YOU DON’T KNOW HOW IT FEELS TO BE ME

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

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OT Meets Raising Lions

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

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The Just-Right Challenge

Occupational therapists are known for using the term , the just-right challenge. The term  was originally coined by occupational therapy Dr. Jean Ayres and later used in other occupational therapy frameworks. The just-right challenge can be looked at from many different points of view and becomes a little more complex when assessing this in children. I say this because adults have such a large influence on the environments they present the children with. For instance, every adult has their own individual perception of the world and what they find easy and challenging. The adult then has to either pair their point of view or shift their point of view in order to create situations that aren’t too easy for the child that there is no satisfaction in the activity, but also not too hard that the child feels so frustrated they stop trying to meet the challenge. To press further on this, there are also so many different types of parenting, teaching, and coaching styles, which adds another layer of complexity when it comes to challenging our children with some adults presenting with an authoritative outlook, some with a passive outlook, and some with a balanced outlook. How the environment is laid out for the child will influence how he/she perceives stress, how they go about completing tasks, how they interact with others, and how they see themselves and their abilities.

For simplicity, I offer an analogy of how I approach creating a just like challenge for children.  I see myself, the adult, as the earth and the children as the seeds. As the earth, I am a steady, enduring medium in their environment. I am taking it all in, monitoring by sensing what is going on inside me, what is going on around me, and sensing how the child is sensing the situation. I know as a seed, they are going to need just enough sun, just enough water, and just the right timing for the blooming of the flower to occur. If we overdo or under-do during a time of growth, we take away opportunities for the flower to bloom and to flourish. Again, we are monitoring, pacing, and making the child feel safe as we plot out the environment.

As we know, life is organized and disorganized all at once. The best is when we see the seed coming out of the ground, starting to sprout. However, there are other times in the process where either us the adult or the child have complications that arise and we have to problem solve not in a way that fixes the situation and makes it perfect, but challenges us as we patiently wait for the development of what we planted.  Perhaps there was a lack of water or maybe the sun didn’t come out one day. Sometimes that happens. Perhaps the flower is feeling lonely or they are upset because they are not growing as fast as other plants. The flower may not want to wait and they want to be a full grown flower RIGHT NOW! We get it right? But our job isn’t to just fix all that for the child or to bear down on them with unrealistic expectations. We can’t neglect the flower and we can’t pull the flower up from the ground and make it grow. It just doesn’t work that way. Our job is to be that steady ground, never wavering, showing up, shifting with what comes up in the moment. And in all honesty, it feels good to meet a just-right challenge. Enduring roadblocks, boredom, and some uncomfortable feelings is worth it when you begin to master and adapt to what shows up.

Here are some tips for creating just-right challenges:

  1. Give yourself just-right challenges! Where are you too hard on yourself and where can you implement a little more discipline? Once you have an idea how you operate, then you can observe how your child operates.
  2. Make a list of child’s strengths and weaknesses. In what situations do they thrive and what things hard for them?
  3. Once you know your child’s strengths, really highlight those! We all have a purpose, talents, and gifts. Put them in just-right situations and let them shine!
  4. Once you know what is difficult for them, create situations that you feel are doable and allow for room to adjust to either something more simple or complicated. Example #1: Your child is afraid to ride their bike. You have been pushing them to ride out on the street, telling them it is not scary, encouraging them that they can do it. You see they can sit on the bike and even pedal the bike, but looking down that long sidewalk seems daunting to them. This is showing you, the challenge is too hard, even if it doesn’t make sense to you. You would make the challenge easier by practicing pedaling in the driveway. Then the next challenge would be riding to a cone you put out or a certain crack in the pavement and with each mastery, going a little further. Example #2: Your child despises handwriting. They may cry and scream, refusing to participate. Once you get them to the table, they scribble on their book or do everything but practice making the letters. You might not know if they find it boring, meaningless, or maybe it is really hard them. So your next step is to explore. The next time handwriting practice comes around, you don’t avoid writing in the book, but you add a fun element. Perhaps they can make their letters with chalk and use a wet sponge to write over the letters. Maybe you write letters on their back with your finger and they have to write out what they think the letter was. These additions will help not only help them sensory-wise by adding different tactile mediums, but will also make the task feel more playful and purposeful. Once you have done this, then you write just a few letters or words and you can graduate the amount over time. Another example is having them trace letters if the task is still too hard.
  5. Just-right challenges add up! It might seem at times what you are doing isn’t making a difference or that it’s taking a long time to master a skill. However, all kids benefit from persisting and embracing challenges. Remind your children of how far they have come and how far they can go.
  6. Allow frustration and failure. These are ok things to experience and they will not hurt your child! I am not talking about extreme frustration and failure because that’s not just-right. It can be so hard to watch a child struggle, but I feel when I let them struggle, I am really telling them that I trust them, that they got it, and I know they can move through whatever the challenge is. It’s very empowering to the child.

