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. https://doi.org/10.5014/ajot.2018.029413

Michael Myers in a Mat Man shirt, holding a box of crayons

It’s coming.  The end of summer.  The end of lazidacial mornings of drinking coffee on the porch in my pajamas with the dog at my feet.  Orientation is around the corner.

Whether you are entering the school doors for the first time or the 12th time, first day anxiety is creeping its way into your head like a bad 80s horror character.  

I like to picture my first day anxiety anthropomorphically, like Michael Myers with a Mat Man shirt on holding a box of crayons.  Chi chi chi, wah wah wah. He sits on my shoulder, like DeadPool on the overpass, coloring an IEP calendar. I ask, he answers.

Wonder what the caseload is going to be like this year?

Comparable to planning a trip to the hairy edge of Saturn

From under what hellish mountain of paperwork will I be shoveling this year?

Somewhere in height between K-2 and Everest

How will I get everything done?

By medicating

How many times will my schedule change? 

If a train is traveling at 80 mph and 30 people are walking in the opposite direction, how many cats would it take to fill the Lake Eerie?

Do I need a swear jar at work? 

Probably

When will I have lunch?

Whenever you damn well please, as long as you can eat it under 3.2 seconds

Don’t get me wrong. I love what I do.  I love my students. I love my co-workers.  But I still struggle with making each year manageable.  So now that I have completed my masters, I want to get back to writing.  It helps me process the day to day quirkiness that is school-based therapy.  

The work-wife (I’ll get into that in a later post) and I thought we would do a podcast about topics, trials, and tribulation of how to survive school-based service provision.  But for now, I think I will start here. Any maybe, just maybe you will come for the ride. Check out the scenery, share your experiences, or just nod your head in solidarity.

Adventures in Assistive Technology: Adapting the Power Wheels

I had been dying to do this project for over a year, since I had first heard about the Go Baby Go through the University of Delaware.  It was an AH HA moment.  I could totally do that. Adapting a powered toy car so my kiddos could have access to play with their peers as well as build other skills such as switch use, or head and trunk strength, or language, upper extremity strength... you name it, I could justify it.  It is my magic, as an OT, ya know to justify ANYTHING!

So a few weeks ago I finally resparked the flame of innovation and started asking for donations of used power toys.  And to my joy, my nieces and nephews donated their John Deer truck because they weren't using it anymore and they wanted to help my kids.  There I was, John Deer in hand. Now to get the rest of the supplies.

Ratcheting PVC cutter
Cuts through pipe like buttah'

Switch. Check.  (ablenet.com)
PVC piping. Check.  (local neighborhood hardware store)
Nuts and Bolts. Check.  (local neighborhood hardware store)
Kill Switch. Check.  (amazon.com)
A husband to help me rewire. Check.

Once my Mr. Fix-It helped to rewire and solder the gas pedal to the switch, I got my Ratcheting PVC cutters out.  These are a necessary tool if you work with PVC.  Worth every penny.  I also got to steal Mr. Fix-Its Dremel tool and new Milwaukee Power Drill to perforate the holes in the piping and the truck to install the support frame.

Finishing touches included good ole pipe insulation,  duct tape to provide a softer support to the bracing, and industrial Velcro for a lap belt and shoulder support.  And voila, Pimp My Ride: John Deer Power Wheels edition was complete.

My son testing it out

When I envisioned the outcome, I primarily had my students with significant physical disabilities in mind, but the benefits of the project spread beyond that group.  Students with autism found it quite intriguing and motivating.  Those that were non-verbal, vocalized and expressed words such as "Cool!" "Go!" "4 by 4" and "Deer".  It gave others a chance for parallel play and structured communicative play by incorporating voice out put switches with phrases like "Do you want to go for a ride with me?" and "GO!"  Driving also encouraged bilateral hand use and intrinsic hand strengthening, as the children have to use push the switch while holding the steering wheel as they drive.  For my more involved students, I steer while they activate the switch.


Though not 100% complete, I still need to set a secondary switch for a right cheek activation site, this project is well on its way to fulfilling its purpose: increasing participation amongst children with multiple disabilities during free time play.  I actually wish that I had considered completing a research study on its effects on social participation.  Maybe next year....

