Occupational Therapy Notes: Early Intervention

Showing posts with label Early Intervention. Show all posts

3.29.2015

Building Pre-Dressing Skills

One of the most obvious ADLs is dressing. And this is often an area that OTs may address in early intervention or school settings. If you're interested in building these skills for your child or a young client, read below for some of my favorite strategies.

Undressing- Before a child is able to dress themselves, they start to undress themselves. In a reverse chaining method, you can allow your child to do the last step of the undressing. This might be pushing pants off from ankles, or pushing a shirt over his head. Socks and shoes are also a favorite for kids to doff.

Play Dress Up - Dress up games serve double purpose- imaginary play and building physical skills. Some examples might be using different hats, or using the commercially available hooded towels or blankets to practice putting things on their head. I made a cape for my son out of an old t-shirt by cutting off the sleeves and front of the shirt.

Another piece in the dress up category would be gloves or booties that come in these kits with a coordinating book. A friend gave us the "Tickle Monster" book and my son loves donning and doffing the gloves.

Pullover bibs- These are such a simple way to practice the overhead movement. They don't catch as much as the ones with a big pocket, but depending on what you are serving they will be more than sufficient. I see these often at discount stores, but there are also a number of tutorials for how you can make your own.

Dolls- Practicing dressing and undressing dolls is a great way to build fine motor skills, use of fasteners (usually velcro) and address valuable social-emotional skills also.

Button Snake- When it comes to practicing fastener skills, the button snake is becoming well known in therapy and mommy communities. I have made these out of scrap materials before because I'm cheap and don't want to spend a lot of time on it. Tonya at Therapy Fun Zone makes much nicer ones and also has ideas such as making a button sandwich out of felt pieces.
button snake 1web

Image via Therapy Fun Zone

What are some of the ways that you use to build dressing skills?

12.05.2014

Using a Christmas Tree for Child Development

I am really in the Christmas spirit this year. Partly because I was looking for some happiness and positive energy after a bleak fall, and partly because this year my son can really start to enjoy the season. He pays attention to everything and has plenty of commentary about what's going on, so he was very excited when the first decorations went up (during his naptime) and asks everyday to turn the lights on.

For a little while, there were no ornaments on the tree. I didn't want my little climber to get any ideas and try to get up to the higher branches, and I know that there is no way to keep some ornaments intact around kids (they can come back in 10 years or so...). But I decided to make the tree a more interactive experience for him with minimal hassle from me.

Closer view of some soft ornaments

A couple ornaments for mom on top, most for the baby on the bottom.

I set out the ornaments that were soft and unbreakable. I took off all the wires that we normally use to hang ornaments. I made sure that all of them had a loop to hang by- some needed additional yarn to have a larger loop. The loops are varied lengths and materials which presents different challenges. I also made sure to put out a bucket and box so that my son had a location to put in and take out (a favorite toddler past time).

I really only showed him how to pinch and spread open the yarn loop to make it large enough to fit on a branch a handful of times, and that was enough to inspire hours of self-directed play. It's a very easy activity to set up, and from that we have an easy starting point for practicing communication and cognition concepts. We talk about the characters, what color they are, on/off, in/out, up/down - it's a very natural way to play with a child and promote development in multiple areas.

Here's some ideas for good ornaments for toddlers and preschoolers to use for their personal decorating:

- Pipe Cleaners / Beads: If you have a preschooler or an older sibling, there are plenty of ways to make inexpensive, unlikely to break, ornaments that you can treasure as kids' projects in years to come.
- Easy bead and pipe cleaners
- A variety of easy ornaments
- Triangular beaded candy canes
- lace and bead wreath
- pipe cleaner wreath

- Plastic Canvas: One of my aunts just loved to do plastic canvas crafts. Some of these were designed to be magnets, but many were ornaments. Since they are all yarn, they are no worries about injury or ornament damage.
- Pre-made from Etsy
- Ornament patterns 1 2 3

- Clothespin ornaments: The pinching requirement to operate these is another great fine motor challenge, and it makes for a nice change of pace.
- DIY Snowmen
- Etsy set

While ceding my tree to my toddler seemed pretty logical to me, especially since I don't want to spend everyday telling him not to touch the most interesting thing in the room, my husband reminded me that it was my OT brain and not just a "common sense" thing. So hopefully this will be a helpful share to others.

11.09.2014

self care for young children

I really enjoyed putting together the Chores for Young Children entry, what OTs might call IADLs. Here is the compliment- the ADL for young children, between 6-18 months.

Obviously kids are mostly reliant on mom and dad for care, but as they get older and more able to interact with the world, they can begin self care tasks with support. These skills necessarily overlap with gross motor skills and communication skills. If you have a child who is having trouble learning a new skills, you may need to isolate down to only a component instead of asking for a motor response and a communication response simultaneously.

When I think of basic ADL/self care, I think of feeding, grooming, bathing, dressing, and toileting. (It's the FIM training in me). I will address those areas.

One of the first self care tasks that a child can do is eating. Very young children can learn to put their hand to the bottle or breast to focus on hand to mouth activity, and 5-6 month olds may hold their own bottle. (most recommendations are for a child to not take a bottle to bed with them, FYI) If you introduce foods around this time, a child can actively participate. Yogurt or thickened cereal will stick to a spoon pretty easily, and the child can dip the spoon instead of scooping, and start feeding themselves. They will likely need assistance for much of the meal, but starting this bit of independence early is very important.

Grooming is another area where young kids can participate early. With a soft bristled brush, a child can brush their own hair after a demonstration even before 12 months. If you use baby wipes or a wet washcloth to clean up after meals, provide a second one for the child to work on their own hands and face first. The third part of grooming is brushing teeth, which can be a battle for some kids. However, we started with a set of graduated brushes by Nuby that move from being all rubber to having bristles. This worked well for my son and he loves to imitate us and move the toothbrush himself. Your mileage may vary- the mouth is a very sensitive area!