“Nature does not hurry, yet everything is accomplished.”
-Lao Tzu

Michaela E. Gordon, OTR/L

    Posted in Motor Skills and Planning | Leave a comment

    Craniosacral Therapy

    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

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    How am I ever Going to get my Child to eat Fresh Foods?

    A young female nerd dressed in bow tie and eyeglasses is deciding between eating an ice cream cone or broccoli. She is making a disgusted face at the broccoli. She is choosing the treat.

    I am sure that there are many parents out there that have the struggle of getting their children to try new foods and adding those foods consistently to their repertoire. Literature shows that approximately 25-40% of typically developing children and up to 90% of children with disabilities have issues related to feeding and eating (Clawson, et al, 2008, O’Briend et al., 1991). A child’s acceptance of food is influenced by their biological make up, their culture, and their individual experiences they have around food.

    There is a developmental, sensory-motor process to introducing different food consistencies to an infant and child. The infant will start with breastfeeding or bottle feeding since they are suckling and sucking with very primitive fine motor abilities. As the baby’s head and trunk stability develops, pureed foods can be introduced. From there, more solid foods can be added as the baby’s ability to manage and chew food becomes more efficient. As the baby ages, they begin to pick up food with the fingers, manage a sippy cup/open cup, and begin to use utensils. Challenges with recognizing or managing food textures, temperature, and tastes as well as oral motor or fine motor challenges, can all influence your child’s ability to try new foods and to continue to expand their food repertoire.

    Children also go through developmental phases of rejecting previously accepted foods and they can also become picky with trying new foods. These phases are not long -term and if they continue for a long period of time, these issues could be related to other sensory-motor or social-emotional difficulties.

    Interestingly, there is literature indicating that taste buds are influenced by what we eat. For instance, if the child eats processed foods and then you try to introduce a whole food such as a piece of fruit or vegetable, the child may perceive the whole food in a completely different way due to the processed items their taste buds are accustomed to. The child may not accept the food you’d like them to try because of the other foods included in their diet. It’s similar to when you try to eat healthy. At first, it’s so hard to stop eating the processed food. Once you get on a roll, you wonder, “Why was it so hard for me to stop eating that? I love vegetables!” Then after a while, you might start to eat “cheat foods” again. Next thing you know, you feel like you are picking up your baby spinach like a stack of hay and painfully enduring every bite, while you dream of your next favorite splurge. Kids are no different!

    Lastly, food and drink consumption is not just a part of our survival mechanism, but it is also a social experience. We commune and celebrate life through food with friends and family. We begin to create associations between our emotions and the foods we eat. Some associations can lead to unhealthy eating habits, taking us away from food for nutrition and positive communing with others. Some of us comfort ourselves and our children with sugary or salty processed foods when we feel sad or lonely. Some of us have intense conversations during mealtimes, leading to negative associations, which affects the food experience. A parent may become upset and get involved in a power struggle over the child eating his/her food, which leads to mealtimes becoming an enduring experience rather than a relaxing, enjoyable experience.

