Water, Water, Water... Everywhere!

Deanna Macioce, MS, OTR/L

Playing in water is a fun part of summer play and a great way to beat the heat on those hot summer days.  For most, it is the type of play that is not allowed in the house, so now is the time to incorporate these activities that offer an array of therapeutic benefit into your sensory diet.

Let’s start with the one that offers some of the most therapeutic benefit-swimming.  Swimming is a great way to provide proprioceptive input and helps with overall body awareness.  Even if your child is not yet able to swim, just providing play in the water is beneficial. So, get a bucket and let them scoop and dump the water while hanging out in the pool.  The activity of actual swimming offers great core strengthening and motor planning.  Moving through the various swim strokes addresses bilateral coordination, as well as reciprocated body movements.  Getting in a pool this summer will be therapeutically beneficial to any child, and a lot of fun.

Just as there are sensory bucket activities with beans, rice, and others items to help incorporate tactile play, there is no reason why water cannot be one of those items.  Water tables and bucket playing offers a tactile media for kids to have a splash in. Increase the fun by having the child scrub cars at the car wash or bath their dolls using shaving cream and then rinsing off in the water table.  Let this summer be the perfect time to get messy!

To address those fine and visual motor needs, have your child use water squirters or shooters for target playing.  From water guns and blasters, to the small hand squirters, everyone’s needs can be met.  Set up a target range, or use a beanbag toss board to have children work on hand-eye coordination by aiming the water at the particular target. For improving fine motor strength, use water guns of various sizes for trigger pulling.  In addition, this activity will help with increasing finger flexion and hand strength needed most for tasks such as handwriting and scissor use.   Using the smaller character or animal squirters are ideal for your younger children or those with a more immature grasp to address grasp and finger strength.

And you can always include stroke, letter, and shape making with water play.  Fill up a bucket and using a paintbrush, have children draw and copy strokes.  Tracing can be provided by drawing the shapes or letters on the cement with sidewalk chalk, and then allowing the child erase it with the paint brush.  With this activity, you can work on shoulder, elbow and wrist stability by having them pretend to “paint” a wall, house, etc. in the vertical position, and you may even get some cleaning done in the process.

Cooling off in a sprinkler or at the spray park allows children some gross motor playtime, with a different tactile experience.  Based on the set up the sprinkler, this activity is an ideal way to work on direction following and motor planning.  In addition, it is these activities allow for peer interaction.

So no matter how you choose to cool off this summer, make water play a way to improve your child’s sensory diet with activities that you cannot do during those cold winter months!

Products in Motion: Southpaw's Cocoon Swing

Dr. Catherine Hoyt OTD, OTR/L

In pediatric occupational therapy, we focus on participation in skills and activities appropriate for the age and developmental level of the child. We also have to consider what is important to our client; which in pediatrics is the child as well as the family.  Addressing the child's needs and the family's goals can sometimes be a challenge. The appropriate equipment can help us to foster adaptive responses to engage the child in play, the main occupation of children.

For one 4 year old child, John, his family really wanted him to be able to play with children his age doing typical pre-kindergarten activities such as finger painting, swinging, listening to music, attending large parties and eating treats. John is a happy, energetic and bright little boy, but some of these experiences caused him a lot of anxiety and he would say things like "I'm afraid I won't like it" or "I'm scared".   John was scared of going into any space that was at all dark or restrained his movement in any way.

We used the Cocoon Swing because it provided an experience where he was able to challenge himself while still feeling safe. The swing let him sit comfortably and have a bit of reduced lighting while still being able to see out.  The Cocoon Swing also let him experience a bit of pressure from the fabric of the swing but still have the flexibility to move his body.  The Cocoon Swing was a little scary to him at first, but he was able to manage that anxiety because it provides the just right amount of comfort by being able to see through the fabric and out the top. It also provided the deep pressure around his body, which was calming to him. It helped John develop the capacity to challenge his fears knowing that he is able to overcome them.  John continues to face challenging activities and he is still learning,  but this swing has helped us move forward in therapy.