My baby loves bathtime, but again, this can be a struggle for some kids. Keeping the bathroom warm and steamy by running the shower beforehand can be helpful. As your baby starts to learn words for their body parts, they can better understand lifting that part for washing or using their own washcloth to help. They may even enjoy dumping rinse water on themselves. In a related way, my son loves to help apply his lotion after bathtime. We put a little squirt on his stomach or legs and he works on rubbing it in.

When it comes to dressing, it is easier to take something off than put it on. So very young children will work on doffing hats, socks, and pullover bibs. Then you will start to see the child help you put his arms through shirts and take a more active role in dressing. By 18 months, the child can play at dressing with spare, larger clothing in free time. Be forewarned, he might start undressing in awkward places! Doffing clothes before bathtime is often a good time to practice. You can begin work on fasteners by undoing velcro closures on shoes, though getting them off his feet may still need help.

Finally is toileting! You can teach your baby to change his own diaper in 2 easy steps! Really? Of course not, just checking to see if anyone is reading this far! But it is realistic to have an older child (~15 months) carry the clean diaper to the changing table, and tap his hips or tummy to indicate that he has a dirty diaper. I do have friends who potty trained very young, but at this point we're just working on indicating so that he can concentrate on other skills.

What do you think? Are there additional strategies or self care tasks for toddlers that you'd like to share? Please let me know!

10.05.2014

Chores For Young Children

My primary life role at this point is as mommy, though I definitely bring my OT perspective to the table. This can mean presenting my toddler with frustrations to find the "just right challenge" or trying to have him follow an "if/then" chart. Another feature has been including self-care and chore tasks early on into our routine. Kids like having a purpose, being helpful, and celebrating an accomplishment so learning chores is positive at any age. I am focusing on chore activities for kids under 18 months.

(isn't he just adorable, even from the tush angle?)

Before your child has the motoric control to help with chores, you can narrate the activities you are doing as he is with you. This can be very simple- "I'm turning off the light. Now I'm locking the door." etc. This helps build his speech processing and general cognition.

One of the first things we taught our son was how to turn the light switch off. It was easier to push down than turn up, and it gave him an instant and noticeable effect. We probably started this about 7-9 months and it continues to be a favorite.

Placing things in and out is another early skill that is learned. Before he could really follow directions to transport an object, we let him play in the laundry baskets and dump items in and out (before they were folded!). Then he graduated to putting dirty clothes in the hamper, into the washing machine, and taking trash to the trashcan. (13-15 months)

Kids enjoy housework activities with real or child sized versions of typical cleaning items. Usually this is more of a pretend play than actual help, but there are some exceptions. A regular swiffer sweeper can be modified so that it is small enough for a child to use, and can then still have the swiffer wipes attached. Also, the swiffer dusters are lightweight and can be used for cleaning surfaces your toddler can reach. Any dirt picked up is a bonus, since it's something he enjoys anyway. (14-18 months)

Here's a list of some of the chores that we have been working on. Obviously all of these should be done only while the child is supervised and with child-safe products. You may also want to visit my pinterest page for ADL activities which has several additional lists of chores and guides for teaching children with disabilities.

Turning lights on/off

putting dirty clothes in basket

pushing basket to room

putting dirty clothes in washing machine

pressing buttons to start washing machine, dishwasher, Roomba (my son is fascinated by buttons... I try to discourage this but he has gotten really good about starting the washer even without me helping him)

Taking trash items to trash can

picking up spilled food (crackers, large pieces)

cleaning tray with a wipe after eating

taking bowl to sink to be washed

picking up toys

sweeping the floor

spraying cleaner on windows (there are a ton of recipes for child-safe cleaners, or you can just use water)

putting away bath toys

hanging up towel

Please feel free to share additional ideas! I will do another post on self-care activities when I can!

8.08.2013

Breastfeeding the Child with Torticollis

In honor of World Breastfeeding Week, I decided to prioritize writing this piece. Torticollis is a common issue for infants and as I found personally, it can complicate breastfeeding considerably. Despite these factors, torticollis is often unrecognized and information on how to troubleshoot breastfeeding in this circumstance is limited. So this piece has information that I have gleaned from a few sources, my own OT background, and my recent experience with my son.

Product Review & Giveaway: Aimee's Babies DVDs

When I started making out my baby registries, and had one on amazon.com where the options were limitless, I decided to cast a wider net than the "standard" baby gifts. I have been interested in infant massage since my time in the NICU but not able to work out the time or money to go to a certification class. When I saw a massage video from an occupational therapist (one with a newly reactivated blog I had been following even) I decided to add it to my registry and try to learn a little about massage before I had my baby. Unfortunately, no one bought the DVD for me. However, I purchased the massage video for myself at a discount when the Aimee's Babies blog ran a promotion. Aimee then contacted me about reviewing the massage and developmental milestones DVDs on this blog.

My husband and I watched the videos together and collected our opinions on them. This way, we would have both an OT and layperson opinion.

The Baby Massage video is available as a DVD or digital download, and has a supplementary app also available. The video first briefly reviews infant development in motor and sensory systems. Aimee approaches the need for infant massage through a sensory integration perspective. After the introduction, she demonstrates performing the full body massage on an infant with description of her actions. She uses the Baby's First Massage method, which is intended for a typically developing child.

My husband and I both felt that the developmental section moved very quickly. While I was familiar with the information, he was less so, and would have benefitted from a slower pace. There was also some confusion because not all of what was referenced applied to newborns (which is what I think of when I hear 'babies') but also to the 6 months and up group. The developmental section would have benefitted from more of a multisensory learning method- listing out the developmental exercises that were being spoken about or just referred to through the pictures. Some senses, like position-in-space, were only briefly referred to and that confused my husband as well.