    That’s a lot to think about right? Here are some tips to help you to start work on increasing your child’s food repertoire:

    1. Walk the walk! If you want your children to eat fresh, wholesome food, then you, the parent needs to be an example of that. It’s good for you and it’s good for them. If you don’t eat fresh foods, you will realize that your taste buds aren’t necessarily craving those vegetables, but rather something processed liked a bagged snack or sugary treat. It’s a group effort to train the taste buds in the family so your bodies recognize the food that will keep them vibrant and healthy!
    2. Shift your mind from the American children’s menu! Yes, children tend to prefer more bland, simple foods as they are developing, but it doesn’t mean we should feed them fried foods, processed foods, and sugar-filled foods. You can make simple foods and keep them healthy. I love Joy Feldman’s cookbook, Joyful Cooking: In The Pursuit of Good Health. It has a wealth of information about preparing fresh foods and she also has a section of fun ideas for kids.
    3. Some children like the spicy, salty, sour and more flavorful foods! It’s also important to know that some children need the extra taste in order to recognize the food they are eating. There are many spices and herbs to enhance the taste of food.
    4. Children are smaller than parents so you want the meal to be appropriate to their size. Some kids will feel overwhelmed by the expectation of eating a lot of food and just won’t eat it all if the plate looks as big as them!
    5. Your child’s plate should exude compromise! What I mean is that the plate should have 1-2 things they like to eat and 1 thing you’d like them to try. There is no bribing or guilting them if they don’t eat the food. However, there is also no extra food given to them if they are still hungry and they haven’t eaten what was offered. If you have a child that is strong-willed and refuses to eat the offered food or you have a child that is not ready to accept that food for other reasons , you will want to plan for healthy, smaller meals or snacks in between so they have more intervals of eating.
    6. Don’t give up! It can take up to 25+ times of food exposure before a child might eat a food. That’s a lot of times. So just be patient as you expose them to the foods.
    7. Eat at the good ‘ol kitchen table! Some parents don’t realize how much their kids are snacking and drinking because they don’t sit for a proper meal. Parents are usually busy and on-the go, so I realize this is hard, but it’s a good habit to teach children to stop and eat. It is also a good habit for you too!
    8. Move those bodies! Mealtime can feel long to a child and you may find that your child doesn’t want to sit to eat. You may even find yourself chasing your child around the house trying to get them to eat their food. Instead of that, have your child jump on a trampoline, rock back and forth on a therapy ball, get some bike riding or swinging in, or wheelbarrow walk them to the table so they get out all their wiggles out before they eat.
    9. If you feel you are having a really hard time getting your child to eat, you may need a referral to an occupational therapist or other specialists to rule out other aspects that may be impeding their eating development. You can contact your local occupational therapist and inquire about feeding supports.

    In today’s world, we have many food options (or at least we are led to believe we have “food options”) and it’s no wonder that parents are up against so many food struggles. Be patient and kind with yourself and your children. Your job is to present them with opportunities to eat fresh foods and their job is to eat it. May you and your children be vibrant and healthy!

    Michaela E. Gordon, OTR/L

    References:

    Clawson, B., Selden, M., Lacks, M., Deaton, A. V., Hall, B.,& Bach, R. (2008). Complex pediatric feeding disorders: using teleconfereing technology to improve access to a treatment program. Pediatric Nursing, 34(3), 213-d216.

    Feldman, J. (2012). Joyful Cooking: In The Pursuit Of Good Health.

    O’Brien, S., Repp, A. C., Williams, G. E., & Christophersen, E. R. (1991). Pediatric feeding disorders. Behavior Modification, 15, 394-418.

