Occupational Therapist

By Michaela Gordon, OTR/L

Contributing Author, Dr. Felicia Lew

Since the arrival of technology, we are spending much more time sitting and looking up close at 2D environments such as phones, tablets, and televisions. A study was published in Preventative Medicine, (Varma et al., 2017) involving 12,500 people 6-84 years of age. The participants wore activity trackers to measure how long they were active and sedentary throughout their day. The outcomes indicated that 19 year olds spent as much time in a sedentary state as 60 years old individuals! The study also indicated that 25% of boys and 50% of girls ages 6-11 did not engage in the recommended amount of 1 hour of moderate to intense level of exercise per day.

If this is the case, what activities are our children and teens doing on a daily basis? How are they using their time? According to the Common Sense Media website (www.commonsensemedia.org, 2019) , a survey of 1600 children and teens revealed the average 8-12 year old spent almost 5 hours on screens per day and the average teenager spent 7.5 hours on screens per day. This number did not include additional screen use for school or to complete homework. I think this answers what children and teens are doing with their time!

As caretakers of children and teens, we must then assess what ill effects technology and media have on their health and well-being. According the Common Sense Media website, ill effects of prolonged screen time include addiction to screens, loss of focus, lower empathy and social connection, and health problems such as eye strain. The researchers indicated that parents must educate their children and teenagers about the ill effects of technology and teach them how to moderate its use.

Occupational therapy can address these present concerns. One focus area of occupational therapy is sensory integration, which is our brain’s ability to recognize, interpret and organize information obtained through our senses. Our sensory systems have an intimate relationship with each another. The systems work together to give us a sense of where we are in space and influence how we relate to our surroundings. Sensory-motor experiences are critical to brain development. Unfortunately, a child minimizes his movements, exploration, and interaction with the world when sitting for many hours in front of a screen. He deprives his brain of the rich sensory experience of the real three-dimensional world. His view is fixed on a two-dimensional object and he is missing out on what’s around him!

What about vision and technology? The visual system is the primary sensory system being used during screen time. The increased time looking at screens has taken a toll on our eyes, both short-term and long-term. There is evidence that outdoor play reduces the incidence of near-sightedness (myopia) in children. The American Optometric Association (www.aoa.org, 2020) states that the rate of myopic school-aged children continues to rise. The AOA states that 1 in 4 parents have a child that is near-sighted and 75% of near-sighted individuals were diagnosed between the ages of 3-11. The AOA recommends that family members receive annual comprehensive eye exams. Myopia can increase the risk of retinal detachment, early cataract development, and glaucoma. Therefore, early detection is important.

Furthermore, the importance of vision in child development is multi-layered. A child may have 20/20 vision, which is considered “perfect vision”. We call this visual acuity or how clearly the child can see. What is often missed is assessing a child’s functional vision. One important area of functional vision is visual perception. Some examples of visual perception are: finding objects within a background, identifying objects based on their parts, and determining the spatial orientation of objects. Another area of visual function is eye motor skills and coordination of movement between the two eyes. A child who is unable to visually fixate in one spot or track words across a line to read is a very frustrated child. I see a variety of negative behaviors in children when visual challenges are undetected and untreated.

As an occupational therapist, I want to do my part to guide children towards healthy development. Many occupational therapists can provide assessment and treatment to address visual perceptual challenges. A therapist who is trained in sensory integrative treatments typically uses a ground-up framework by assessing how the child processes different types of sensory input. We often see that children with poor vestibular processing also have poor visual perceptual skills. Assessment of balance, postural imitation, and bilateral coordination skills gives us a sense of the child’s visual perception. We also look at reflexes like anti-gravity postures, which can also tell us how the other sensory systems are interacting with the child’s functional vision. We also look at fine motor skills and handwriting skills to gain more specific insight into the organization and precision of the visual system.

Once we have gathered the appropriate information, we treat targeted areas to improve sensory-motor functioning. Part of the therapy process involves providing a home program to promote healthy sensory function at home. The program may be a schedule of sensory-motor activities, modifying or eliminating unhealthy habits, and educating the family and child on how to develop their sensory systems for long-term success.