After the developmental section, we got to see the massage. I was happy to see that Aimee discussed specific contraindications to massage and referred to the general benefits of massage. I would have liked to see a brief discussion of the research that has been done on infant massage. Again, my husband and I felt the pacing was a little too quick. We will definitely need to watch the video again before trying the massage. My husband commented that it would have been nice to have this at the pace like an exercise video so that you could perform the massage on your baby at the same time.

Since I knew the benefits of infant massage before watching the video, I think I was more receptive to the overall concept than my husband. While there were a few parts of the massage that gave me the willies due to my own tactile defensiveness, I felt like the overall massage showed good face validity in light of what I already knew. My husband, in a phrase I never thought I would hear, said that he did not feel confident doing the massage on his baby because he still felt the baby would be a "porcelain doll" and was afraid it might hurt him. I think a larger reference to the research might have helped assuage his safety concerns.

Next, we watched the First Year Milestones DVD. Aimee described the purpose of this video to empower parents to be more vigilant about their child's development. She stressed that parents should not overreact to the exact timeframe of the milestone, but that they should be able to discuss what the baby can and cannot do with their physician and the importance of early intervention if there is a delay. The video was broken up well with menus to skip to the appropriate age range.

This video is considerably longer than the massage video, so I could only get my husband to watch the newborn section. This section again has a sensory processing base, and was primarily devoted to reflexes (which makes sense given the age of the child). The newborn section was very distracting to me because much of the video footage was done during a photo shoot, so there were repeated camera flashes. The audio and visual for this section could have been better coordinated as well. Watching this video before the infant massage would have been helpful since it was more in-depth than the developmental review in front of the massage video.

In the 3-12 month sections, this video really begins to shine. The skills Aimee discusses are really well illustrated in the videos of the different children. The developmental exercises that are discussed are pretty easy to do and Aimee gives suggestions for how to incorporate them into the day. I really appreciated that she gave a specific time range for tummy time at various points, because I have seen in my EI work that parents really have no idea how much time to shoot for (if they are aware that tummy time is necessary to start with). These sections were really well paced and developed and would be very beneficial to anyone looking to learn more about development. Some of the terminology may be a little over the head of a layperson but did accompany a video demonstration of whatever was being discussed.

My husband described the video as "very educational" and found the video footage of same-age babies to be helpful in understanding the developmental concepts. He stated that the video was helpful and made him feel more informed as a first time parent. He also mentioned that this was presented like a class, and might be good as part of a new parent class at a hospital or pediatrician's office.

I thought that the developmental video would actually even be helpful in a college level pediatrics class to illustrate the concepts discussed. We had photos and a day or two where we observed our instructor interacting with an infant, but a video would have been a valuable addition. The video would also be helpful for practitioners switching into pediatrics. With a little tweaking and adding footage of abnormal development, this video could be re-edited to really focus on educating OT professionals, but it is a valuable resource as is.

SUMMARY The Aimee's Babies DVDs would be helpful for new parents in learning more about development and appropriate ways to interact with your child. I think that the developmental DVD should be a prerequisite to learning the massage, so giving both together would be a good idea. Prices are comparable or better to similar products, so that shouldn't be a problem. I'm excited to see the future of the Aimee's Babies line, as she has announced plans for toddler and preschooler videos.

GIVEAWAY!! To help share the love during OT month, I will be sending out the Developmental Milestones DVD to one lucky winner chosen at random. This would be great for a student, new parent, or anyone interested in better understanding the first year of development. All you have to do to be eligible is Like the Occupational Therapy Notes Facebook Page before next Friday, April 26, at 10pm Eastern time. The winner will need to send me their address by 10am Monday morning or a new winner will be drawn- I'm having a baby and can't afford to wait around!

I got the Baby Massage video at a discount during an Aimee's Babies promotion, and received the Developmental Milestones video for free. All opinions are my own, except where my husband's are noted, and I was not compensated or influenced.

3.08.2013

Educational Resources for OTs working with Infants & Toddlers

I really like working in Early Intervention. Depending on how the state sets up the organization, an EI worker may find themselves pretty isolated with limited training opportunities for improvement. And if you're self-employed, you can't be dropping hundreds of dollars on continuing education classes that may or may not be beneficial. Here are some free online resources that can help the transition, as well as some other books that I have found helpful. (as always, I have no financial relationship with any service unless directly mentioned)

Zero to Three is the national page for infants and toddlers. They have podcasts in English and Spanish, policy based webinars, and free parent resources and guides. They also offer a professional journal ($78/year) with options to pay for CEUs and a yearly national conference.

Pathways.org provides a number of great visual and written resources for families and professionals. They have handouts on a/typical developmental comparisons and the importance of tummy time, among others. They have a free course and videos online to help professionals identify atypical development.

Virginia's early intervention system offers free archived webinars, online modules, and additional resources on their website. Check out their professional development center, and their informative blog articles. They even invite submissions from other authors, so this may be a way for you to expand your writing repertoire. This is one of the best state sites that I have found, but checking other states' pages may turn up many useful resources.

This Prenatal Drug Exposure Handbook(pdf) from a Michigan school district has been very helpful for me when discussing with parents what the potential sequelae of exposure are at different ages and start them with a list of practical tips for the child as an infant, toddler, and older child.

Feeding issues are so prevalent in the infant and toddler ages. One of the best sites that I have found is Your Kids Table, written by an OT with great sensory and behavioral strategies to try to broaden a child's diet.

Early Intervention Support offers many resources, mainly for parents on typical development and frequent issues with the 0-3 population.

Beyond Basic Play is a blog by a PT with great info on development as well as "tips and tricks" to facilitate certain developmental tasks such as catching a ball or moving between positions. Great basic tips to incorporate into practice.