    Posted in Nutritional/Environmental | Leave a comment

    Handwriting Without Tears

    My first several jobs as a therapist were in the school setting. One of my responsibilities was to teach handwriting to the students. I exposed them to many choices of pencil grips, papers, curriculum, and other strategies to help students improve their handwriting skills. I also was involved in educating teachers and other staff in these strategies so the students could use them on a regular basis. The challenge I found was that each classroom was using a different curriculum so the style being taught was not necessarily uniform. Children would report confusion with the styles being taught from one year to the next, including terminology that was being used to teach handwriting. The other issue that seemed to occur was their seating position. Some classrooms had children of different heights sitting at one table or children were provided with desks and chairs that did not meet their postural needs. This created less stability for children while trying to produce legible written work. Materials were also another issue as each classroom had different types of pencils, papers, and worksheets that did not meet every student’s needs and were not always age appropriate. After seeing all these challenges, I began to search for other avenues to teach handwriting. I had heard about Handwriting Without Tears and about 2 ½ years ago, I decided to attend the Handwriting Without Tears conference. I thought the curriculum was excellent because it was developmentally based. The materials are user friendly and can be used with children with a variety of needs. I also like that the products are a reasonable price and the curriculum is easy for parents and teachers to learn. I then went on to get trained in the Print Tool, which is a handwriting assessment. I feel this is a great assessment as it measures 8 components of the child’s handwriting and gives a clear picture of what aspects of handwriting need to be addressed. Once I completed both of these courses, I then decided to become a Level 1 Certified handwriting specialist. Handwriting Without Tears is the curriculum that I choose to use in combination with other therapeutic modalities.

    I am sure there are many parents as well as teachers out there that are wondering if technology will soon take the place of paper and pencils. Perhaps at some point this may happen. Electronics are becoming a means to provide children with information and to express themselves. However, the literature is indicating that there is still an importance for handwriting and there is still a need to develop handwriting skills. According to a research review conducted by HWT in 2009, handwriting continues to be a primary tool for assessing children’s knowledge in the classroom (Feder and Majnemer, 2007). Another studied conducted by Marr, Cermak, Cohn, and Henderson (2003) indicated that children in kindergarten are now spending 42% of their fine motor time on paper and pencil activities during the school day. Handwriting skills are also important, as they are part of many state standardized assessments. In 2005, a handwritten essay was added to the College Board SAT. Graham and Harris (2005) did research that indicated that handwriting plays a major role in producing creative and well-written text.

    The research review by HWT (2009) supports the structure of their curriculum. In 1996, the National Association for the Education of Young Children recommends that infants through eight-years of age learn best when the teaching methods are developmentally appropriate. The Handwriting Without Tears curriculum focuses on this with the variety of materials and activities i.e. making a person with wood pieces and other materials; drawing a person; coloring; pre-writing strokes; sensory-based materials (dough, chalk, sponges); and music. HWT curriculum also focuses on the biomechanical skills that are required for handwriting. Rosenblum, Goldstand, and Parush (2006) found that children that demonstrated insufficient posture, fine motor skills, and positioning were less proficient in handwriting than children that had sufficient biomechanics. A study done by Smith-Zuzovsky and Exner (2004) pointed out the connection between the quality of children’s hand skills and their seated position. The Handwriting Without Tears curriculum includes instruction in checking seating as well as activities to promote good posture, paper positioning, and writing utensil grip.

    The other question parents may have is how will their child develop good handwriting skills and who will teach them these skills? A 2007 national survey indicated that only 12% of teachers rated their formal preparation to teach children handwriting as sufficient. A study done by Graham et. al. (2007) suggests that professional development should be available to teachers in order to prepare them for handwriting instruction. Parents can seek out handwriting workshops in your area or seek out an occupational therapist to conduct group instruction with your child along with some of their peers. As cited in Medwell and Wray’s literature (2007), children that were enrolled in an 8-week handwriting intervention program produced more legible handwriting then their peers, with a 46% increase in the quality of written text. This literature indicates the importance of children receiving daily, supervised handwriting instruction. Parents can also seek out individual occupational therapy services to help your child develop age appropriate handwriting skills. The occupational therapy services can provide your child with a combination of treatments in conjunction with handwriting instruction. I have found when the child is responsive to treatment and the family has strong carryover of therapeutic activities, that not only does the child’s handwriting skills improve, but also their sensory-motor skills and social-emotional skills. I have also found that teachers are able to provide suggested strategies and materials to the student with much success. I have seen many children have great success with the HWT program and I look forward to continuing to help children develop stronger handwriting skills.

