Three Little Words

As the end of the school year draws to a close, I find that my school age clients get a little bit impatient, frustrated and less cooperative. I think it's a combination of fatigue, burn out, and anticipation of the holidays and Christmas.

One particular client, a boy with Cerebral Palsy, flatly refused to cooperate one day. Knowing that he was likely to be a little difficult, I had prepared activities that I thought would be fun. I only had a few things with me as I was seeing this boy in his home. When he showed no interest in any of the tasks I had on offer, I knew I had to try harder, as there was no alternative. In my therapy room I have a huge range of resources, but on home and school visits I am limited.

"I don't want you in my house", said the boy. "I'm the boss here" he added.

I told him that he wasn't and that we were there to work, that his father would be disappointed if we did nothing, and that it was to help him to use his arm better. "You need to practice using both your left and right hands to play the Wii!" His favourite thing to do.

"I don't want to", he said when I offered him different games. He had not even looked at them.

Complete resistence.

I needed him to understand that I wasn't going anywhere.

"I like you", I said. "I want to be here, and I would really like you to play this game with me".

Well those first three little words made the biggest different. The boy looked at the game I had in front of us, looked up in to my eyes and said "OK". For the rest of the session he was involved, he participated, and he worked hard. I was so proud of him and so thrilled that our therapy session was productive.

I think there are so many messages here in this story. It's important to show consideration and care for other people. It's nice to be told nice things, and it's nice to be nice. I meant what I said, and I think that's important to.

We Did It! Hooray!!

Working with young children and having several of my own, daily achievements are often celebrated Dora The Explorer style by singing "We did it! We did it! We did it! Hooray!" This is one of the first things that came to mind when I discovered that a client of mine, a 12-year-old boy with ASD, had learned to shower and toilet with minimal intervention.

My last blog post focussed on a particular therapy session, spent role-playing the steps involved in wiping after using the toilet. I had mentioned this particular client to help explain the many ways in which OT's work with people to improve their ability to participate in daily living activities.

This last session was one of many that had been spent developing and introducing schedules for daily self-care tasks. Weeks before had been spent discussing the steps involved in tasks such as showering and toileting, role-playing each step, and perfecting posters for actual use, in addition to coaching the child's mum on how best to introduce these concepts at home.

Mum had been particularly worried about this last point. After years of developing a routine that worked, this was a big step for both of them. It was bound to cause some stress as any change in routine often does, and it was going to be a time consuming process.

I never expected to be so excited and proud when I discovered that my client had learnt to both shower and wipe himself when toileting with only minimal supervision required for each activity. Only months beforehand, he had been completely dependent and showed little interest in changing that fact. We now have new goals for therapy based on other daily tasks and I can't wait to see what else this amazing kid can do. Hooray!

Back to Basics

I have previously blogged about my therapy sessions focussing on skills such as handwriting and age-appropriate play. Occupational Therapists work with their clients on a very broad range of daily living skills, including self-care.

One of my clients is a 12-year-old boy who has Autistic Spectrum Disorder (ASD). His mum has up until this point assisted with all self-care tasks, including toileting.

As a school camp was coming up, we decided to dedicate one therapy session to helping this child learn the steps involved in toileting independently - in particular wiping. First we discussed why it was time to learn this skill and reassured him that Mum would be close by to assist when needed. Kids with ASD find change to routine challenging and it's important to introduce change slowly, and with as much information as possible. Children with ASD respond well to visual cues and step-by-step instructions, so this was the method employed for this boy.

After discussing the steps involved, we role-played going to the toilet. If you ever had any illusions that OT was a glamorous career choice, they will be shattered forthwith!

I grabbed a role of toilet paper and we sat on our chairs. I explained that we are pretending to have just been to the toilet. I showed my client how we wrap the toilet paper around our hand and then wipe ourselves clean. We discussed how we knew when we were clean and what to do with the paper once finished. Mum and I explained why it was important to be clean for hygiene reasons and because we don't want to smell!

The 12-year-old was able to copy my actions and respond to my verbal instructions. After a few goes, he was better at pulling the paper off the role and wrapping it around his hand. We felt that he was ready to try this by himself at home in the lead up to school camp.

Following this session, I was really satisfied by what we had achieved and excited by the prospect of this child learning such an important life skill.

A Short Break

I have a very adventurous two-year-old daughter. This week she fell off some equipment at the playground and fractured her right elbow (Type 1 Supracondylar fracture). She now has her arm in a bright red, arm length plaster cast. She does not appear to be in any significant amount of pain and has tolerated the cast well. I on the other hand, am beside myself.

The doctor at the fracture clinic assured me that in three weeks time, the injury will have healed and she should have no long term complications. The only restrictions given were not to get the cast wet or play in the sand.

The past few days have been challenging - mainly because my daughter still insists on jumping on the lounge and hurtling down the hallway either on her bike or on her chubby, two little legs. I am more concerned about her 'good' arm, than the injured one because it's going to take the full weight of any extra falls.

Bath time has been the greatest challenge, as my patient loves swimming in the bath, and has had difficulty keeping very still while I bathed her. The compromise we have reached is that she will keep still if I allow her to use her non-plastic-bagged arm to splash water at me.

The lesson I have learned from this experience is this:

Don't take your child's health for granted.

A fairly obvious lesson I know, and one that I should have already been taught - given I work with children who usually have long term and complicated health conditions. But it's easy to walk out of the practice doors at the end of the day, and travel home to my family where all that has happened earlier is forgotten. So I have been reminded of this important lesson, and will endeavour to remember it - long after my daughter has returned to throwing herself off equipment at the playground.