Aimee's Babies is a site that I was not familiar with before. She is an OT who has re-initiated her blog and also sells DVDs and apps for parents to help their child's development. I haven't tried these out personally but they appear to have good face validity.

Info Spot for the Special Tot is run by an OT and mom and has lots of good information and resources on typical toddler issues.

The best book that I have bought has been Transdisciplinary Play-Based Intervention. I feel like this is a great resource for how to address the full scope of skills for infants and toddlers and gave a lot of good ideas on how to adapt activities. Some of this was information I knew or could reason out from school, but learning about ways to embed communication, emotional, and cognitive development was really valuable.

I'm really hoping that my upcoming course will be excellent. It was hard to spend the money knowing that I can count the course for state and national requirements but not for the EI service, but I know I need to get moving on some CEUs before the baby comes. I am really excited about it and excited to have an educational day at all. I am sad to miss my NBCOT and AOTA peeps and the great educational offerings that I usually get there. I truly am an OT Geek and like to learn new things. Please share any resources you have for working with infants and toddlers in the comments section- especially if they are free!

2.22.2013

OTNotes Greatest Hits Volume I: 2008-2012

As part of my blogiversary, I wanted to celebrate entries that have gotten lots of views, lots of comments, or that I felt were particularly good writing. I've tried to group these thematically to make for best reading. If there is an entry that you remember and isn't listed, or something you wanted to say about one of the pieces listed, please feel free to share your thoughts in the comments!

Entries for Students - I started this blog originally to help people in OT school, so it should be no surprise that I have lots of popular entries for students.

How to get into OT school

Writing goals -I need to update this since my approach has changed somewhat since I wrote it

Writing Sensory Goals

Case example with goals - This is an acute care joint replacement case

NBCOT study tips -please take note: this was written several years ago, has no info on simulation questions, and I cannot legally update it until 2014.
giving an inservice - should help you pick a topic and some basic presenting tips
searching for an OT job - short plug here, I have gotten 3 jobs from AOTA's OTJoblink. Consider it.
interviewing tips

the importance of asking questions

Acute Care - How many hours have I spent in the hospital? A lot. Sometimes people in this area are very reductionist, but there is a lot to learn and improve upon if you're an OT in acute care.

How to compile a relevant past medical history
prioritizing evaluations - a few different methods
Acute Care Tips and Tricks - some essential tips learned after many years
who gets to go home? - 3 short case studies of "similar" people who all discharged to different locations
Adventures in serial casting - this is a review of the research surrounding serial casting efficacy
Patterns - a couple of patterns observed in admissions based on weather and other external factors

Pediatric- I'm still getting my sea legs in the land of peds, but here are a couple of good entries. As I start to feel more confident, there will probably be an uptick in this category
Mat Man -maybe my favorite photo entry
infant toddler trauma awareness -a lot of really good information on trauma training
starting in Early Intervention: assessment -how I picked my EI assessment

Energy Conservation- this is a fondness of mine. At one point I had a whole EC series planned... may still do something along those lines sometime.
energy conservation in the summer
energy conservation for holidays

Professional Issues- Various issues that I think are relevant to the profession in an overarching way

collaboration with Girl Scouts - I really want to see a greater connection between OTs and Girl Scouts
Malcolm Gladwell thoughts - remember when Malcolm Gladwell's books were really popular? here are some of his ideas applied to OT
OT twitter chat - some advice on getting started in twitter chat, which I would definitely encourage. Check out #OTalk2US if you haven't yet
thoughts on a Glee episode -the OT connections mirror version of this got picked up by AOTA's 1 minute update and really exploded. People were very opinionated over this issue, or just the show.

Personal Issues: glimpses of my more inner life

struggling to be an ot for family
reading without getting carsick -there really should be more information online about how to accomplish this
unanticipated blessings related to presenting at conference

Uncategorized- some of the randomness that is truly me
chicken dance - a little inspirational story that showcases my favorite strategy- make a fool out of yourself.
OT quotes -these are not quotes from OTs, but more meant to be generally inspirational. I should have renamed this or actually found real OT quotes, but it is what it is.

podcast with AOTA presenter -I did my very first podcast!

aquatic exercises -specific treatments for aerobic pool exercises. I now do several of these myself since I am doing prenatal water exercises
metacognitive analysis- how I approach puzzles

I think this is a pretty good list and definitely shows that I have some seriously diverse interests that I've been writing about the past five years. I think that I will probably make this an annual event, and reflect back on the best posts of the year.

1.08.2013

A very NEW NEW NEW year

I won't say "New year, new me" but there are a lot of changes taking place in my life.

Job changes are so ever present in this blog. If you are a student, you should be comforted by the fact that there truly are SO many options for OTs, it's often true that you can work as much as you want. The only downside of this right now is that I am dreading tax time with 4 (I think?) W-2s and a 1099 with small business deductions... it's enough to make you hyperventilate. At any rate- my early intervention work is something that I really enjoy. I have families that I am close to, coordinators that respect my evals and opinions, and a burgeoning caseload. It has taken 6 months (and the willingness to be very flexible) but the business has grown well. I still have my occasional hospital days, where it is nice to switch up and work with adults (particularly neuro cases) but I mostly enjoy visiting with my friends. But now, I will have the option to cut back on both as I want to with the onset of a new job.

I will be starting (very very soon!) at an outpatient pediatric facility 2 days a week. I had seen the job posting on AOTA's OTJoblink (what is this, the third job I've taken from there?) but was still debating about applying when I was contacted directly from site about my interest and asked to interview. I didn't expect them to be able to provide regular hours at a rate that would offset losses without some kind of crazy demand to drive to multiple locations or covering other types of outpatients, but they well exceeded my expectations. I look forward to getting started there and am really pleased to find a pediatric practice even in my small town area.