    Reference:

    Handwriting Without Tears-Research Review: http://www.hwtears.com/hwt, (2009)

    Posted in Motor Skills and Planning | Leave a comment

    Autism and Occupational Therapy

    There was a recent 3-part series in the February 2012 issue of OT practice about working with people with Autism. The first article was written in regards to authentic partnerships with people with autism. There was a 23-year old young man named Paul that shared his insight about what is was like to have therapists working with him and the importance of these practitioners having expectations for him. At age 14, he was able to type out his thoughts through a technique called the Rapid Prompting Method. He expressed that it was important that people believe in his ability and that the people around him had expectations for him when working on specific goals. Research has indicated significant differences in a person with autism’s receptive (language the person understands) language skills and expressive (what the person verbally/physically expresses) language skills (Dawson, Soulieres, Gernsbacher & Mottron, 2007). The young man Paul reported that he understood what others were saying to him, but was not able to express this knowledge or verbally communicate with others. He pointed out that before he was able to express himself through keyboarding, other did not expect him to participate in conversation and would carry-on conversations without him.

    Recent literature has revealed significant discrepancies in determining a person with autism’s intelligence at all ends of the spectrum because the standardized tests rely on expressive verbal responses and demonstration of motor skills (Dawson, Soulieres, Gernsbacher, & Mottron, 2007; Estes, Rivera, Bryan, Cali & Dawson, 2010). The inaccuracy of these results impacts society’s perception of these individuals’ abilities and ultimately impacts their quality of life. The young man Paul in the article was quoted giving advice to professionals, “Always acknowledge a person’s intelligence and they will be more receptive. Often we can be perceived as being unintelligent and it can diminish the relationship between teachers and students. Structure and forceful instruction are important to help initiate activity” (Kotler & Koenig, 2012).

    Paul also felt that it was important to build as much independence as possible. He felt that learning self-help skills are critical in order to live independently in the future. He felt that therapists play a major role in breaking these tasks down and practicing them regularly in order to acquire the skills. He also discussed his perception of relating to others. He expressed that he can feel empathy towards others, but often times, he cannot express those emotions in a way he would like. For instance, he may be able to type out his feelings, but would prefer to hug the person. However, when attempting to physically comfort another, he became disorganized in those emotional situations and he was unable to express his feelings. Paul expressed that he would like to see therapists acting in more personal ways such as recognizing a person’s disorganization and helping them connect their minds and emotions to their physical responses (Kotler & Koenig 2012).

    Paul expressed that occupational therapy has improved his sensory processing skills through the use of sensory diets so that he can use strategies that support him during different states of anxiety. Paul also expressed that daily activities were arduous for him and he wanted to hear from others during those learning experiences that he was learning, that he could have a typical life, and that he could be independent (Kotler & Koenig, 2012).

    Paul was asked about what he thought his strengths were as a person with autism and how the way he processes information benefits him versus thinking of those ways as dysfunctional. His response was, “ I never dream I’d reach the level I have. I thought I was trapped forever without a voice. It is so mind blowing to face having my autism as part of me, but not defining me. Very liberating” (Kotler & Koenig, 2012). He also gave advice to practitioners about focusing on a child’s strengths first. He said, “Younger children very much need to hear that they can accomplish more than some people believe is possible. Specifically, it is very helpful to measure progress, making note of not only needs, but also talking about strengths and how those strengths overcome areas of need. Allow for success often and interpret success as the result of a person’s strengths” (Kotler & Koenig, 2012). Paul made one more statement in closing of this article and said, “I feel the answer lies in my acceptance of having autism as a positive thing. Don’t’ dwell on autism as an injury. Listen and observe and go with talents. If strengths are used to stake goals on, the autistic person each day earns respect for himself” (Kotler & Koenig, 2012).