Bike Riding: Stacking the Blocks to Success

Deanna Macioce, MS, OTR/L

Whether you are driving through your neighborhood, the local park, or down a busy avenue, you will almost always catch someone riding a bike.  Bike riding is a universal activity that is enjoyed by people both big and small.  We tend to think that it is a rite of passage during childhood, moving from training wheels to the ultimate two-wheeler, and often hear the phrase, "it is as easy as riding a bike".  However, that is not the case at all.  Bike riding is one of the most complex activities to master, and for our children with sensory processing difficulties and special needs, it appears to be as challenging as climbing Mount Everest.  May is National Bike Month, and with summer sneaking around the corner, it is the perfect time to focus on this. 

If we take a look at the 'building blocks' to bike riding we see that it involves much more than just progression, growth and development.  Bike riding entails balance, bilateral coordination, trunk and shoulder stability and visual skills, as well as the cognitive abilities to discern safety and direction following. Therefore, we need to be cautious and aware of where the break down of skills are for our children before we just plop them on the seat and tell them to "go".  And we need to ensure their comfort level so that we keep them feeling safe and not losing their confidence. 

Improving a child's core stability, including trunk and shoulder control will help enhance his or her overall balance, which is required for successful bike riding.  This is where many of those therapy ball activities come into play, both in upright sitting and the prone position.  In addition, utilizing the bolster or disk swing helps with improving trunk control, while offering a bit of movement.  Increasing the challenge to the task by including a hand-eye coordination activity is always beneficial for incorporating the necessary visual skills for success.  T-stool and scooter board activities, as well as wheelbarrow and animal walks are just a few other ways to help improve this 'building block'.

When looking at balance, performing activities on a balance board or disk can be beneficial.  Especially those that require a good amount of weight shifting, such as obtaining bean bags from the floor and then having the child toss them into a target.  Performing activities that encourage one-foot balance and utilizing balance beams are quick and easy ways to address this 'building block'.

Bilateral coordination can be addressed with a variety of activities, but those that encourage reciprocated movement are ideal, such as climbing a rock wall, ladder, or rope pulls.  In addition, the Pedal Walker is a great way to help children get the feel and movement pattern needed for pedaling a bike.  Cross-crawls, jumping jacks, and reciprocated jumps are quick and easy and can be done in any environment.

Visual skills often are the ones that tend to impede success.  It is not easy to steer a bike while looking at the ground, as well as visual skills are apparent for balance.  Strengthening them can be incorporated into almost an activity.  As mentioned above, those that require hand-eye coordination while the rest of the body is doing something are most beneficial.  Activities that entail keeping the head upright should be utilized, including target throwing and ball catching.

With just a few suggestions to help improve the 'building block' skills, once these components are strengthened, it is time to work on removing those training wheels.  It goes without saying, but it is always important to make sure that the safety gear is on, including helmet and pads, both elbow and knee.  It is important to show your child how to stop the bike, using his or her feet to regain balance and control.  And do not be afraid to let them feel what it is like to fall.  This will take away some of the fear when it happens, because, it will! Starting off in a grassy area is ideal, and sometimes using a spot with a slight slope will give them both natural movement and encourage them to learn how to use the breaking system. 

Bike riding is not just a physical activity that offers movement and exercise it also allows individuals mobility to get around, socialization with peers, and the ability to explore.  Therefore, finding other options to help your child get the bike riding experience, such as a specialized tricycle, the Southpaw Hand Cycle, or a youth trailer cycle that attaches to the back of an adult's bike, such as the WeeRide Co-Pilot, may be beneficial.

So, now is the time to stack those building blocks, helping our children to get out there and enjoy the fun of bike riding....Happy Trails!

The Changing Face of Autism

Deanna Macioce, MS, OTR/L

1 in 250…Those were the statistics when I started life as an occupational therapist.  Autism was something that we touched upon during school, but not much different than Cerebral Palsy or Down Syndrome.  And now the numbers are reported at 1 in 50. I have been a pediatric OT treating in a variety of areas, homes, schools, clinic based, and in the community for over 10 years.  However, the face of Autism has changed and intensified during these years.  And based on these numbers, it should not be a surprise that Autism has actually shaped and developed me as a therapist and a person; just as it has our schools, daycares, and so many community programs.

