​BY JAYMIE MERRY

As an OT working in a sensory integrative clinic, I am working with clients who are having difficulties with regulation (including arousal level, sleep, bowel/bladder, and breath challenges), sensory defensiveness, emotional regulation (anxiety, inflexibility, anger, aggression), motor coordination, feeding, and social skills, among others. Each client comes with so many questions. Where are these challenges coming from? How deep do they go? When did they start? Can I really treat all the way back to the root of the issue? And if I can, can that support these children to make real, lasting, and deep changes with greater efficiency?

As OTs, we are all on a journey. My journey took a turn for me at the Camp Avanti Pre-Camp Conference in 2017, when Patti Oetter and Irene Ingram challenged us to be thinking about how far back we really can treat. They introduced their Advanced Intervention Model (AIM) for early developmental etiologies. They taught us about a model of development that begins at conception, teaching about the innate mechanisms that are in place in typical development that assist a child to move all the way up to skill. They also taught us about when something happens that interferes with the developmental process during this early time, such as trauma, stress during pregnancy, cord wrap issues, drugs, induced labor, emergency C-section, prematurity, and embryonic development issues, the trajectory of that child’s development could potentially shift and may be playing a role in the issues we are seeing as pediatric occupational therapists.

I now had a framework to begin thinking about the true roots of the issues I was seeing with the clients on my caseload. So I started looking at my client’s histories. I began asking questions. I began observing with more precision. And I began experiments and playing with some of the concepts and strategies I learned with my kids and families. Using rhythm, vestibular, relationship, movement patterns, and this developmental framework, we could go back to the point in development where something went awry and provide a more organized experience of what those early life experiences could have been and create new, more efficient patterns at the most foundational level, from the bottom up.
For a child who did not get enough movement in the womb due to bed rest, we could use drumming, rhythm, and lycra to create the vestibular, deep pressure, rhythmic, floating atmosphere of the womb. A child who was born wrapped up in the umbilical cord could be wrapped in a lycra tunnel and empowered to unwrap himself with the motor patterns he was not able to use the first time around. And a child who was not in full control of their birth (due to a C-section or induction), could wiggle out of a lycra tunnel or from in between two crash pads with control and competence. With the right combination of factors, it is amazing to see how kids will start to heal themselves, teaching us so much along the way.

And then to see the real results of these interventions! Anxiety turning into confidence. A need for control turning into more flexibility. Anger turning into joy. Frustration turning into kid power. Sometimes results would happen right away. Sometimes it took a while. But hey, I’m still learning. I am so excited to continue playing with these concepts and strategies and learning along the way. My perspective on treatment is shifting, my practice is becoming more refined, and my kids are becoming more and more who they are meant to be.  

Patricia Oetter and Irene Ingram will be presenting Advanced Intervention Model (AIM) for Early Developmental Etiologies at the 5th RAIR Symposium.

1. High Quality Continuing Education - Meaningful, Substantive Content
            Why spend your CE dollars on theoretical information you already know or short webinars that don’t provide enough information to change your practice skills? You will learn new information and practice new skills at the RAIR Symposium.

2. Top Instructors
     RAIR Symposium speakers have years of clinical and teaching experience, are often internationally renowned, and frequently have publications and research to their credit. They offer extensive clinical perspectives from their own practical and often very original work. You will have the opportunity to interact with speakers while getting questions answered and engaging in timely discussions.

Family Speech & Therapy Services is proud to have initiated employer-sponsored, group conference attendance to the Richter Air Symposium.  

At Family Speech & Therapy Services, investment in our therapists is one of our top priorities.  That is why we have partnered with the Richter Air Symposium to develop employer-sponsored, group conference attendance.  As part of our commitment to professional growth and development and our focus on group learning experiences, we will now be offering group conference attendance to all benefit-eligible therapists. Because of our efforts, other employers can choose to offer the same benefits for their staff - benefiting our entire, professional community!

Family Speech & Therapy Services recognizes the Richter Air Symposium as the premier pediatric conference in our area.  We believe that this symposium offers our therapists a unique opportunity to advance their knowledge, improve their clinical skills and gain exciting new treatment ideas alongside their colleagues.