    References: Kotler & Koenig (2012). Authentic Partnerships with Adults with Autism. The American Occupational Therapy Association, OT Practice, 6-9.

    My thoughts:

    I thought this article was great. So often we approach helping others from the way we see things and through the approaches we learn. As a practitioner working with children with autism and their families, finding a balance between the child’s strengths, and alternatives for learning and working on skills for interaction in their school and community environments is an ever evolving process. I believe that each person should find value in who they are and I do agree with Paul that we should foster each child’s sense of worth.

    I also agree with Paul that children with autism do need structure and support to initiate tasks. For all people involved in working with a child with autism, I believe the key is that this structure and instruction have only one agenda and that is to help the child in a way that empowers them. I feel it is not necessarily the approach one takes to teach the child because every child needs different instruction. This instruction can vary given the situation or period of time. What is critical when providing instruction is how you are “being” towards that child. Each child deserves honor and respect. The person supporting the child may feel they need to implement an environmental adjustment to reduce stress, a sensory break to re-organize, or to encourage the child through a non-preferred task. Whatever choice is made could be different depending on the situation and the person making the choice. Regardless of the approach, walk in that child’s shoes first, communicate your intentions, and proceed forward in the best interest of the child.

    There have been many times that I have sat with parents and after long discussions with them, we have come to a momentary stand still about how to proceed forward when a child is in a consistent state of disregulation. These have been described as regressions and it is important to carefully put a plan in place that recognizes the child’s challenges during these times and develop a plan to organize the nervous system. This is also a critical time to listen and observe the child as they are the ones that have the final say in whether the plan is effective during this time.

    Typically we (the adults) decide to give up our agendas and let go of our momentary ambitions for the child. In my opinion, letting go of these ambitions can be difficult as we are humans with a goal of helping a child grow and succeed. As my mentor would say, “Welcome to the human race!” which was a comment I frequently was told when I was trying to make a situation better from the only perspectives that I could imagine possible and that was to keep pushing forward! We really wanted the child to be learning the higher cognitive and motor skills. We would be trying to come up with strategies to do this, but in actuality the child needed this time for organizing the nervous system and we just simply needed to respect that. This realization often times felt to us adults that we were going backwards, but really as a team, we were moving forward because that child was empowered because we were listening to them and we were then moving at their pace. The child would start to be able to express what they needed, they would start to feel better, and in the long run, they ended up with greater participation in the therapy and had more successful learning experiences.

    I would also like to comment on test scores. Testing time for parents that have children with autism can be a stressful experience. The parents often times see their child making so many functional gains in their natural environments, but yet the test results do not reflect that. Perhaps these test scores divert us away from strength-based focus. We live in a society that asks for diagnosis, measurement of ability and needs, and prognosis. On one hand, these variables give us direction and help us build a support plan for the child. On the other hand, it can also create a stigma about the child’s ability, puts a focus on their issues, and limits the perspective about what they are capable of doing when given the correct supports. However, as mentioned in the article, the skills are being measured from one focal point in which motor skills are involved and typically no assistance can be provided during the testing process. Depending on where their services are taking place or who is paying for the services, in some ways direct their plan of care. It is important that there is a blend in their plan of care by looking at all the possibilities for learning that continue to build their strengths and support them to develop needed motor skills for daily tasks. I believe it is important as a practitioner to add in qualitative data to all reports to indicate progress that has been made and to indicate approaches that are working for them in the natural environment.