Occupational therapists can work with children on ocular-motor exercises (e.g. shifting eyes from one spot to another) and visual-perceptual activities (e.g object finding board games, block design games, mazes, and handwriting). We can address upper-body coordination skills to assist with improving ball skills. Occupational therapists can perform visual screenings to determine if further examination is needed by an optometrist. Occupational therapists are not licensed to work with lens prisms or color lenses unless under direct supervision of an optometrist. Visual therapies can be quite powerful on the central nervous system. When we work with the eyes, we are really working with the mind.

Occupational therapists may not be able to treat all of your child’s vision struggles so it is important to receive further assessment by a developmental optometrist if your child presents with more complicated visual challenges. Engaging in both occupational therapy and vision therapy either simultaneously or sequentially can be beneficial. Despite some overlap of therapies provided by both disciplines, an optometrist and an occupational therapist will bring their unique perspective and expertise when working with your child.

Developmental optometrist Dr. Felicia Lew has kindly offered more insight into her work as a vision therapist. She gives us further insight into what a parent would expect from vision therapy.

Dr. Lew, what is the difference between a developmental optometrist and an optometrist or ophthalmologist?

Good question, as there seems to be some confusion about this. First, the similarities. Both optometrists and opthalmologists evaluate and treat eye conditions that do not require surgery. These include infections, glaucoma, and removal of foreign bodies. Both optometrists and opthalmologists also administer comprehensive eye exams.

Second, the difference – surgery. Opthalmologists operate. Optometrists do not. Ophthalmologists undergo extensive surgical training, and usually specialize in particular types of eye surgery. The most common form of pediatric eye surgery is to correct misalignment of the eyes. This is done by cutting the muscles surrounding the eyes and then repositioning them. Optometrists spend all their time in graduate school learning about the eyes and vision system, as well as related subjects such as optics, pharmacology, and neurology. Optometrists’ training also emphasizes optical correction, which allows them to help patients correct their vision without surgery with devices such as glasses and contacts.

Developmental optometrists are a sub-group of optometrists who take a more holistic approach to vision care known as “vision therapy.” They obtain a doctorate degree in optometry and then pursue further training through organizations such as the College of Vision Development and the Optometric Extension Program. Most developmental optometrists begin their careers as traditional optometrists. But then they realize that vision care is much more than helping patients see 20/20 and making sure patients do not have eye disease.

A traditional optometrist usually spends 30 minutes or less with a patient for a comprehensive eye exam. A developmental optometrist, however, may spend several hours with a patient, spread over several appointments, to complete a comprehensive eye exam, a developmental eye exam, and a functional vision evaluation. In my practice, I watch a child’s eyes and look to evaluate issues such as (1) whether the eyes work together as a team, (2) blinking, (3) reading difficulty, and (4) sensitivity to sensory stimuli. I also evaluate head and body posture, balance, and interactions with surroundings. I thoroughly assess eye movement and alignment with the aid of computerized tracking equipment which utilizes sensors to detect and record eye position. I also evaluate visual perception and processing areas such as visual memory, visual closure, directionality, visual figure-ground discrimination, and writing skills.

Following such a comprehensive evaluation, a developmental optometrist will create a treatment plan that does not include surgery or drugs. The goal of vision therapy is to rewire the connections between the eyes and the brain more efficiently. This leads to improvements in the patient’s life which can include a safer and more stable visual world, interest and engagement in surroundings, enjoyment of reading, faster completion of schoolwork, and cosmetic and functional alignment of the eyes.

Developmental optometry’s less traditional approach has gained much attention in recent years. World renowned institutions such as the Mayo Clinic and Harvard’s Boston Children’s Hospital have been implementing programs in developmental optometry and vision therapy.

And this just makes sense. In his book Brain Rules, developmental molecular biologist John Medina explains that vision “trumps all the other senses,” occupying more space in the brain than the other senses combined. Given its importance to overall health and wellness, we need to address all the complexities of the visual system when fostering learning and development in children.

What type of specialized therapies do you perform to improve visual perception?

My toolbox is overflowing. In addition to prescribing glasses and contact lenses in the traditional sense, I can use lenses, prisms and filters to modify sensory perception. For example, I can place lenses in front of the eyes to enable a patient to more accurately identify sounds and locate where the sound came from. I also use a lot unique gadgets and gizmos for vision training which keep a child visually challenged – and having fun at the same time.