The reduced schedule will help me maintain some of my other OT activities and provide time to rest. I've also been spoiled pretty much since my first job- if you don't work 5 days every week it's a lot easier to make doctor appointments, get your errands done, and keep from being overrun with laundry. Again, students! You can work as much as you want to- 0-7 days/week. I've said before that after our move, though I miss some features of Baltimore, that life was largely falling into place for my husband and I with the exception of my job. Hopefully this will be the last moving piece for awhile and things will be settled nicely.

I
~~did~~rocked my sprint triathlon last year and really enjoyed it! I had wanted to work up to an Olympic distance for the fall or summer of 2013 by the latest, and hoped to work to running a half marathon by this coming August. Now I've had to reset those goals and think about working back up to a 5K by this fall. I had also hoped to get a Girl Scout troop started at my church but the girls' interest was intermittent at best and I truthfully didn't want to be doing a lot of work when people didn't really want to be there. I still have a Sunday morning class but I'm getting ready to step back from that as well- I'm starting to feel a lot more effective with toddlers than teens.

My involvement with OT extracurriculars is changing too. I anticipate this will be my last year as the VP of Advocacy for the state OT association (provided I can induce someone into running for the position). I expect that I will still be involved in the bill review committee or other events, but I won't be the go-to person anymore. There aren't a terrible number of responsibilities and things to do with that job, but when they need done, they need done NOW. I had to step back from my NBCOT work this year, which is sad because it is a great group of intelligent people and work that I really enjoy (not to mention nice trips that are very fun also!). I plan to reapply as a volunteer in the future, but I will be missing my SQDC peeps. Possibly worst of all, though I love my AOTA presentation group like a little OT family, I will not be able to accompany them as their continued tour of awesomeness hits San Diego this spring. I will be very sad to miss seeing these great people who are spread both cross-country and internationally- and some of the #OTalk2US #OTalk and #occhat crew that are visiting from abroad.

(Before you get too teary on my behalf, remember that with all ebb there must be a flow, and that I just am not good at telling news sometimes so I put it all in a crazy order)

This is a lot of life changes all at once, and though they were planned in various degrees, it's all to accommodate the change that you can't really possibly plan enough for. I'm having a baby! He's coming (ready or not) this spring and the one thing I'm sure of is that no amount of preparation is really going to cover it. There's awe and anxiety and excitement and attempts to not get overwhelmed... and a lot of naps. Change is coming to my life in ways I know I cannot even begin to anticipate. But I think it will be worth it.

Lest you worry, faithful reader, I will be keeping the blog. It is fun for me and so while there may not be copious posts (when have there ever been?), there will be posts. There may be baby related posts... it is what it is. This month I am celebrating my 5 year blogiversary, doing my first big giant giveaways (they are AWESOME!) and hope to clean out my drafts list one way or another. I still tweet more than I write fully because it's been hard for me to carve out writing time with some of the other demands of life (5 eval calls in a week, hello) and if you want a (more) prompt response then you should tweet at @OTnotes.

Hope that you are having a wonderful, healthy, happy new year as well! Who can really say what it will bring, but I'm certainly looking through rosey glasses right now.

12.14.2012

Adventures in Scheduling

With all the crazy scheduling that is required as a therapist, you'd think they'd make you do logic puzzles as part of an entrance exam. Here are a few general thoughts on the mishaps inherent to scheduling. (this is a bit scattered since I'm still jet-lagged, so please forgive any dangling modifiers or unresolved thoughts)

First off, I think that there is this cultural norm of what a "workday" entails. If your parents worked non-medical white-collar jobs then you can probably identify with a 9-5 workday as we see in so many shows and movies (at least those that actually indicate that people WORK for a living, as opposed to being independently wealthy enough to just sit around and talk). Even in college, actual "working" time for me did not get up to 40 hours/week until the end of OT school (at which point we raced right on past 40 and never looked back). I know that there's tons of people out there doing simultaneous job and college, or 2 jobs regularly, all I can say is more power to you. But I had this expectation that a "normal job" would have normal hours and that the schedule would not be that bad.
I have realized that was complete BS.

This enlightenment took its time coming. On my phys/dys fieldworks, I had a hard time adjusting to a 7-330 schedule, especially with a nonexistent lunch that was dominated by meetings and paperwork. Despite that, people almost never left on time, needing to stay for one reason or another. It was frustrating as a student, waiting at the end of the day to get your notes signed and be told to have to redo them (now) when it was already past "quitting time." The woes of being a salaried employee- you will often work over the expected time.

Scheduling within your day is another insane proposition. In acute rehab, we had to work as a team to make sure (each day) that the client had their required time in all services, minimal time wasted sitting in the gym between services, at least one ADL per week, and so forth. In the hospital, coordinating cotreats was the biggest scheduling portion, and knowing that your whole day was likely to be derailed by patients going to tests and whatnot. The hazard of hospital work is ending up with a back-heavy day because not enough could get done in the morning. School scheduling had to work with the class schedule to make sure that they weren't being removed from important learning opportunities or special classes or being overbooked in a day. (We did pull-out services and I could not even conceive of how to schedule push-in during my year balancing so many different schools. I would love to hear experienced therapists' tips on that.) However good your schedule is, it is likely to get derailed by an IEP meeting or school assembly or lockdown drill. Outpatient scheduling might be assumed to be the easiest, but often you are dealing with people who need to be seen outside of their own working hours or school hours, so fitting in times can be tough.

I'm great at logic puzzles, but daily scheduling is a monumental frustration to me. One of the few beauties of being a prn employee is that I can just show up and do what is already assigned... and if the patient needs to schedule for their next time, I usually turf that to someone else.