    Paul mentioned how important the sensory opportunities were for him in order to reach optimal levels of bodily organization. Over time he was able to express his more specific needs, which then created more effective plans. Each person has specific needs and response to sensory input. Research on sensory integration has been able to guide practitioners in categorizing responses to sensory stimulation and provide a plan according to those needs. However, patients with autism can have different needs from moment to moment or within different time periods. It is important to observe and communicate with the child about those needs to ensure they are being properly met. It is also important to have an open dialogue with parents, teachers, and other people in the child’s life to ensure they are providing supportive sensory choices to the child and making adjustments to the sensory opportunities as needed.

    Lastly, Paul made mention of acceptance of the person with autism and helping children with autism expand their talents. Goals should be targeted for problem areas, but should be addressed using the person’s strengths to attain the goal. We fall into our place in the world because we are each unique and have different purposes. It is so exciting when a child with autism reveals a hidden talent or when they say their first word whether it is expressed verbally, with a picture, or with a communication device. It is so amazing to connect with a child that can direct you through gestures and communication devices to get their needs met. It is touching to see a child with autism hug and kiss their moms and dads with a smile on their faces. Those are the gifts they give to us. Through these special moments they teach us not to limit them, not to make assumptions about them, but to give them opportunities to express themselves in ways that are true to them. Lets not focus primarily on the difficulties, but give these children opportunities for success and joy in as many moments of their lives as possible. Let us teach others to embrace their gifts and to support them to use their amazing talents so that they too can contribute to society. It is always a pleasure to be part of these life journeys. Thank you!

    Posted in Social-Emotional | Leave a comment

    Transformation of Beliefs

    Girl drawing back to schoolFrom the moment we are born, we are establishing behavioral responses, which eventually become belief and thought patterns. We also develop perceptions of ourselves and begin to develop ways to describe ourselves. Whether these thoughts are positive or negative to our being, on some level we accept them because there is comfort in their familiarity and they simply make sense to us. The thoughts and beliefs become our identity and we then live our lives in a manner that fits these thoughts and beliefs.

    When a child first begins therapy, the therapist typical asks the parent to describe the child. The information is important because it gives us a sense of how the child is going about their daily life. In order to communicate the person’s function, we must put them into words and/or make observations. Based on how they interact and/or the description we provide of them, the environment gives them a response. These responses and interactions can solidify beliefs about who they are as a person and how the world sees them. It can also create a list of dislikes and likes that categorize them into what experiences they are willing to have on a daily basis. For instance, a child may be described as very intelligent, but has trouble paying attention. Another child may be described as wanting to play with other children, but becomes aggressive when a peer plays with their toy. Another child is great a school, but falls apart at home. Depending on how others respond to these perspectives or interactions will on some level effect the child’s perception of themselves. If the intelligent child is getting in trouble for not paying attention, they may perceive themselves as inadequate and become disinterested in school with a potential label of being “lazy”. The child that becomes aggressive over his toys may begin to play the role of a bully. The child “holding themselves together” at school may develop a high level of anxiety with a potential label as a “worry-wart”. As a result, the adults in the child’s life uses all sorts of strategies to dissolve the issue at hand and the effectiveness of these strategies can vary from child to child.

    Often times, these children have sensory processing disorder, which is impacting their ability to process sensory information, which in turn impacts their interactions within their environments. They develop coping mechanism or adaptive responses in an effort to function in their environment. Addressing sensory-motor issues can help the child to better receive, integrate, and modulate sensory information. Research indicates that if organized sensory input is provided consistently over a period of time, that it will create changes to the nervous system, which will improve daily interaction and performance for the child.

    Parents, families, teachers, and peers have a pre-established perception of the child. Although the child may be experiencing neurological changes, they too continue to have established thoughts forms and beliefs from their past experiences. It would be beneficial to point out the positive changes to your child. It would also be beneficial to have your child try activities that were perhaps not so successful in the past. They may find that they are enjoying activities that were originally aversive. It is also critical that the adults involved with your child recognize these changes and help them to manage any residual behavioral responses. It is important to consider re-establishing new thought forms in regards to how you interact with your child. Do you find yourself describing your child to others in the same way even though they are functioning differently? Do you need to adjust how you engage with them? Do you need to modify the level of support you are giving them? Are you expanding their opportunities for experiences? Now that they appear to be more organized, what are the next skills to develop and focus on? How can you support them while engaging with their peers?