Both in-office and home therapy incorporate games and activities which give feedback to a child to make them more aware of how their eyes and brain work together. Many activities integrate the other sensory systems so a child can make connections between the senses to better understand their surroundings. When appropriate, I use computer programs like virtual reality games to provide controlled increases in complexity and difficulty to improve visual skills.

When do you think it is appropriate for a child to work with both you and an occupational therapist?

Good question – and difficult to answer because each child is unique. I will recommend seeing an occupational therapist or other professional if the concerns that need to be addressed are beyond my scope of practice. I find collaboration with occupational therapists and practitioners of other disciplines invaluable to a holistic approach.

Do you recommend vision therapy before occupational therapy or vice versa?

The general rule is that a child with developmental concerns should have a developmental eye and vision evaluation in addition to evaluations with other professionals to identify whether the areas which need improvement are primarily related to vision. If so, I would probably recommend vision therapy first.

However, I see many children after they have seen an occupational therapist. I appreciate this, because it means that they already have done work in areas related to vision development such as primitive reflexes. This primes them for what I do. Often, occupational therapists will refer a child to me if she thinks there should be more emphasis on the visual system.

If you could pick one habit to change in order to improve a child’s visual health, what would it be?

Ah, an easy one — less screen time and more real-life play, especially outdoors. Playing in free space is so important for healthy development.

That being said, some newer studies indicate that computer games can aid the development of vision skills. Also, exposure to blue light – which digital screens emit – boosts memory, alertness and cognitive function but too much can cause eyestrain, poor sleep and possibly macular degeneration.

So, a moderate amount of screen time is OK. But focus on playing outside

References:

https://www.aoa.org/newsroom/myopia-rates-on-the-rise-syvm

https://www.commonsensemedia.org/sites/default/files/uploads/research/2019-census-8-to-18-key-findings-updated.pdf

https://www.sciencedirect.com/science/article/pii/S0091743517301949

I work with children and fairness is a big thing that comes up in play. When there is a sense of unfairness, soon after follows blame. What I have noticed is that the children need support with responsibility, empathy, and communication. When these skills are not developed, the children stay in this vicious cycle of, “I want to play with you, but if the relationship is unbalanced, leading to my needs not being met, then I want to blame you.”

I find this same cycle occurs in adult relationships including patient-healthcare practitioner partnerships. We are living in a time where patients or clients have more access to information and therefore want more choices and more explanation. Western medicine has operated for many years under the “we know best” model, where patients mainly give their power away and it is expected they follow the doctors’ recommendations. There is also this theme of Western and Eastern medical professionals working in divide, which further complicates the healthcare practitioner-patient relationship since many patients are now wanting to explore what both fields have to offer. This imbalance in the relationship leads to further dis-ease, making patients sicker and healthcare practitioners working in defense versus in openness and collaboration.

What’s troubling about these scenarios is that they are vicious cycles that show a lack of responsibility, empathy, and communication. We would all benefit from stopping this cycle and creating a more productive and integrative approach.

Lets start with responsibility. As a therapist, I’m upfront with my clients about my responsibilities and their responsibilities. Some are written in policies and some are discussed in person. My job, as the therapist, is first and foremost to think, “How many I serve you? What knowledge has been gifted to me that I can share with you to better your life? What are the possibilities available to help you?”

What I feel is not productive is, “You are 100% responsible for yourself and if something is hard and goes wrong, that’s not my problem.” Would you want to play or be friends with someone that is going to bail on you during times of difficulty? Would you want to keep playing with someone that manipulates the rules so they can ensure a win every time for themselves? To me, that sounds like a misuse of power and attempting to get out of responsibility.

Of course, the client has to make all final decisions. Of course, the client needs to get to know themselves and develop a better sense of their needs. Of course, they need to make some attempt at recommendations. It is a two-way street. However, maybe they don’t have interest in studying health like you. Maybe they don’t know how to clinically think about their situation. That is why they came to you! We are all gifted in different skills and thank goodness or it would be pretty hard to survive here on Earth. So, it is important that the patient is not left feeling blamed or shamed for a compromised immune system, a genetic make-up, a neurological difference or simply not being able to figure out how to solve a problem. Healthcare practitioners should be ENCOURAGERS and LEADERS!

