case of XXX Syndrome that is one of the prominent factors. XXX Syndrome is characterized by the presence of an additional X chromosome in each cell of female children/fetus. If the extra X chromosome occurs only in some of the cells it is called a mosaic, and has less developmental impact. It is not an inherited condition and usually occurs during conception and is related to a delayed or incomplete splitting of the egg during fertilization. Occurrence is about 1 in 1,000.
XXX Syndrome can be mild to severe in its developmental impact. These children are often very tall, have vertical skin folds in the corners of their eyes, delayed motor skills, speech and language difficulties and various associated learning disabilities. Other issues include social skill issues, self-esteem and related personality and psychological issues.
In preschool, these little girls “look” like their peers but just seem a “bit off”. Following directions, engaging in-group tasks, frustration with following verbal directions and creative activities are often difficult for these children. In addition these children are often very dependent upon the teacher or authority figure for guidance and demonstrate little independent initiative. It is as if, at a very early age they have learned that they cannot “go it alone”. Behaviors are often unpredictable with the exhibition of task aversion in one situation and the ready engagement in another.
To better understand the profile of a XXX little girl, the following excerpt from an assessment is provided. The name and identifying information has been removed. This little girl was about 5 years old. She had a tested functional IQ of 130. Treatment goals and summary are included to help give a template of potential treatment planning. It is extremely important to be sensitive to the parents in these situations. “Jane’s” mother blamed herself for “waiting” to have a baby and said that it was “her egg” that caused the “problem”. Helping parents see function not dysfunction and encouraging them to seek counseling can be as much a part of your occupational therapy treatment as the actual interventions with the child. In addition, it is important to stress to the parents that these children will not “outgrow” these concerns. They may “morph” into other actions/behaviors, but they do not self-resolve. Therefore stressing the importance of early intervention and that this is not a “quick fix” should be discussed at the onset of treatment.
Summary of Functional Responses
Scored as strengths, emerging (present but not fully developed) and a concern
· Imitating basic one-sided postures
· Dominance on right
· Hop one foot and two feet
· Balance on left foot eyes open (stronger than on right)
· Stack blocks to 10
· Scissor use
· Jumping forward
· Ability to sustain self in task with supports
· Knew colors
· Knew shapes
· Heel toe walking forward
· Able to connect dots
· Able to respond positively to structure
· Could state opposites
· Catching a ball
· Jumping backward
· Write name
· Right/left awareness
· Copy skills
· In-hand manipulation
· Block designs to 3
· Making choices
· Awareness of 2-deminsional boundaries
· Draw a person
· Heel toe walking backward unassisted
· Crossing midline of body with opposite side
· Figure ground discrimination issues
· Part-whole perception
· Perceptual constancy
· Spatial organization
· Emotional stability reactions in unfamiliar tasks
· Using both side of the body during a task
· Fear of failure
· Targeting with a ball
· No nystagmus
· Places elbows into side of body for stabilization
· Pencil/crayon control
· Visual scanning
· Task initiation
1. Pair verbal directions with visual demonstrations; possibly have Jane assist when providing the class with a demonstration for an activity.
2. Ask her to repeat (and partially demonstrate) directions to assure understanding.
3. Minimize visual/auditory distractions as much as possible.
4. Encourage correct posture for deskwork (left hand stabilizing paper, appropriate pencil grasp).
5. Encourage Jane to participate in activities to build muscle tone and motor planning such as; performing different yoga positions.
6. Allow Jane to keep her hands busy with a fidget toy or squishy ball.
7. Allow Jane extra time to complete activities.
8. Encourage visual tracking skills by highlighting choices on activities.
9. Encourage and/or allow her to go first when performing group gross motor activities to encourage initiation with task.
10. With tasks that she knows how to do such as putting on her shoes, do not assist her—encourage independence in self-cares and known tasks.
Jane presented as a bright, timid young girl who found it difficult to separate from her mother, however shortly after she entered the testing area she “warmed up” to the OTR. Maximum encouragement was required from OTR to encourage participation in testing.
Present performances seemed to be negatively impacted by her visual perceptual, visual motor skills, and low tone.
During testing, Jane had a difficult time performing fine motor and visual perceptual- motor activities as noted by her inability to cross midline and visual track the items viewed. She showed the ability to identify shapes but was unable to reproduce the images onto paper. When faced with familiar and unfamiliar challenges such as copying pictures or identifying appropriate choices, she immediately became fearful of the challenges and broke down and started crying. Her reactions outlined the characteristic of a child that is having difficulty with translating visual information into appropriate motor responses; this is another common characteristic of Dysgraphia.
Jane became extremely frustrated by her lack of performance as demonstrated through her slow initiation and response to tasks. Maximum encouragement, visual and verbal prompting was required by the OTR, however it was noted that she 90% of the time only accurately responded and participated when visual cues were provided. This was the same behavior observed within her classroom when noted that she did not perform the drawing activity when auditory directions were given, instead she performed after she looked at the images drawn by her classmates.
Many of the sensory motor issues such as low functioning tone and no nystagmus response as noted during Jane’s evaluation, stems from her sensory system not receiving the appropriate feedback in order to organize the incoming information needed to produce functional movements. These issues can be related to a known disorder commonly known as Sensory Processing Disorder (SPD). Children often unknowingly seek out other ways to receive the sensory input that is missing. In Jane’s case, these issues are affecting her ability to perform age appropriate tasks, therefore causing her extreme anxiety and frustration.
Jane is a great candidate for being able to benefit from occupational therapy interventions. She is very bright, and when supported, is very motivated to acquire new skills.
1. Increase tone and co-contraction abilities
2. Increase visual tracking.
3. Increase hand manipulation and finger isolation skills
4. Increase following directions and task-planning abilities.
5. Stimulate vestibular (nystagmus) responses inclusive of but not limited to balance and reciprocal movement patterns.
6. Increase crossing the midline of the body and gross motor movement patterns; such as skipping, somersaults, etc.
7. Facilitate a more functional pencil grasp.
8. Increase problem-solving abilities.
9. Increase frustration tolerance and the acceptance and ability to benefit from corrective remarks.
10. Teach the Sensible Pencil Program.**
**I particularly like the Sensible Pencil Program™ for early writers because of its guided worksheets and prewriting picture format.