Monday, August 27, 2018

Orientation: Finding your Peeps

One of the most important things I have ever done was to find MY PEOPLE.  You know, the ones who get me.  The way I sing everything, all of the time, much to their chagrin.  My introverted nature.  My longshoreman mouth.  My sarcastic humor.  Because these people have been my rock of stability during the storms that happen during the school year.

So how does one locate a peep?
1.  Put on a "Hi My Name Is" and replace your name with Inigo Montoyo or Slim Shady
2.  Look for people who get the joke.
3.  Smile, because they are probably your peep
Ok, Ok.  This may not work in all situations and with all types of personalities.  But finding common ground with at least one person in your work environment during orientation can help set the mood for the year.  I personally am not an icebreaker person but the concept makes sense; force the group to split and speak to one another outside the normal clique.  Forced connections.  Meh.  I like to connect organically when I have the time and energy to pop into rooms and speak in a less chaotic environment.  Or maybe for the first few weeks, try to eat lunch in the staff lounge.

Often, I find that therapeeps (OT, PT, and Speech) will sit together because we typically understand each other's backgrounds.  We are healthcare providers who happen to be in the education setting.  We are using our super powers to help children access their school lives.  But that doesn't mean we cannot look beyond our scope of practice for connection.

Branch out.  Find a teacher of visual impairment, or teacher for the deaf and hard of hearing, or social worker, or special educator, or regular educator, or secretary, or teaching assistant, or nursing assistant.   In fact, FIND ALL OF THESE PEOPLE because you will need their expertise to get through your school year.  There will be questions, and these people may have the answer.  It is vital to daily survival to identify with whom you can connect and consult.

Will they necessarily be the people to which I vent and shed a tear? Probably not.  That is only reserved for the sacred circle of peeps.   But these individuals will collectively help you navigate the school year.  And maybe, just maybe you'll find a peep or two that make going to work a little more sugar-coated.

Tuesday, August 21, 2018

The Grind: EBP Systematic Review of the strength of sensory techniques and modifications

In my day to day practice, I am constantly integrating sensory-based interventions.  Many of the students with whom I directly work are preschoolers on the autism spectrum.  I am lucky enough to have an actual treatment room with a ball pit, a doorway platform swing (linear only), a trampoline, tunnels, stairs, balance beams, and a steamroller.  I even purchased light covers to soften fluorescent lighting.  And I use the heck out of this space.  I love watching my students' motor planning evolve so that they freely move and engage through the obstacle courses, vocalize, socialize, and participate in later tasks.  My practiced-based evidence, the results of my sessions and its impact on my students' functioning, supported the continued use of these sensory-based techniques.  But I wanted to know more: What does the research say?

Back to the Grind

Well, Bodison and Parham (2018) published a systematic review that reviewed over 11,000 studies from 2007 to 2015.  Only 8 (out of 11,000!!!!!!!!!) met the inclusion criteria of studies that were peer reviewed, in English, had pre and post-testing related to sensory functioning, and the outcome measures of the impact of sensory techniques and environmental modification on a child's function and participation in daily activities, not just physiological changes noted in a lab.  The included studies focused on the following intervention:
  • Qigong Massage
  • Weighted Vests
  • Slow Linear Swinging
  • Sensory Enriched Preschool
  • Sensory Environment Modifications
Nitty Gritty
  • Qigong Massage has been effective in infant and preschool-aged development and behavior, ***when the occupational therapist has extensive training
  • There is limited evidence for use weighted vests with kiddos ADHD; using weighted vests for children with ASD was not recommended due to the lack of evidence
  • Slow linear swinging may or may not improve on-task behaviors for children on the spectrum; it is dependent on arousal level
  • There is insufficient evidence that embedding sensory rich activities into the preschool classroom improves development over a typical preschool setting
  • Other techniques like Wilbarger Brushing Protocols, therapy ball, sensory diets, and sensory listening systems were excluded because the quality of the studies out there were low on the evidence totem pole
  • Reducing lighting and sound, paired with a weighted blanket helped children participate in dental cleanings
What do the findings mean to me?
  • If I were an early intervention or hospital based therapist, I would consider going for training in Qigong Massage.  But it would be at least 50 hours of training, which is a huge commitment.
  • Weighted vests.  How many of us have weighted vests in our closets? Evidence is limited.  Though it is in my tool box, I would try other interventions first before implementing one of these.
  • Linear swinging.  Know the reason for using the swing before using. Is it for play and language, reward, balance and strength, or regulation?
  • Preschool.  Definitely need more thought and research here.  I have seen a lot, working public preschool for nearly 12 years. Each teacher sets up his or her room differently.  They use different materials, different approaches.  The children, usually between 3-5 years old, are mixed in skill and developmental level.  Collaboration levels and comfort with service providers are all cogs in the multifaceted machine of the the day.  I work with the kids in and out of the classroom to see what may work and how it could be incorporated into the daily routine with the goal that the child can learn to self regulate in his or her natural environment.  And with the push for push-in services, consultation, and modifications, more experience and studies are needed to figure out what is best practice.
  • Read up on the other techniques before using them!
  • Yes, more research is needed to generalize to a classroom, but it is worth educating teachers and staff to environmental modifications that can help students with ASD.
During my EBP courses I had coincidentally gone through quite a few, if not most of the studies highlighted by Bodison and Parham.  For me, I will continue to use sensory-based interventions as part of treatment for children with sensory dysfunction, but I plan on making more of an effort of keeping better data to see if my practice-based evidence is improving function and on-task behaviors.  