Good coworkers will also adjust their schedules to help one another, even if it means balancing inpatient and outpatient work in the same day, or taking something difficult. But that is another thing that will wreck your schedule... and productivity if you have to track that.

My most common work now is as an independent EI contractor. I'm still trying to get into a good groove for getting the kids scheduled out right. Part of me doesn't want to over-analyze it because I don't have a huge caseload (yet?) or time demand, but my left brain would love to just have regular times for each kid each month. Evals have to be scheduled within 15 days of hearing about them, which is not really a lot of time to work people in if you do have a lot of other engagements... like holidays, which we have a few coming up.

Holidays are a whole issue all their own. Remember getting days off in school for holidays? And long Christmas breaks? That does tend to go out the window. Hospital and SNF people have to rotate through holiday coverage... when you start out, especially if you're young and childless, expect to work some of the biggies. I remember a boss telling me when I was interviewing that they paid so well for big holiday coverage (it was good- effectively 3x normal pay plus a PTO day to be used later) that they never had to force people to work major holidays. 6 months later, when those of us who were under 30 were all sitting there on Christmas day, I found those words to be particularly irritating.

Another fieldwork instructor would be laughing at the turn my life has taken. She had her own business, and I remember being aghast when told that we would be working on a major holiday. To student-me, I could not even conceptualize why you would be working on a national holiday. Well, now that I am mostly self-employed, I get it. I just scheduled a kid on a major holiday without even thinking twice. Major reasoning- I no longer get paid to take holidays... or paid regularly at all. If I have a "day off," it's just another day making no money whatsoever, and I've had plenty of those days for awhile.

Now with my EI kids I would like to schedule multiple visits in a day in a geographically sensible way, but it hasn't worked well yet. If I do a community outing, it's hard to say exactly how much time that will take, so planning the next visit can be tricky. Accounting for travel time is hard sometimes as well. But there's just the general Murphy's Law that comes into effect here also: the people who live near each other will have opposing personal requests, one will want morning and another will want evening; one can only do Thursdays and another Tuesdays; everyone will want 10am; on and on it goes.

Is there a moral to these scheduling woes? (is there anything logical written by someone whose personal time changes have zapped her ability to do anything but stare like a zombie?) I guess the overriding theme would be that you have to be flexible. No matter how nicely laid out your schedule is, it is likely that it could all go to pot anyway. No matter your personal preferences for workdays, if you want to get paid and your employer decides you're working weekends or holidays, that's what will happen. Until you go into business for yourself, and then you'll probably work those days anyway. And if you like the freedom of "set your own schedule" prn work, it's probably good if you have a backup income and a good budget.

12.07.2012

Photo Phriday- My Office(s)

So right now my work life is mainly Early Intervention as an independent contractor and prn work at a local hospital/outpatient center. It's a primarily self-employed, no-guarantees type of existence. Work gets done but much more differently than when I had a predictable schedule and landing zone. So here's a peek at the many offices of Cheryl.

I took this at the desk I was borrowing at the hospital. Depending on my schedule, sometimes I will stop in during the day or clock out and continue to enjoy a heated area to conduct business. (It's also nice to just be able to engage with people instead of hanging out alone!) I was able to borrow a printer, scissors, markers and glue to make these visual stimulation patterns for one of my kiddos.

I bought these (rather expensive) stamps when I thought there was a hope of getting back in the schools this year. The kids loved stamping their attendance sheets and I thought these would be a superb treat for them. These sit on my computer desk at home which only gets used when I have to type an eval or print something. Unfortunately there just haven't been many opportunities to use these and it seems a little self-aggrandizing to stamp a "terrific" on my own things.

The mobile office- e.g. front seat of my car! I spend more time in my car than probably anywhere else. It's depressing. You can tell that it's very well used... pictured includes the typical wallet, coat, lunchbox and clip board. But there's also the cat toys for multisensory play, straws and applesauce for sensory sucking, and a Child Guide magazine buried in there.

Here I am in my most used spot on the living room floor, making some weighted objects for the kiddos using beans and a pair of girls' tights. In retrospect, I definitely should have thrown a pantyhose in there before the beans and maybe double socked, but they should serve their purpose and I needed to be quick. Cameo appearance by my trusty lapdesk, holding the lappy I most often use. Working wear is what you make it... including Halloween shirts in November and sweat pants from high school.

Speaking of working wear, this lab coat has been hiding in my closet since 2006. You can still see the original folds from the factory! I wore it for the pinning ceremony, used it to store a couple of pins I probably would have lost by now, but otherwise have not even thought of wearing it once. It's also not even close to being the correct size so I am not sure it would look professional if I actually did put it on. Does anyone else have a hiding coat? Or are there mythical people at top of the line facilities that wear them and aren't constantly confused with doctors? I would be interested to know.

11.21.2012

10 Minute Tuesday- Intro and cell phones

I am going to start my new feature, which may dribble a bit in the holiday time but I want to make it regular in 2013. This involves me writing for 10 minutes and topic switches are permitted- anything to get the post written!

Obviously I missed getting this done on Tuesday but I essentially worked 13.5 hours and was nothing short of exhausted. Did inpatient hospital in the morning, outpatient in the afternoon, and an early intervention client late that evening. It's funny to see sensory overload sometimes, I came home and my husband wanted to talk to me about a video he was watching at the same time that there was something on the TV and I just had to tell him to choose. I could not possibly focus on all that when all I really wanted to do was get in a fetal position and sleep for 20 hours.

Sad that I missed today's #occhat which appears to be on adaptive equipment use and practices when issuing equipment. I have lots of thoughts on that and have posted before, may need to do another after reading their grabchat. I also have interesting really old-school AE pictures from when my mom was in school to do voc rehab. It's neat to me to see how people used to make certain things, and some of them have completely gone out of vogue but would still be useful. The copyrights are expired on most of them so I will have to scan in some pictures if people are interested.