I still remember the first child on my caseload that had the Autism diagnosis. As a new graduate, there was so much that intrigued me and I wanted to learn everything that I could about the child and the diagnosis.  I was thirsting for the knowledge and ready to eat it up.  And although there were many resources, the information often was still vague, and there was not the mass quantity that there is available today.   Websites and organizations such as Autism Speaks, were not yet developed, as well as the knowledge and technology were definitely not where they are today.

In addition, I often reflect on the first parents I worked with trying to figure out why their child seemed “different”.  For one family, it was a child at almost 3 years old that showed no interest in opening up any present at Christmas, or knew the exact route Mom needed to take home from daycare; a daycare that never worked with a child on the spectrum.  For another family, it was a daughter who had a toy room filled with toys, but never interacted to engage in play with any of them.  For me, these were difficult situations, but growing ones.  A major challenge then was that these parents never heard of the word Autism.  They had no clue what characteristics would put their child on the spectrum.  Autism then was not known like it was today.  Therefore, it made the process a bit more difficult and definitely longer.  Today, it appears that we almost all know someone who loves a child with Autism, as well as medical staff, teachers, and daycare workers are all being educated and informed in order to better understand and care for our children.

Today, with increased knowledge and learning about Autism, the signs and symptoms have changed and have become more specific.  The Autism Speaks website (www.autismspeaks.org) list the “red flags” for the possibility of being at risk:

•    No big smiles or other warm, joyful expressions by six months or thereafter
•    No back-and-forth sharing of sounds, smiles or other facial expressions by nine months
•    No babbling by 12 months
•    No back-and-forth gestures such as pointing, showing, reaching or waving by 12 months
•    No words by 16 months
•    No meaningful, two-word phrases (not including imitating or repeating) by 24 months
•    Any loss of speech, babbling or social skills at any age

It also offers parents and caregivers the opportunity to complete a screening, the Modified Checklist for Autism in Toddlers (M-Chat), which is a great way for parents to take a quick look at some developmental skills that should be occurring, and indicate whether or not their child is meeting them.  Because, as parents, sometimes we are not fully aware of what is expected of a child at a certain developmental stage.

As an OT, my theoretic knowledge to treat these children is rooted in sensory integration or Sensory Processing Disorder (SPD). The SPD and STAR Center website states, “more than 75% of children with autistic spectrum disorders (ASD) have significant symptoms of SPD. However, the reverse is not true. Most children with SPD do not have an autistic spectrum disorder” (www.spdfoundation.net).  They also note that by “addressing sensory features (it) is foundational to improving the social and communication problems of children with Autism.”   This is why OTs, with many others help make of the team of people ideal to work with these children.

I like to look at who the child is, and not the “label” he or she carries when developing a treatment plan.  So, therefore it is important to look at where the family is and what their needs are at that point in time at home, in the school, and with whatever community interaction the child has. In my years of treating, I have addressed the concerns and developmental needs of toddlers and young children, however spanning over 10 years much of my focus has now been on school-aged children up through young adults, changing the needs and focus for both these children and the families.

For me, Autism has been part of my “job”, but it has also been a journey.  For the past 5 years, I can honestly say that Autism has shown itself more than 90% of the time on my caseload.  And although I am not a parent of a child on the spectrum, I am a person who has been touched by this diagnosis.  I have walked this journey with many parents and caregivers, and am so thankful for all that they taught me.  As an individual and therapist, I have learned to listen and support these families.  Truly understanding what their concerns are and what they need to function as a family. I know I am only a “stop” on their journey and there are many more that they will make, but while they are “visiting” me, I hope to use my knowledge, skills, and therapeutic use of self to make a difference.    