Bodison, S. C. & Parham, L. D. (2018). Specific sensory techniques and sensory environmental modification for children and your thaw sensory integration difficulties. A systematic review. American Journal of Occupational Therapy, 72, 7201190040.

Monday, August 13, 2018

The Grind: EBP Review - A Systematic Review of the Efficacy of Handwriting Programs

Last year, I completed two courses in Evidenced Based Practice (EBP).  Prior to them, I thought I was doing my due diligence in reading and applying knowledge learned through continuing education courses and reading articles both peer reviewed and not.  But I was completely missing the ball on being an effective consumer of research. It's not just about reading the content, but also analyzing it.  Basically, how efficiently did the authors answer the WH questions of who? what? when? where? why? how?   Therefore, in an effort to keep my brain percolating with the evidence to make informed decisions in treatment and evaluation, I will share my interpretations of current studies and how they might apply to school-based services.  

Welcome to The Grind.

I was intrigued when I came across the systematic review by Engel, Lillie, Zurawski, and Travers (2018).   Engel et al. searched through 455 sources to get to 13 studies that met the extensive criteria of peer-reviewed journal articles within 2006 and 2015 that examined if, which, and by how much handwriting curricula were effective in improving legibility, speed, and fluency.  Ultimately, the studies that were robust enough to be included in the analysis focused on the following handwriting curriculum-based interventions:
  • The Write Start
  • Peterson Directed Handwriting Curriculum
  • Handwriting Without Tears (PreK and Elementary)
  • Fine Motor and Early Writing Pre-K curriculum (which seems to be a part of the Pathways to Learning by Mead)
  • Size Matters
  • Write Direction (only found a reference to it on YouTube)
  • handwriting clubs
  • Explicit Handwriting Program
Nitty Gritty
  • Curriculum-based handwriting programs (CBHP) do have a positive effect on legibility/letter formation.  Size Matters, Write Start, and Explicit Handwriting Program had the biggest effect sizes on legibility
  • There is mixed evidence that supports CBHPs improving speed of handwriting, in fact it may slow some children down
  • There isn't enough evidence that CBHP improves fluency of writing
  • There were not significant relations between age of instruction or amount of time spent on instructing and outcome on legibility or speed
So what did this mean to me?
  • I have been a user of Handwriting Without Tears for years.  I can say that I may not use every piece of the curriculum with the fidelity to the extent that I would like, but I believed that the curriculum was based in research.  But clearly, there are many other handwriting curricula available on and off the market that can have an impact. 
  • I am going to have to do some professional development on the Write Start and Size Matters.  It might be worth it for me to expand my repertoire of interventions to see if either would be relevant for my caseload.  Heck, I am pretty confident I have a manual somewhere in my office at work for at least one of them.   
  • I could not find anything about what exactly the Explicit Handwriting Program was or how it was implemented, so it's not high on my radar.
  • And if the curriculum do not impact speed of handwriting, what does? Guess I'll have to do more searching.
The nice thing about systematic reviews is that the authors are taking on the brunt of the work.   Are there limitations?  Of course!  As a consumer of research,  you are dependent on the authors to include what you are looking for in population, intervention, and outcome.   However, systematic reviews typically give you the most bang for the buck.  You can always dive further into specifics by weeding through the references.  If you don't have NBCOT or AOTA membership, I highly recommend that you get it.  They provide you with access to research relevant to practice.  It really is worth every penny.  If not, there are other avenues to try, that I will address in later posts.

Let me know what you thoughts are. 

Engel, C., Lille, K., Zurawski, S. & Travers, B. G. (2018). Curriculum-based handwriting programs: A systematic review with effects sizes.  American Journal of Occupational Therapy, 72,