Empathy is another piece and it important in a partnership. Being the helper or the patient, both have there challenges. As the practitioner, maybe they don’t have the answer yet, but they are willing to keep trying different methods and researching alternative options. Maybe they have something going on in their own personal lives. Perhaps they are working in a system where they don’t feel allowed to expand their thinking outside a set of choices. As a patient, maybe they don’t have a support system encouraging them to change. Maybe they don’t have the means to follow through with recommendations. Maybe their illness is robbing them of energy resources to go the extra mile. None of us want to be dealing with tribulations, but they are indeed part of life. So, whether big or small, we need to have patience and understanding with one another.

Lastly, partnership requires good communication. It’s amazing how learning new phrases and building up your word bank can improve your relationships. For instance, you may hear from the doctor, “Wow, this is the worst test I have ever seen!” They may say, “You’ll have this the rest of your life and there is nothing you can do about that.” How is that helpful? How about, “These test results have me curious about looking into this avenue. I’m thinking we should try x,y, and z.” The doctor can say, “I don’t  know the outcome for you. With this condition we haven’t found permanent, reversible solutions yet. However, we are learning more every day and we are going explore all that is imaginable to get you well. We are going to face this together.”

A partnership is an investment. It is an exchange of effort and belief in one another. It’s searching beyond what you know and looking for solutions in the places that you don’t even know exist. It’s reconfiguring the situations into something fruitful. It is about the patient returning back to their wholeness, leaving the practitioner in a better place before your journey together, preparing them to take the journey with the next patient. We get well when we get brave, when we have faith, and when we move beyond the discord and into possibility.

So, let’s get away from fear and move towards doing what is right. Let’s act with discernment and love. Be that person that is going to walk alongside others in good faith. Be that patient, that believes in themselves and knows that healing is there for the receiving. Be that walking miracle in all you do and then spread it to those around you.

Michaela E. Gordon, OTR/L

At my first job, I remember seeing these white brushes. I knew they were for some sort of tactile stimulation, but did not use them with students. I moved to CA and here I would also find the white brushes! I was shown the protocol at an in-service. I didn’t fully understand the neurological underpinnings of the protocol, but I thought this was a great tool, so I started using it with clients.

I later realized after taking the class, it is really important to go to the training because you need to learn about the mechanism of pressure, which is difficult to conceptualize from verbal or written directions. Also, when I train families with the protocol, I typically have to review the technique with them 2-3 times before they can execute the procedure in an effective way.

I was excited when Pat Wilbarger and her daughter Julia were coming to the area to teach the neurological foundations and the application of their protocol. Pat was one of the first pioneers in the field of sensory integration and she created this protocol to help children with sensory defensiveness. Sensory defensiveness is when the brain perceives non-threatening sensory signals as a threat, causing chronic, undue stress to the individual. During the class, Pat said something that helped me to truly to understand the importance and intent of the protocol. She said, “This sensory defensiveness is serious stuff! This is a matter of quality of life for these people so you really need to understand what you are doing.” It’s a matter of quality of life. I will never forget that. It’s a matter of being able to function in the world and being able to let others close to you. It matters.

There are lots of misconceptions about the Wilbarger Deep Pressure Protocol from its purpose to its details. I am hoping to clear some of these misconceptions up. First, the protocol is often called the “brushing protocol”, which sometime leads both non-trained professionals and non-professionals to miss the objective of the protocol, which is to provide pressure. Some individuals also confuse “brushing” with lymphatic dry brushing, which is surface, light-touch brushing with a different type of brush, which is counter-productive to addressing sensory defensiveness. Pat developed a specific brush where the bristles are a particular shape and texture as well as a rounded handle to ensure good delivery of deep pressure. This pressure is without scratch, tickle or itch.

Second, the purpose of the brush is to apply specific PRESSURE to the skin. It is not light touch or a massage. It is all about specific pressure. The brushing procedure is followed by joint compressions, which is also specific PRESSURE delivered to the proprioceptive (joint/muscles) system. Doing both is important so the brain can properly interpret and integrate the messages from the sensory signals. The tactile stimulation is given with pressure, but even so, can over-arouse the system. The joint compressions that follow are given to provide grounding input without overstimulation so the individual can benefit from both types of stimulation.

I often get complaints about the frequency the Wilbarger Deep Pressure Protocol has to be delivered, which is to be performed every 1.5- 2-hours throughout each day for at least 4-6 weeks or until symptoms resolve. I can assure you that this is not to torture you or your child. If you want to change physiology, the body needs consistent input that is delivered at a specific frequency and duration over time. So the more you can follow the protocol, the more likely your child’s physiology can shift.