Returning to the Roots of OT

Deanna Macioce, MS, OTR/L

The history of treatment in the profession of occupational therapy found itself rooted in the use of crafts.   Therapists used a variety of crafts to help improve the fine motor, visual motor, coordination, and mental capabilities, as well as others of individuals.  They were a way to assist in improving an individual’s ability to perform their “daily occupations”.  However, due to the demands of insurance companies and the increased focus of “functional activities” you no longer see crafts being using in traditional therapy settings such as hospitals, clinics, and nursing homes.  Crafts were an ideal way to perform task analysis and devise a treatment activity that would address an individual’s need based on a variety of problem areas rather than just one specific activity. 

In the area of pediatrics, occupational therapists focus on the “functional” activities of children.  This includes, play, self-care, behavioral, and educational concerns.  Therefore, it can be easier to justify the use of crafts.

Just as in the ‘old’ days, crafts can cover a wide range of skills and can be adapted to address the various needs of children, while still focusing on their functional activities. The same craft can typically be graded, even if only in positioning and set up, to address most children on a therapist’s caseload.  From sensory needs, fine motor and visual motor skills to bilateral coordination, sequencing, and attention skills, crafts can do it all.

 Tactile sensory skills can be addressed with finger painting, doing hand and foot print crafts, and using glue, as well as using stickers, foam pieces or sequence. 

Both fine motor and dexterity skills can be address by gluing small objects such as marshmallows, dried pasta or pieces to complete a paper lion.  Increase the challenge by having the child use tongs to obtain the objects if grip and strength are part of the treatment plan.  Ripping small squares off a strip of paper to glue onto a template such as a heart, balloon or pumpkin helps to improve the use of the pincer grasp while encouraging bilateral hand skills needed for higher functioning activities.   In addition, the use of crayons, markers, and paint brushes for drawing and coloring help improve hand-eye coordination and visual motor skills, as wells grasp and hand endurance.

Scissor skills can be addressed initially to make snips for grass, a lion’s mane, or the petals on a flower.  Then moving to lines, shapes, and templates.  In addition, changing the type of paper used, such as construction paper versus card stock.

Attention, sequencing, and modeling skills can be addressed through the presentation of the craft and how the directions are delivered.  For some, you may provide just the model and the pieces, and have them form it, while others you may have directions just written out.  Doing the necessary sensory preparation for regulation and organization makes these activities even more fully encompassing of a treatment plan.

So, as we move into to April celebrating Occupational Therapy Month, it is a great time to go back to our roots encouraging the use of crafts in our treatments.  Not to mention it is fun, creative and they make great keepsakes. 

Why use Vibro-acoustics as part of your MSE treatment?

Linda Messbauer,  OTR/L

First, Vibro-acoustics is a process using two sensory systems in the body; the auditory and the touch system.  The response to the music through the auditory system is pleasurable based on the individual’s tastes and preferences in music or that which is meaningful to them.  But it is the touch system that plays a major role in response to the vibration and the one that will be discussed here.  Think about it, the skin is really the largest organ in the body with more receptors than any other sensory system.  Skin is the boundary between “Me” and “Not Me” and the “container” for all function, whether that be our organs or skeletal system. It provides our physical connection to the world and serves to keep us comfortable and safe.

One postage stamp size piece of skin contains:  9’ of blood vessels, 30 hairs, 300 sweat glands, 4 oil glands, 13 yards of nerves,  9,000 nerve endings, 6 cold sensors, 36 heat sensors, 75 pressure sensors and 600 pain sensors*¹…WOW

One of the sensory receptors is the Pacinian Corpuscles which is a type of mechanoreceptor. It is located in connective tissue of bone, body wall and body cavity. Depending on its location it can be cutaneous (skin), proprioceptive (pressure & movement) or visceral (organs).  It is sensitive to vibration and pressure; it transmits vibration to the brain to allow perception of distant events and is also part of tactile discrimination for feeling smoothness and textures.  It is considered “rapid adapting” meaning its firing potential is generated when force is first applied, and then becomes unresponsive to steady pressure.