Overall, I would consider this an advanced project due to the nature of adaptation and tools needed.  If I didn't have my husband's support, I don't think it would have made it out of my basement.  Also, there are a significant amount of obstacles.  First, logistics.  The size of the vehicle is big.  It's a two-seater.  And even though we removed the dump bed from the truck, it is still large to store (ask my co workers).  So if you are considering doing a project like this, you need to examine your storage capacity.  You also have to respect administration for your building.  I am lucky to work with educators and facility managers that don't mind my therapeutic antics.  Second, cost.  Though the power wheels was donated, I purchased most of the materials.  PVC is cheap; foam insulation is cheap; switches can be costly.  I completed this for under $50 but I had a lot of materials and tools already.  Third, overall understanding of positioning and access sites.  Position of the body is key to accessing life, including switches.  If a child is not supported appropriately and safely, the participation in motorized play will not be successful.

Sea Choice Universal Kill Switch
Available through amazon.com

So if you are interested in researching a project like this, check out Cole Galloway and his team at the University of Delaware.  I downloaded their instructions, and then modified it to fit my needs.  For example, the kill switch they used is a single throw switch; my Mr. Fix It recommended the coil based like ones used on boats. Since it attaches to me while the children are driving, I don't have to worry about them driving off.  Go Baby Go project developers recently published new directions which are clearer and more organized.  And if you want to help me make another adapted car, you can visit my Donor's Choose site.

Special Thanks to Maddie and Patrick for donating their toy! Without it, my students would not be having nearly as much fun!

Back to School Tried and True

By this time of year, I am prepping to return to work and have found something that I cannot wait to use.  But honestly, this year, I can't wait to go back to my tried and true, my go-tos, my faves.

1. Music
People think I am nuts, but I sing everything. EVERYTHING becomes a song. Working with 3-5 years olds all day long will do that to you.  Almost each session incorporates something from Handwriting Without Tears Get Set for School album.  Kids love it.  I love it.  The songs address so many things from socialization, left/right discrimination, body awareness, language, pre-math concepts, I could go on and on.  In fact, the students even when they leave preschool, still expect to sing the Hello Song and do Tap, Tap, Tap.

My other top music pick incorporates technology.  Inclusive Technology's apps have such catchy tunes that I'll incorporate an app for my kiddos that need to work on cause and effect, assistive technology access learning, turn taking or counting.  The activities are great one on one or in groups.  I often will connect my iDevice to the Smartboard in the classrooms after our music and movement activity and before we move to the fine motor fun.  They just released two multi-songs apps that I might just splurge on, because I know I'll use them.

2. Scissors
I love cutting.  Put a tool in a child's hands and you can see their eyes and bodies hone in on the activity.  Snipping the paper strips or theraputty is, well, therapeutic.  Snipping through the resistance of the putty builds strength of the intrinsic hand muscles, while forcing bilateral hand skill development.  Adaptive scissors help to make it accessible to most, if not, all students, with the just-right assistance level.  And I started downloading or making play mats from Teachers Pay Teachers to support early math skills like one to one correspondence, number recognition and counting.

Scissor Assessment Kit from Achievement has a great variety of left and right adaptive scissors for just about any need or ability.

3. The Peanut Ball
I think I need to order about 5 more this year.  The peanut ball is such a great tool for core strengthening, balance, attention, and upper body strengthening, that its versatility equals its weight in gold.  Sit on it. Straddle it. Lay on your belly. Lay on your back. Throw it. Kick it. Carry it. Roll it. Do any of those while participating in an activity and the session gets even more bang for the buck.

4.  Theraputty
I  have been having so much fun adapting and creating activities using Fun and Function's variety of putties.  I heart the Animal Rescue Discovery Putty.  But over the year, the kiddos have lost most of my animals.  So I purchased the Emotions Putty which are totally cool.  It comes in Calm which is labeled as Soft. When cool, it is blue. When warmed up, it turns purple, like the old school mood rings.  It also comes in Energize which is labeled Firm.  It's this metallic glob of fun that reminds me of Terminator 2 when Robert Patrick oozes and molds into forms.  It is so mesmerizing that kids and adults alike will choose it.  The Putty Elements packs are a great addition. Because they are named Earth (green/ medium), Desert (red/ extra soft). Sun (yellow/soft ) and Sky (blue/extra firm) that along with science, it can support persistence and strength.  Note, it felt like their resistance did not match their labels; but that was ok.  For the ages with whom I work, I am less concerned with the resistance level than I am with engagement with a substance that will either challenge their sensory or fine motor needs.