Another missing piece is the sensory diet. This is Pat Wilbarger’s coined termed for providing other types of sensory inputs throughout the day along with the therapressure protocol. Again, we are looking to shift sensory input into informative data versus false alarms that puts the individual into distress. The person needs an opportunity to get organized input on their own in conjunction with the therapressure protocol that is delivered by an adult or themselves. Individuals with sensory defensiveness are often avoidant or distressed by daily activities so they do best with predictable, planned sensory activities. Over time, the person will be more likely to seek out and engage in a variety of activities that fulfill their sensory needs. However, until their physiology changes, they will need support and encouragement.

It must be noted that Pat Wilbarger figured out something remarkable. While working with her friend and colleague Jean Ayres, she realized that some of these children were avoidant of treatment versus naturally gravitating towards sensory stimulation that met their needs. Pat was also able to determine that the timing of sensory input was important. Her clinical findings indicated that children generally needed to be engaged in sensory input every few hours in order to keep the integration process going. Due to this discovery, she realized that it wasn’t enough to treat a child just in a clinic, but sensory stimulation needed to be continued in homes and schools. That is why it is important for parents, therapists, schools and other adults in the community working with the child to communicate in order execute the sensory diet and therapressure protocol. As they say, “It takes a village!”

So do the sensory diets and the therapressure protocols require some planning and effort? Yes. Can it feel stressful and at times tedious? Yes. However, I think the missing link is that parents, teachers, therapists etc. may not have gotten the message I received and that is, “This sensory defensiveness is serious stuff! This is a matter of quality of life for these people so you really need to understand what you are doing.” I think when we keep the intent of what we are trying to achieve out in the front, it keeps us on track. We do the best we can to deliver consistency to the defensive/avoidant individual. We do our best to come up with a plan that can be realistically implemented. It doesn’t need to be perfect. The goals just needs to be clear and we have to keep working at it.

Pat Wilbarger has absolutely left her mark on this earth. Both she and her daughter Julia have gone all over the world delivering their knowledge and expertise on sensory defensiveness. I have seen with my own eyes the difference this method can make for individuals with sensory defensiveness. They regain confidence and joy. They begin to understand themselves and connect with others.

A thank you to Pat and Julia Wilbarger for all they have taught me and the rest of the OT community.

“Never doubt, that a small group of thoughtful, committed citizens can change the world; Indeed, it is the only thing that ever has.” -Margaret Mead

Michaela E. Gordon, OTR/L

Do you ever hear a kid say, “You don’t get it. You don’t know how it feels to be me!” That is the truth. We don’t know what it feels like to be them. We can only empathize and try to relate based on what we are experiencing. When it comes to sensory defensiveness, children are over responding to sensory input, which causes a fight, flight, or freeze response. It is not necessarily the actual stimuli that is the issue, but rather the way the sensory signal is being processed when it reaches the higher level pathways of the brain.

We all have some degree of sensory preference and sensitivity. And some sensitivity is good. If you were walking across a street and noticed that a car was both close and coming at you, it is a smart move to run as quick as you can! However, if you are walking across the street and you hear a car way off in the distance, but your brain says, “Run, you are about the get hit!” when that is not the case, then the brain has just sent you a false alarm, which can be confusing and distressing. If the brain is constantly misinterpreting  non-threatening sensory input as a danger, this can impact the child’s confidence while interacting with the world and can give them a sense that the world around them isn’t safe and at the very least, uncomfortable.

Here are the types of sensory defensiveness one might be
feeling:

1. Tactile defensiveness. This is the most recognized type of defensiveness. These children have strong reactions to touch information. They may complain about hygiene routines. These complaints can include brushing their teeth or hair hurts, bathing is uncomfortable, clipping their nails or getting a haircut is painful. These children complain about their clothing, refusing to putting on their socks and shoes or only wanting to wear a specific piece of clothing. These children may also have difficulty with accepting touch from others so they avoid hugs or they will report that others have hurt them because normal touch felt like a push or some other assault.
2. Auditory defensiveness. This is also a widely recognized sensitivity. These children put their hands over their ears to block loud noises. They may refuse to go into public places or use the restrooms because of loud sounds like music or the toilet flushing. These children may be bothered by everyday sounds at home and school so they avoid situations, have meltdowns, or become aggressive due to the noise.
3. Movement defensiveness. In the OT world, we call this gravitational insecurity where the child develops great anxiety when experiencing movement. These children do not feel comfortable moving through space, especially if their feet leave the ground. In babies, they may be fearful to stand or walk. In toddlers and children, you might see them avoiding riding their bikes, climbing playground equipment or using swings. These children usually crawl upstairs versus standing. You will often seem them keeping both their hands and feet on the ground when scared or unsure. They often cling onto parents and teachers for dear life and can’t bring themselves to go enjoy play with the other children.
4. Visual defensiveness. These children are often sensitive to light. They may ask to turn the lights off or you’ll see them squinting or rubbing their eyes.  Their parents may need to put a screen up in the car to block the sunlight. These children may become overwhelmed with fast moving environments or fast moving television shows. These children can be easily startled by visual stimulation, especially peripheral stimulation they weren’t expecting.

If you are someone without defensiveness, these scenarios may not make sense to you. Perhaps you are a good integrator of sensory stimulation, but your child or student is not. Instead of the sensory signals informing the various parts of the brain in a rational way so the child can learn, play, and relate, these signals are heading right to the watchdog of the brain, the amygdala. The brain tells the child, “Danger, danger! You must protect yourself!” These constant false alarms can be overwhelming over time and can impact the child’s emotional well-being and their ability to participate in everyday life tasks. It can take a toll on relationships and make the child feel like there is something “wrong with them”. So when a child says, “You don’t know how it feels to be me,” you may want to answer, “You’re right, I have no idea how it feels to be you AND we are going to figure out how make this better.” In other words, we are going to figure out how to get your brain and body working in a more integrated manner.

Here’s the good news! We know that using sensory integration treatments and tools, we can retrain the brain to better understand the sensory signals so they are correctly informing the child as they interact with the world. Several things need to happen in order for this to be accomplished. The right tools need to be identified, the tools need to be implemented with frequent consistency, and the child needs to want to participate on some level. If that can happen, it is amazing how the nervous system can shift and the defensiveness can either be reduced and in some instances completely resolved.

It is an honor to help children overcome these challenges. It can really have such a positive impact on their quality of life, yielding to a more comfortable and confident child. If your child or a child you know presents with sensory defensiveness I encourage you to get them to an occupational therapist.

“Dwell in possibility.” Emily Dickinson

As an OT, I have searched endlessly for an effective behavioral approach for children with sensory processing challenges. I was lucky enough to meet Joe Newman, author of the book RaisingLions. In a short period of time, I was on a trajectory to work with him, adopt his philosophy of addressing behavioral challenges, and assist in entraining his approach within the communities that I work within.

It is the responsibility of all adults working with children to address behavior. In my opinion, it is important that the child and the adult feel emotionally safe to express themselves and that everyone feels respected. Without these healthy boundaries, deep connections will be difficult to foster and children will struggle to understand the balance between their needs and wants and those of others.

In my practice I work with many children that have sensory modulation challenges. Sensory modulation refers to the brain’s ability to respond appropriately to incoming sensory stimulation in order to maintain an appropriate level of alertness so that the child’s responses match the situation within a reasonable range. Some children over-respond to sensory stimulation causing strong emotional reactivity, impulsive action, and intense physical responses such as crashing, bumping, excessive touching, excessive movement, and/or loud singing or talking. These children often have poor emotional control and can become oppositional and irrational in their behavior. On the other end of the spectrum are the children that are under-responsive. These children are passive and often miss sensory cues. They have difficulty with keeping up with peer interactions and often need support to complete daily activities. These children are prone to having passive tantrums. Due to their chronic low arousal, they become accustom to others initiating tasks for them or in some cases doing the tasks for them. It can be challenging for adults to recognize these children’s level of ability because they will express they don’t know how to do something or that the task is outside of their abilities even when it’s possible that they could do the task.

I believe we need to recognize these children’s struggles, but we can’t let this block us from seeing their capabilities. These children need both empathy in regards to the challenges they face, but also good boundaries and effective tools so they can learn needed developmental skills.

In OT, we work with children with sensory modulation challenges by presenting them with different types of therapeutic sensory activities that have either an excitatory and/or inhibitory properties so the child can learn how to get into and maintain a level of alertness that allows them to interact with their environment in a meaningful and productive way.