OK my main topic was going to be cell phones, and how essential they really are in today's world and especially my OT practice. I seriously cannot imagine doing my early intervention job without my phone. For today' client alone, I was able to do the following:

- text to confirm the appointment before driving there

- access my master file of client names and addresses

- get directions and navigation from an unfamiliar starting point

- show an app that would be helpful to the family's goals

Seriously, without my phone, I would have had to use my rolodex to get their number, just leave a message on their machine and hope they'd be home when I got there, have to add in an extra 25+ minutes to get back on my familiar route, and spend a lot of time making equipment by hand. I have also used my phone to show a picture of a toy that would be helpful, and in the school system it was so crucial to get a picture of hand function for the evaluation. That's barely scratching the surface of what it is capable of, but I really couldn't do without it in practice.

Time's up! Hope you enjoyed this post and that I'll be able to keep up the pattern.

11.10.2012

Trauma Awareness for the Infant/Toddler Population

I recently attended our state conference and there was a standout session by Marcella Jacobs of the Kennedy Krieger Institute on OT and Trauma Training for Infants and Toddlers. It was very informative and thought provoking, so I've decided to share some of the things that I learned from that session. Warning, there are some sad references in this post, because of the types of trauma that infants and toddlers incur.

First off, she brought up a point that maybe some will find as common knowledge but I think is important to reiterate. If you move into a specialized OT role (though we all interact with children of trauma, knowingly or not), or a position that is not traditionally filled by an OT, you are going to have to look outside the OT CE box to learn new and relevant things. So to become a trauma-aware OT practitioner, she looked to courses offered mainly to psychologists and other groups that would apply to her OT life. Something to think about when planning your professional development.

As someone who has spent so much time in the phys-dys hospital world, "trauma" usually means multiple orthopedic injuries with potential (possibly undiagnosed) neuro injuries. Obviously, this isn't the same in pediatrics. Trauma to an infant or toddler can be any experience(s) that cause continued autonomic nervous system activation which changes the chemistry and constructs of the developing brain. So while that can be physical, such as shaken baby syndrome, it can also be chemical, such as prenatal drug use, or emotional, in the case of abuse. Other potential causes of trauma include neglect, hospitalization, or disaster. Being placed in foster care and having a continual rotation of caregivers and "siblings" can also be traumatic.

Brain scans show that compared to a person who did not have a traumatic experience, a person s/p trauma may have less activity in the fronto-temporal regions. This includes a less active parietal lobe which can lead to decreased speech. Occipital lobe activity is increased, which is sometimes seen in a child's hypervigilance.

Children with disabilities are at an increased rate for abuse and neglect, so it is likely that OTs will encounter children who have gone through or are going through a traumatic situation. I remember an upper-elem student that I worked with who was very verbal about the effect that his disability had on his family life- his deep sadness at not having his parents around was continually heartbreaking to me. And truthfully, if you are worried that your parent might not come back for their next scheduled visit or whether a complication of a condition you barely understand will land you in the hospital tomorrow, how can you really be ready to learn and grow?

I had not heard of the term "PURPLE crying" before, let alone knew that it was a normal baby phase. But when this was discussed it was clear that this would be a time when abuse would increase. Personally, this was incredibly intimidating and terrifying to me as a person who does not have children yet, but by having the information, new parents are more prepared for this time period. The aftereffects of shaken baby syndrome are just horrendous... I may never forget the faces of the toddlers and older school children I saw who had survived, and the EI team was absolutely inconsolable after a child died from this.
PURPLE Acronym

I had also not heard of the ACE study, which looks at the effect of 'adverse childhood experiences.' The ACE score is from 0-10 and measures exposure to traumatic experiences in the first 18 years of a person's life. There are multiple studies that have shown an increased risk for adverse health behaviors (smoking, drugs, alcohol use), heart disease, suicide attempts, development of depression, cognitive impairment, and early death. Again, these questions make me think of the kids I saw in the school system some of whom had such varied awful life experiences.
The ACE Study Pyramid illustrates how childhood adversity leads to early death.

The ACE Study Pyramid illustrates how childhood adversity leads to early death.

There are numerous signs/symptoms of trauma in infants and toddlers. Withdrawal can be common, and OTs may also notice decreased purposeful play, sensory processing differences, and uneven development/splinter skills. There are many invisible symptoms as well which have major effects in a child's life. This includes decreased growth hormone, decreased development of mirror neurons, decreased brain size and development, and decreased serotonin.

OK, this has been intensely depressing so far to write up. And it may have been that way for you to read. If you've made it this far, you deserve a reward, and if it's been making you sad you may need to inflate those endorphins through exercise or finding a way to think happy thoughts. (chocolate? cat videos?) Not trying to make light of the situation, but having ways to deal with the stress you're exposed to as an OT is imperative to prevent burnout. I think that this was one of the reasons that I couldn't tolerate ICU rotations well.

Finally, the good stuff! Some treatment ideas! These are more directly from the presentation but I am going to share them because I think that it is a difficult resource to get. The CDC states that the most effective treatment model for infants and toddlers is to promote parent/child attachment. This is directly in line with the early intervention model of empowering parents to improve their child's development. Research shows that music followed by tactile input is the most effective treatment. Ms Jacobs recommended using both a sensory integrative and trauma informed treatment approach. Helpful tips included making sure to decrease the stress response before doing anything else; being mindful of your own nonverbal cues including eye contact and touching; avoiding teasing and sarcasm; and being consistent and kind.