Calm Emotions Putty

5. Dice
I am not just talking about the standard dot dice from the board games; I am talking about turning a couple of those random blocks you have laying around and creating new activities.  Roll picture/word dice to create silly sentence that not only address writing skills such as spacing, formation, and capitalization, but also supports language development and awareness.  Roll a move, dance a groove.  Easy way to add a movement break into an activity or the order to which a student completes an obstacle course.  Changing the way a learning center or activity is built, such as adding the playful component of dice, can change the attitude and engagement of a student learning a novel skill.

Foam Dice with Who? Where? Verbs? When? Boardmaker Pictures to prompt sentence expansion

Now that I have shared some of mine, what's in your back to school tool box?

'Appy Hour Review: Five Speckled Frogs

In the consistent nature of Inclusive Technology apps, Five Speckled Frogs is a great springtime addition to the repertoire.

Like other similar apps including Five Little Aliens, Five Rock Stars, and Five Swimming Sharks, Five Speckled Frogs offers a catchy and familiar song with two additional counting activities.  It also costs $2.99 in the iTunes app store.  Switch accessibility is still an option. And of course the visuals and sounds are pleasantly aligned with the other apps/products.   But, here is the best part….. app designers listened to feedback! There are back buttons and a two finger tap in the upper left hand corner to quickly go back within the app without having to close out of the app completely.

Not only is it refreshingly wonderful and gratifying that as a consumer, my voice (and presumably others) was heard, but it shows how dedicated this company is to serving the educational community of special needs.  I hope to see this feature in updates of the other apps!

Five Speckled Frogs is such a frequently used concept in the pre-K setting, that there are many ways to create lessons and activities.  Now in the special education assisive tech community, we can say, "Yes there is an app for that."

Kiwi Crate, the busy mom's answer to arts and crafts

I love Kiwi Crate.  Flat out, this has been one of the best investments in a monthly subscriptions I have ever done.  Way better than Highlights or Ranger Rick.  It takes the thinking and preparation out of arts and crafts time.  For me, I have to be on my toes of creativity at work everyday, and some (or many) times I just don't have the where-with-all or energy to come up with things to do with the boys.

So well over a year ago, I came across Kiwi Crate in some magazine, I think it may have been Family Circle.  On the whim, I explored the website and ordered a single month activity box.  From the moment that little green box came in, the boys and I have been hooked.

Each month, a box filled with materials and instructions for two activities arrives at our doorstep.  The boys spot it and scream, "THE KIWI CRATE IS HERE!!!!!!!!!!!!!!!!"  Once inside, I am guaranteed at least and hour (if not two) of engaged, happy kids.  Yes, I am there too.  It is a time that I can just play with them during the hands on crafts and not have to worry about instructing on each step.  Kiwi Crate provides the how-to with easy to read steps and picture supports.  My oldest, now 8, can easily read the guide to the youngest, 5 and they can generally do quite a bit independently.

There is a mess-o-meter that helps prepare me for how much of one there will be. But it is never too much for us to handle.  And I am always surprised at the amount of left over materials that I do have to keep for a later date.

A monthly subscription ranges from $16.95 to $19.95 a month, plus either a full extra cost for a sibling (or just 9.95 for extra materials per month).  I'm not saying it is cheap, but for the time that it would take me to go to Michael's or AC Moore, come up with an idea and materials list, organize it, and execute it, I would be close to that cost and more importantly my wits end.  Like I said, its an investment, but one well worth it.

I have recommended it to friends and parents of my students to help increase playful engagement, without the thinking factor.  Sometimes we forget just how to play with our kids between school, soccer, bed, and bath.  Plus there is the added bonus of it being an educational product.  It addresses sensory, fine motor, hand eye coordination, math, language, science but most importantly, persistence.