When working with children with sensory modulation challenges, we also have to address the behaviors that arise due to the nature of these challenges. With the Raising Lions approach, I have found success in helping children learn impulse and emotional control because of the opportunities that the method provides in comparison to other behavioral approaches. Here is why I feel the method is effective:

1. It’s relational. As an occupational therapist, we work not only with the whole person, but the dynamical responses within the child’s relationships. Raising Lions is a relational approach. It respects the child’s autonomy, but also works towards interdependency with others.
2. It’s non-judgmental. Children with sensory modulation issues are usually up against a lot of criticism because their behaviors are typically inappropriate during their daily interactions. Raising Lions approach provides boundaries in a non-judgmental way so the child doesn’t start to take on the image of the villain, class clown, or helpless victim to name a few.
3. It’s a non-stimulation protocol. Getting stickers, losing tokens,  and long explanations are all excitatory mechanisms for a child with over-responsive modulation issues. These approaches may work short term, but usually become ineffective over time. The child heavily relies on these systems and they often do not correct the actual issue, modulation. The Raising Lions method allows the therapist to stop all activity in a very neutral and natural way.You can then have the child re-enter the activity or therapeutically change the factors to achieve what we call the “just-right challenge” so the child can achieve regulation. Basically, it allows the child an opportunity to harness his/her ability to manage incoming stimuli without adding more stimulation, which prevents over-stimulation.
4. It gives the parents and the child a blue print and clear options. Children with modulation issues typically don’t respond to standard parenting practices such as timeouts, sticker charts, and long talks about behavior. It’s because these children are responding to impulses and their actions are typically ahead of their thinking. The child’s states of dysregulation can dysregulate the family system, leading parents to strategies such as bribing, threatening, caving in or other desperate attempts to gain control of the situation. Raising Lions helps parents to learn to stay calm and neutral. It helps the parent to regulate and detach from the child’s behavior, which creates an environmental opportunity for the child to learn how to modulate in small durations of time. It helps the parents do the same, and the therapist and…it’s a win-win!

Examples of how I use the protocol in therapy sessions:

1. I want to get Johnny ready to do some coordination activities, but he’s crashing and rolling on the floor and grabbing everything in sight. His mother tells me he started off his day like this and also reported he had a hard day at school. I’m thinking he is over stimulated and I want to give his sensory system some organizing input. He decides out of a choice of two activities that he wants to bounce and roll on a therapy ball while listening to a song with a steady beat. While doing this, Johnny starts to sing in a loud voice and he begins to slam his hands loudly against the ball. Instead of telling him to stop, lower his voice, or take the ball away, I ask him to take a minute. I turn off the music and wait for him. When he is done, we return to the task. I continue to do this until he shows modulation while on the ball. Johnny is learning to regulate in two ways. One he is taking the small breaks which allows him to make a different choice in how he’s interacting during the task and two, he’s learning how to use offered tools in an effective way to positively influence his neurology.
2. I have asked Suzie to start practicing her letters in her handwriting book. She has already done some preparatory sensory work to get her ready for this task, but Suzie really dislikes writing and she definitely doesn’t like to use a pencil grip. While writing, I notice her move the pencil grip up the pencil. We have already discussed the purpose of the grip and she knows it is part of the process so I don’t lecture her. I ask her to take a minute. She returns and I then notice that she is writing the letters excessively large and  she is looking at me to see my reaction. I calmly ask her to take another minute and when she returns we redo those letters. Using the Raising Lions approach in this situation is helping Suzie move through the discomfort of using muscles she is not use to activating due to the grip and it is also helping her to learn emotional control during a non-preferred task.
3. Bobby is playing a game with his sister Katie. He is really competitive, especially when he’s playing his sister. Before starting, we discussed whether his alertness level was high, low or just-right. He tells me his engine feels high and he picks an activity from a choice of 2 things (running and crashing into the bean bag or jumping on the trampoline). I know Bobby has trouble sitting still so I also give him a cushion with texture that gives him a consistent regulating input.However, Bobby starts to lose and I can see a change in his behavior, which is the start of a potential explosion. I ask Bobby to take a minute. His sister then laughs and makes faces at him while he’s taking a minute so I ask Katie to take a minute as well. In this situation, the Raising Lions approach is used to give Bobby a moment to pause before the anger of losing sets in and gives him a chance to make another choice. It also lets him see that there are boundaries for his sister too, which helps him to see his sister also needs minutes to adjust her behavior. I find this a powerful choice especially for children that are frequently in trouble or villainized.