    Lastly, whether you are a therapist, teacher, or parent, we must also look at are own selves. Healthy families and communities all originate from a healthy individual. Identifying what labels you or the world have place on you, may help you to understand your own functioning, which in turn can allow you to address established beliefs that are no longer servicing you well. This can give you greater insight into your child and how you can better help them. We were all little infants, toddlers, and children at one point. Chances are your family wanted to the best for you and they wanted to you have a happy and meaningful life up to your last and final day. This concept of well-being is critical for all of us. By working on this for yourself, you can then model it for your child. That is why therapy is not just for your child. You as parents as well as other people in the community can also receive positive changes by being a part of the therapy process.

    Posted in Social-Emotional | Leave a comment

    The Therapeutic Experience

    Building BlocksThere are some frequent questions that are brought up when your child needs therapy. The thought of therapy can leave the parents experiencing a variety of emotions, which we will touch upon is this conversation. For some parents, they come to find that their child has been diagnosed with a disability. For other parents, they feel a sense of frustration because they see their child has some difficulties that other may not feel are significant, but the parent feels are impacting the child’s self-esteem and their everyday functioning. So whether you are a parent that is hearing that your child needs therapy services or whether you are a parent desperately looking for a therapist that can help identify and address the concerns you are seeing in your child, initiating therapy services can create many anxieties. What are the long-term needs look like for your child? Who will help you help your child? How will these needs affect your family? How will these needs affect your ability to work? Who will support you? The beginning stages of this process can be quite overwhelming, but surrounding your child and your family with knowledgeable, caring, and committed persons can make all the difference.

    The therapeutic experience is determined by its purpose and participation. It about learning your child and his/her needs and determining a plan in a calm, well thought out manner. It is about gathering therapeutic tools that will empower you as parents. This can include direct participation in therapy, reading a recommended book, utilizing a home program, or becoming part of a support group. It is about your child engaging in therapeutic experiences that give them a better sense of themselves, which in turn creates more purposeful interactions in their functional settings.

    Therapy is most beneficial when all parties are working in the best interest of your child. It is human nature for us to pass judgments on the way we approach difficulties or come up with solutions. When there are a variety of professionals in your family’s life, it is important for all of us to work towards solutions in a collaborative manner. The more balance there is between approaches, the better quality of the efforts.

    Often times, children are getting services from a variety of sources and the professionals may not realize your other commitments. You may also have other family obligations such as activities for siblings or work commitments. As you begin to gather professional recommendations, there are many factors that need to be considered. The recommendations are based on the assessment of the child’s level of functioning and your concerns. As parents, you are the driving force behind determining what your child needs. Deciding to participate in therapy and for how long are difficult decisions to make. The therapy should be family-directed and should focus on the areas that you find to be of concern. It is important that you keep an open communication during the therapy process to ensure that your family’s needs are being met and that your child is benefiting from the selected therapies.

    Throughout the therapy experience, progress on goals and annual re-evaluations will help to determine modifications that need to be made in your child’s plan of care. Changes can also be made at any time, but establishing times to closely examine the plan of care will ensure that your child’s needs are being met. In addition, evaluations are important because they give us a baseline to determine if your child’s skills are falling within a range similar to his/her peers. The scores will help the professional determine areas of concern including concerns that may not have been noticed by observation.

    Therapy can be a wonderful and beneficial experience. It can empower you as a parent by providing you with the knowledge and tools to help your child succeed. Therapy can help your child to develop a better sense of themselves and help them to foster their strengths while supporting them through their difficulties. Therapy can help them to develop needed skills to participate in daily activities. My goal is to create a positive and beneficial therapeutic experience for your family.

    Posted in Life Skills | Leave a comment