A Gripping Story

A common request from parents, regardless of the initial referral reason, is for me to assess their child's pencil grasp. From a very early age, most children show an interest in scribbling with crayons, biros they've found lying around, and lipstick tubes! As a child's pencil control improves, they are able to start drawing recognisable shapes and at around school age, are able to form letters and numbers.

Developing a good pencil grasp is essential to mastering writing skills and is crucial to legible letter and number formation. As each school year goes by, children are asked to write sentences and then paragraphs, and the amount of time spent on writing tasks increases. If the child has developed a poor pencil grasp, writing can be an uncomfortable and a dreaded experience for the child.

Why?

If a child holds their pencil too tightly, the muscles in their fingers and hands will tire quickly and become sore when writing over a period of time.

If a child uses poor finger positioning on the pencil, the same problem can result.

Does your child shake their hand after writing for a while? Do their knuckles and fingertips look red and taught? Is their writing illegible or does it get bigger and less controlled with writing?

These are the things to look for when watching your child use a pencil. Here's a link with more information - http://www.drawyourworld.com/grip.html. If you would like further help to improve your child's pencil grasp, contact your local OT or talk to your school teacher.

Pay Attention!

A young boy, 4 years of age, was brought to me for assessment. He had not been diagnosed with any particular disorder, but was easily distracted and found it difficult to pay attention to the task at hand. He had been seeing a Speech Therapist for some time due to a slight delay in his speech development and he dribbled.

The boy's mum was mostly concerned that he would not be able to concentrate in class when he started prep next year. She wondered what she could do to help him at home, in readiness for school.

I gave the child some activities to complete and observed that he fidgeted in his chair, and was easily distracted, and yes - had difficulty paying attention. One of the first things I noticed was that when needing to apply force or pressure, e.g to mould playdough, he would move to position himself over the table to use all his strength, rather than relying on his hand strength alone. When I asked him to throw a ring or ball, he needed to use two hands to get any sort of distance. Throughout the assessment I asked the boy to complete desk-based tasks that assessed things like posture, attention, and fine-motor skills, and more active tasks that assessed his balance, coordination and proprioception.

During the assessment, the 4-year-old managed to respond to multi-step directions, and complete age appropriate puzzles and games. I found that when he began to lose focus and become distracted, his posture also changed and he would recruit compensatory muscle groups to move or exert force on an object. I asked this child if he ever got tired in the neck, back, arms or legs when sitting for a long time. He thought for a second then answered "Yes. Sometimes my elbows hurt." His mum hadn't heard this before and wasn't sure what he meant by this.

By the end of the assessment, it had become apparent that the attention difficulties experienced by this boy were more likely due to low tone, than because of any cognitive or intellectual dysfunction.

Low tone or hypotonia is explained well in Wikipedia:

"Hypotonia is a disorder that causes low muscle tone (the amount of tension or resistance to movement in a muscle), often involving reduced muscle strength. Hypotonia is not a specific medical disorder, but a potential manifestation of many different diseases and disorders that affect motor nerve control by the brain or muscle strength".

I recommended that the child engage in physical activities that promote muscle strength, balance and coordination, like climbing, running, and bike riding. He was already taking swimming lessons and going to structured gym classes, so he was already on his way.

With regards to desk-based work, I suggested that the boy be given a seat and chair that was appropriate for his size and that enabled him to sit with his feet flat on the floor and his back well supported. When performing desk-based tasks, it was probable that the child would become easily fatigued and possibly develop joint or muscle pain. He needed to be given the opportunity to stretch and change postures frequently.

With these strategies in place, and ongoing review of his progress and awareness of his needs, the 4-year-old boy should have no difficulty keeping up with his peers on commencing prep.

Showered With Love

The patience and devotion shown by parents who have kids with special needs, is a constant source of inspiration for me. The more time I spend with these people, the more I wonder where they find the strength to get through each day. Mums and Dads who have kids with conditions such as ASD, Asperger's and Cerebral Palsy love their children as all parents love their children. They want the best for their kids as all parents do. They worry and fret as parent worry and fret, and their days are also filled with the usual highs and lows. And on top of all this, they have to cope with the extra things that happen as a result of these conditions being a part of their lives. And these conditions do affect the whole family in ways that I am only beginning to understand.

I was asked to consult with a mum about her 12-year-old son. He had Autism and was still very dependent upon her to complete self-care tasks. Due to his age, and the fact that her son would soon be entering adolescence, she was keen for him to start showering independently. For most, this seems like a fairly easy task and can be done without too much thought. For someone with Autism, the number of individual steps involved in the process can be confusing and anxiety-provoking - rendering the whole task impossible.

Think about it. When you take a shower, what do you do? You get in the shower, you wash yourself, you get out right? Not quite. Break it down further. When you get in the shower, you need to take off your clothes. First your shoes and socks, then your pants, and underwear and so on. Then you step into the shower.

When you step into the shower, you may need to adjust the screen door or curtain. You need to turn on the cold tap, then the hot, and adjust the temperature. This can be DANGEROUS. Make sure the temperature is right. You need to make sure the shower head is angled correctly. Then you find the soap and wash your body.

More steps! You need to wash your face, your neck, behind your ears. Then you wash your chest, your arms, your armpits .... And now you are beginning to understand.

The next step is to replace the soap, turn off the water, get out of the shower. Break it down further - and you can - and you will begin to see the complexity of this one basic self-care task. If you have difficulty processing and sequencing these steps, you will struggle to do this task without assistance.

People who have an Intellectual Disability or difficulties with Cognitive Processing often require visual and verbal cues to complete basic tasks. When you start to think about all the tasks you complete in a day, a picture begins to emerge of what a family experiences when they have a child with these issues.

The 12-year-old boy and his mother have many challenges to overcome, but I have faith that he will learn in time to independently complete some self-care tasks. We will use verbal cues, visual cues and lots of patience and devotion from his mum.