I laugh to myself because it took me nearly 18 months to write a review, not because I didn't want to but because there was so much I could say about it.  So after the boys finished their October crate this morning, and are currently playing with their Glow Creatures, I figured I would take this moment to scream at the top of the mountain: "THE KIWI CRATE IS HERE!!!"

Friday Fatigue = Mudget Meltdown

I giggle sometimes when Friday comes along since I know Mudge has not had a nap alllllll week.  It's not the teacher's fault, it's not his fault, but certainly he has not grown out of them.  So by Friday, he is a wreck.  Last night he was asleep by 6:20.  Of course, he woke up at 5:30 this morning, but that was expected.

And today was no different.  As with most Fridays, we went to Papa's for supper.  Nudge, I mean Mudge, ate half his dinner and played with his brother and cousin for a bit.  He took his shower, but his mood was distinctively changing.  Like when I turned off the shower and he did NOT want that to happen.  Like when I put on the tiger towel, which was NOT the one he wanted.  Like when he told me "you're NOT gonna be my mommy anymore."  Yeah, I could see where this was going.

He went upstairs naked as a jay bird.  I tried to help him get his jammies on, but he decided NOT to wear underwear and took them off.  Then proceeded to have a hissy fit until we got home.  Awesome, I know. Probably not that different than what you may experience as well with your preschooler.  I suppose it is why I share, in hopes that I am NOT the only one, and neither are you.

And if you want a soundtrack to this experience, check out Justin Roberts' Meltdown.

OT Soap Box- Handwriting

It seems like the schools these days are forced to push kids beyond what they may be able to do.   You know, Kindergarten is the new first grade, Pre school is the new K.  But the problem is, you can't rush development.  Think back to basic child development classes that you may have taken.  There is a basic neurological development of fine motor and visual motor skills.  If you skip teaching these skills, the children often will struggle understanding more complex tasks.

As an occupational therapist in a public school setting, I see it more often than not.  What is the first letter you learn? A.  Two diagonal lines.  These kids are 3 years old.  Developmentally, a 3 year old may be able to form vertical and horizontal lines and a circle.  A 3 year old may struggle with the A because he hasn't developed the diagonal, crossing midline corner to corner.

So what do you do?  Well, luckily there are people, many of them OTs and teachers, who recognize this.  And some of those people have developed programs.  One of my favorites: Handwriting without Tears.   HWT is Jan Olsen's baby.  She is an OT who developed the program after her son struggled tearfully with his writing.  Jan was able to break the concepts down into a fun, practical and consistent technique that both kids and adults can use.  It was only in the past few years that a pre-k program was developed, but it has become a staple in my personal approach.

Mudge and Mat Man

I'll share a are a few key components.  

1. Because the little ones are in fact, little, HWT (and I) encourage use of small crayons.  Break them.  Its OK. And it may be cathartic.  Using small pieces promotes grasp development into eventually a "Tripod" or "Quadropod" grasp.   

2. Teach capitals first.  They are the same size.  They all start at the top.  

3. Use consistent language.  You can form you capitals with 4 simple concepts, Big/Little Lines and curves.  

4. Have fun and make it playful with music and movement.  Kids are multi-sensory learners.

Taping paper to the wall or an easel also helps to place the wrist in a better position to help the child use the inner muscles of the hand.  It also puts it directly in front of them, for better visual attention as well as encouraging the helper hand to stabilize

There is sooooo much more to handwriting than just a pencil and paper.  Language, cognition, position of the body, strength, coordination, vision, sensation, and the list goes on and on.  If one of these aspects is lagging, than chances are the overall outcome will be less than desirable.  If you think your child is struggling, becoming frustrated, not wanting to participating in crayon and paper activities, talk to his/her teacher or daycare provider.  See how (if) they are teaching Pre Writing concepts.  Then determine if something is missing.  If you think your child needs extra help, don't be afraid to ask.  You are your child's best advocate.  There are plenty of things out there.  Check out sites like Handwriting Without Tear, your local school department or child outreach for tips and contacts.

Two Weeks and Counting till the Real Mother's Day...