Parents, definitely consult with your therapist before trying any treatments, anything listed here is considered to be tried at your own risk. I have listed some suggestions that were offered by Ms Jacobs.
Gentle tactile stimulation through grooming and play
Calming music (Vibrational healing sounds were suggested) and performing typical preschool songs with motions
Swaddling and infant massage (if you are trained)
Cooperative games between child and parent- ball games, rapper snappers
Consider deep pressure activities such as weighted blanket or body glove with both parent and child (again, only with therapist supervision! Don't put weights on your kid!)

It's horrible that any child is exposed to trauma, but with proper training and intervention, there is a way for OT to make a difference to these families.

This was a terrific presentation and I'm happy to be able to share some of Ms Jacobs' awesome insights with you.

Further Resources:
National Child Traumatic Stress Network: tons of great resources especially for those in schools
CDC resources on Child Maltreatment
Child Trauma Academy: has free online trainings
You can also email the presenter Marcella Jacobs if you have direct questions

10.19.2012

Photo Phriday: Mostly Cheap Kids Stuff

Welcome back, photo viewers! Since we last met, football season is in full swing, I've had an NBCOT trip to Chicago, and my EI work has been picking up a bit. Today's theme is about therapy-type things for kids. I loved my school job last year, and was so fortunate that they had tons of terrific supplies for us to use with the kids, but I know that in many places school system and EI therapists are going on their own dime. It's no secret that I outfitted my EI kit with items from yard sales, which can be a great resource but uneven in findings. Here are some items that I found that are either cheap or sparked cheap ideas.

OK, we lead with the big guns. This is the not cheap one. This toy is called "Q-Bitz" and is available from MindWare for $25. It reminds me of an IQ test... you flip your cubes to match a design on the card, racing a friend at the same time. I think this would have been too high level for my caseload, but it would probably be a great release for a child with high functioning autism and good visual skills. If you wanted to grade it down and keep a visual challenge, you could easily make 8 square cards with the given designs, take pictures of them, and have the kids match the cards to the pictures.

Sometimes people think they have to spend big bucks to get worthwhile toys for their kids, and everything with the word 'baby' has a 20% markup. The popular version of the stacker now makes a sound with each ring inserted and sings a song when complete, but it can be financially prohibitive for some families or practitioners. But I found this pack of sorting size/shape toys at Big Lots for about $10.

The cheapest source of ideas nowadays is that series of tubes, the internets. With the rise of homeschooling and internet sharing, some great resources have come to light. File Folder Fun is one such site designed for teachers to create compact stations. Our district had a big focus on early literacy, and so when that could be incorporated into OT sessions, all the better. Pictured here are Candy Cane Color Match, Snowman Compound Words, Spaceship Rhyming, and Sunflower Sight Words. Also pictured in the background are hidden pictures from Highlights- also free and a great visual search activity.

If it's a good learning toy and can fit in a baggie, it's that much better. More items from File Folder Fun here (pumpkin words or not; cupcake size sort; past or presents; rock shape match; broken hearts) along with popsicle stick puzzles and Mat Man parts. The trees are part of a sequencing activity and I copied that from a teacher resource magazine- many teachers have huge collections of these if you have free time to go through them.

So this isn't kid-related necessarily... or is it? Just a helpful hint that if you're taking notes, it should probably be enough that you know what the heck you were talking about. I presume these are book pages, but what book? what subject? what year did I write this? Obviously it was a large and seemingly useful book, but no clue from there. cookbook? no clue.

8.09.2012

Getting Started in Early Intervention: Assessment

I have recently been able to get started an early intervention system, providing OT to families in their homes and communities. It definitely required a lot of paperwork to get started, but there was also a need for mental preparation and acquiring tools. Though my school system job involved using IFSPs, I was providing services in a preschool and had (ample!) materials provided. Here are some resources that I used in preparing to perform OT assessments and treatment in an early intervention setting.

I reviewed a number of assessments when I was trying to decide what to buy. Some were seriously outdated or limited the areas assessed. I wasn't able to consider others because they were made to be a true team assessment, which is true of the TBPA. While I can't speak to the practicality of using the assessment as a team arena approach, I do want to discuss the intervention book. So often, the intervention books that come with assessments are rather worthless. This is a book that I want to add into my own collection. The intervention book has many strategies to increase skills in all domains and adaptations for performance factor limitations. I think it would be helpful to anyone in early intervention because it gives you information from a multidisciplinary point of view, so it had info that I had not previously been exposed to.

After looking at multiple assessments (which had to be on an approved list), I decided to purchase the ELAP. The fact that I needed to be able to assess all domains of development, not just motor or adaptive, was a heavy factor in this decision. Also, I needed to keep costs low and the manuals and scoresheets for the test were very reasonably priced and the kit can be assembled in a non standard manner. This is a criterion referenced test which allows you to figure out an approximate age. I have friends who use the EIDP, which is even lower in cost, but I was a little worried that I wouldn't see enough during the test to get a good assessment. I also decided later to purchase an infant-toddler sensory profile (the SPM-P is not approved in my state, so it is the only sensory measure).

This picture shows some of the materials I was able to get for my testing kit. Many of the items came from yard sales or discount stores. I have always loved the pipsqueaks markers, so they were a must-have item for me. I liked the tactile puzzles we had at school so I felt fortunate to find one for sale. I found a surprising number of high quality wooden beads and blocks for cheap, which I was super happy about. The orb over on the right has spinning lights and I got it for a quarter... it is going to be a favorite toy. I need more things that make noise for kiddos with visual impairments, but the squeaky toy I got (in the pet section) is super responsive and loud, so it will do for now. Not pictured, but worth a mention is the formboard puzzle I got from Manzanita Kids on etsy. They were very responsive to my custom order, made it with high contrast materials as requested, and it is a very high quality piece.

Other Resources:
What to Expect from an EI eval- from the dual perspective of therapist and parent

Abby's blog has been featuring parent interviews which includes tips they'd like therapists to know

Occupational Therapy Notes

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