Raising Lions has been such a wonderful addition to my therapy practice. I am now able to slow down and to make more purposeful decisions in approaching children. Although most of the children I work with are initially upset about taking a minute to reset, they start to recognize the pause instead of the punishment, the choice instead of the demand, and the relationship instead of just themselves.  When this starts to happen, so many other positive changes occur.  Here’s to all the Lions!

Michaela E. Gordon, OTR/L

When I was younger, I attempted to run from my brother as he dragged his feet across the carpet and touched my arm, giving me an electric shock. It amazed me that in seconds he could just zap me with his finger! Another childhood memory was having sleepovers with my friends and we would all wake up with our hair standing straight up from the static from our sleeping bags. Later in life, I was training for a marathon swim. I was with a group and we swam about 1 mile off shore. A storm moved in quickly with thunder soon following. I was concerned about what was to come as I knew people in water and lighting was not a good combination. We luckily arrived at shore with no time to spare. Lighting was cracking directly over the water and we were thankful not to be the conductors!

In 2011, a chiropractor had given me a craniosacral therapy book and a massage table and said, “Here, I think you’d be really good at this.” I hadn’t a clue what craniosacral therapy was, but after briefly looking through the book, I thought it was interesting so I decided to try a class.

What I learned was that craniosacral therapy is a hands-on technique that uses light touch to access the membranes around the spinal cord and brain to release restrictions and improve the circulation of cerebral spinal fluid. Improving the function of this craniosacral system can positively influence the functioning of the whole body, which results in better health, reduced inner stress, and access to your own body’s inner wisdom.

Initially, I had my apprehensions about the technique as it was so light and the measurement of change is more qualitative than other techniques I have learned over the years. However, as the instructor reviewed the structure of the body, the power of the nervous system, and the electrical exchange between the therapist and the client, I started to realize the what I had naturally experienced in the past and the information that was being provided during the course are really one and the same.

I think what I found most interesting about craniosacral therapy is the idea that you access change through electromagnetic fields. There are an estimated 100 billions neurons (nerve cells) in the human brain. The human body conducts electricity. Everything that conducts electricity has an electromagnetic field. The human body has over 50 complex electromagnetic fields. The hands have 13 picoamps of electricity that can come off of them at one time. If electricity comes off the hands, then we can energetically influence other things we conduct with, including other humans. That is pretty mind blowing if you ask me! As a human and as a practitioner, I felt compelled to explore the possibility of influencing the nervous system through this hands-on approach.

Can we create changes in the nervous system through light touch on parts of the body, specifically the spinal cord and the skull? I do believe we can and I have clinical observations and client feedback that support this belief. The results I have seen have been effective and positive. Children with hyperactivity have been able to transition to a state of calm. Children and adults with anxiety have been able to manage everyday stressors with better success. Children with decreased coordination have demonstrated greater success with motor skills. Babies with poor latches, colic, and physical restrictions are able to eat, interact, play, and sleep with greater ease. In one instance, a child with a seizure disorder had cessation of seizures according to pre and post testing by the neurologist and with no other new treatments occurring at that time.

As humans we innately want to connect and to interact with others and the things around us. When a person whether infant, child, or adult presents with a dysfunction within the nervous system, it influences their choice of interaction and their experiences. The dysfunction can lead to a whole host of issues impacting quality of life or perception of life. Cranial sacral therapy is just an example of how we can help nurture a person’s nervous system as a means of improving quality of life and understanding one’s self. Some individuals may find these types of therapies abstract as they are not commonly heard of in the general population. However, when we can connect these abstract concepts to common experiences such as electric shocks from touching something after rubbing your feet on a carpet or avoiding water when lighting storms are approaching, we can allow ourselves to open up to the possibility that a therapeutic, hands-on technique could create positive influences within our bodies.

As Albert Einstein said, “ Everything is energy and that’s all there is to it.  Match the frequency of the reality you want and you cannot help but get that reality.  It cannot be any other way. This is not philosophy. This is physics.”

-Michaela E. Gordon, OTR/L