No, I have actually loved being home this summer but alas it is coming down to the wire.  School starts back up for me on my son's 6th birthday. This will be the first birthday I will have missed.  Which is totally going down in the mental rolodex as things-that-should-automatically-get-a-mom-out-of-work-card.

But regardless, we still have to start getting back into school routine.  So this week is the re-initaition of sleep by 7 pm.  My kids are ogres when they don't get enough sleep. Add the stress (good and bad) of going back to school, and they are apt to have meltdowns.  Though returning to the same school, Boog will be entering first grade. AHHHHHHH! Sorry.  Just can't believe my Boog is a "grader" now.  Though, him grammatically correcting me should be a hint that he is ready to go back.  "Mom, you mean WHEN we're ready to go in the pool, not AFTER..."  My bad.

Mudge, well, he is going to Boog's school for preschool.  I am hoping for a smooth transition as he will have his big, bad older brother to protect him.  But I am also praying for his teacher, as he holds up his halo with devil horns.  Needless to say it will be an interesting year.

We are pretty lucky since back-to-school shopping only consisted of materials, on sale at Target, Staples, and whereever else had the stuff under a buck.  Boog wears a uniform, the best thing ever! And Mudge frankly doesn't need any clothes.  I bought backpacks on clearance from LL Bean a few months ago, as well as the lunch boxes from Lands End.  So I feel ready...ish.

With all that under my belt, I think I'll start Chrismakkah shopping ;)

What are your back to school preparations like???

Best. Preschool. Ever. Guest Blogger: The Brombergs

Hi, OT Mommy Fans! We are the Brombergs – Sam, Casey, 3 year old Harry, 9 month old Cecilia, and Freddie, the Brazilian Basset Hound.  (Seriously, the dog is from Brazil.  We have papers for him Portuguese.)  Sam and Becca are cousins, and we call Becca’s Mudget, “Little Sam.”  He and Harry are just about a month apart.  We live in Oakland, Maine, which is near Waterville, in the Belgrade Lakes Region.  Casey is writing these posts, with Sam looking over her shoulder making “suggestions.”

Close your eyes for a moment and imagine occupying 200 kids under five with no tv and no timeouts for 12 hours a day.  Before you start panicking at this image, take a look at this place:

This is Harry Bromberg’s preschool.  (I say Harry Bromberg because he is only now starting to grow out of a tendency to refer to himself in the third person.  It’s pretty entertaining.)  Educare Central Maine is a palace – the kind of child care facility you can only dream about, an $11.5 million kiddie castle.  It’s only been open since August 2010 and there is a huge waiting list for both low-income and middle income families.  Harry had been on the waiting list for 10 months before he got in, and Baby Cecilia is now 15 months on the waiting list.  (Yes, the math is right, I put her on the waiting list in the womb.)  We call Cecilia the Educare Baby, because some of the national Educare funders are using her photo in their PR materials.  The kids only made it on the middle-income waiting list because I work for the social service agency who developed the center locally. 

See?  You’d give money to a face like this!

I don’t know about the rest of you, but around here, I’m not sure which experience is more stressful, trying to buy a car or finding a safe, affordable place to care for your kids.  All the guesswork is taken away with Educare.  It’s part of a national network of state of the art child care facilities and the only one in the northeast.  They use a curriculum that is basically Head Start put on steroids, with the added bonus that all the teachers have either a Bachelor’s or Master’s degree in early childhood education, with low student-teacher ratios to boot.  The facility also serves as a learning lab for other child care providers and early childhood education degree students to take classes, do observations, etc.  We have parent-teacher conferences every three months and design goals for Harry, which includes teaching us how to help him with those goals.  They have independent evaluators come and work with the kids to assess developmental skills and milestones.  However, it’s not done like he’s a lab rat.  It’s all about him and what we all do together to help him.  It’s actually really cool.

Research tells us that 85 percent of all brain development happens before age 5, with most of it actually happening by age 3.  It’s amazing for us, having Harry in this program.  We already have a glimpse of what his true potential will be and he’s only 3 ½.  He’s grown so much emotionally and in intelligence since he started in January.  If you’re not a believer yet, watch this video put together by the Ounce of Prevention Fund.  I’m not much of a crier, but this makes me choke up every time I watch it.

Change the First Five Years and You Change Everything