Why is this important to know? Well, when using it to affect change of the human reaction to stimuli, we need to be cognizant of keeping variation or novelty occurring to keep the receptor firing. When vibro-acoustic equipment is utilized the music provides the novelty and variation to promote the firing of the receptor. And when the person moves, for example taps their foot to the beat, they receive more input. We know that when two sensory inputs are simultaneously combined the brain gets more than the summation of the two inputs. It also gets secondary and tertiary areas of the brain involved.  “Voila” as the French say, we are getting more potential synapses and possible neuroplasticity and this of course, is what we want. It also feels good to most people.

So why incorporate Vibro-acoustic equipment into your MSE? Using Vibro-acoustic equipment  increases the potential for changing the Brain and as a result, our behavior or response.

Studies have also shown that Vibro-acoustics contributes to:

• Reduce stress
• Facilitate the Relaxation Response
• Decrease pain
• Relax muscular hyper-tonicity
• Increase communication potential
• Increase  social engagement
• Promote muscle tone
• Increase range of motion

As with any form of new experience it should always be voluntary. With individuals who cannot verbalize their likes or dislikes, it is imperative to keenly observe their response. In my experience a facial expression in less than 3 seconds will tell you they don’t like it or it is too much. This has occurred only a very few times but, the aim here is to promote joy and fun and this equipment certainly does that.

Some precautionary information:

Always know your client; some contraindications include individuals with pacemakers, thrombus, active bleeding disorders, extreme low blood pressure, severe PDST or psychotic episodes. When in doubt, always consult a physician.

1* Credited to Patricia Wilbarger, M.Ed, OTR, FAOTA

References: Music and Spatial-Temporal Relationships, Rausher, FH, et al., Neurological Research, 19, 2-8

                        Molecular mechanisms of mechanotransduction in mammalian sensory neurons, Nature Reviews Neuroscience 2011 March

                        Somatosensory Systems, Neuroscience Online, UTA.tmc.edu

Hunting for the Perfect Therapeutic Activity

Deanna Macioce, MS, OTR/L

Many times we find that we are looking for activities that give us the “biggest bang for our buck” so to say.  Well, scavenger hunts or treasure hunts can offer you just that.  Whether you need to address gross or fine motor skills, sequencing and direction following, coordination, peer interaction or problem solving, you can basically cover all your therapy goals and deliver sensory input in a variety of ways with a hunt. They can take on almost any theme, and can be adapted for various ages and skills levels. 

There are a variety of ways to put together scavenger hunt activities.  A basic approach for younger and lower functioning children that does not require reading is to list the activities numerically, draw a map with picture descriptions or even have them find items by color, shape, or pictured icon.  So, for example, you may have a picture of crab walking to find something that is the color red, followed by a picture of riding the scooter board to find something that is in the shape of a circle, etc. For older children with reading skills, having a clue at different pieces of equipment that will tell them what to do or give them a riddle to find out what comes next.

Scavenger hunts are a great way to work on team building and peer interaction, making them ideal for social groups or class environments.  Working together in pairs or small groups allows children to work on verbal skills through problem solve with others.  In addition, partner activities can be incorporated, such as catching ball, zoom ball, or scooter board pushes within the scavenger hunt.  Incorporate team building by having different puzzle pieces gathered at each spot, and then as a group the children put construct a simple puzzle together. 

Creativity is endless when designing your hunt, and it can be adapted for each child differently if need be.  Making them theme or holiday focus can increase the interest and imaginative play. Fine motor skills can be added by having children gather puzzle pieces, Mr. Potato Head pieces, blocks, or peg board pieces to complete at a table at the end of the hunt.  In addition, you can also use it as a way to gather materials for doing a simple craft of meal.  Or even pull in writing skills by having the child list the steps after he or she are done which is also a great way to work on recalling steps.

Sensory components are definitely intertwined throughout the hunt, and being able to work on so many different therapeutic needs truly makes a scavenger hunt an all-in-one activity…so have some fun planning and gear up for some great hunting!