Family Speech & Therapy Services offers outpatient, pediatric, speech-language therapy, occupational therapy and feeding therapy at our 3 clinic locations in Andover, Otsego and Edina. Additionally, we provide contracted services to schools throughout the metro area for both short and long term placements.  You can learn more about our clinic by visiting our website and blog at http://familyspeech.com or by visiting our exhibit table at the RAIR Symposium.

Diane Bahr, MS, CCC-SLP, CIMI will be presenting on February 25, 2016 at the RAIR SYMPOSIUM. If you would like to get a feel for Diane’s work, here are links to her recent articles for Kids in the House and Dysphagia Café. Click on the links below to see these articles.
 
What Every Parent Needs to Know about Mouth Development from Birth: What Can Go Wrong and Why
Newborn and Early Mouth Development
 
Here are also four recent radio interviews by Diane. Click on the links to read them, print them, or listen to them.
 
Feeding 101: What Baby Food Jars Don’t Tell You (AKA: What do parents need to know when feeding their children from birth to 12-months of age?)

​Sippy Cups, Bottles, and Straws – Oh My! Feeding 201 (AKA: What do parents need to know when feeding their children from 12 to 24-months of age?)

Get That Mouth in Shape: The Scoop on Pacifiers, Thumb-Sucking, & Mouth Toys (AKA: How do you keep your child’s mouth in shape from birth?)

Teething and Drooling: What Every Parent Should Know (AKA: What should every parent know about teething and drooling?)
 

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The 3rd RAIR Symposium has Continuing Education to answer them.

What is a good approach to organizing treatment sessions for children with SPD and/or ADHD? 
Check out Session A: Enhancing SI Perspectives for Assessment and Treatment: The Art of Clinical Reasoning. Instructor Stacey Szklut has vast experience and shares some helpful strategies for "putting it all together" for best outcomes.

If you have lots of experience and background, you may want to attend Session E: The TARGET with Patricia Oetter. Her format allows the clinician to organize and prioritize treatment options.

How does respiration impact function and what can be done about it in treatment?
There are 2 powerful sessions that address various aspects of respiratory function and treatment. Session F: Treating the Head and Neck with Irene Ingram considers the importance of establishing full respiratory function to improve sensory motor development of the head and neck.

Session J with Deanna Wanzek: Air is Good! Deals directly with intervention for dysfunctional respiratory patterns concomitant with a variety of diagnoses.

How can we as OTs help those in the educational system understand how sensory difficulties impact school performance and how occupational therapy can demonstrate improvement in sensory processing?
Session B with Renee Okoye will describe clinical methods for evaluating and documenting sensory performance in the academic setting.

​Session I offers strategies for improving handwriting skills by implementing and synthesizing various sensory and motor interventions.

How can we help parents and others prevent oral motor problems before they disrupt development?
Speech therapist Diane Bahr will be offering a wealth of information to identify the signs of potential oral motor difficulties and ways to intervene to avoid them.

Are there any strategies to develop coordination in students with sensory motor delays? 
Session D with Nikki Rosen will cover a variety of treatment approaches to address gross and fine coordination

Michele Parkins, MS, OTR and Carrie Davis, MS, OTR - presenters of Session I: Learn and Move Together to the Sights and Sounds of Writing - contributed this blog post on the importance of handwriting.

Handwriting is not as old-fashioned as you think! Certainly keyboarding is an important skill, as technology has become a part of our everyday lives. But, did you know that writing by hand, though slower than typing, has benefits over typing?
 
Multiple studies have shown that children learn and remember more when they write by hand (versus typing on a keyboard or other electronic device).  Early literacy skills such as spelling, word recognition, phonemic awareness, meaning, language, letter names, idea generation, and the actual reading of words are all facilitated by handwriting.  Handwriting practice also increases brain activation to facilitate performance across all academic subjects, provides a foundation for higher-order skills, and influences language and critical thinking. 

Engage your clients in handwriting practice and make a difference in all of these functional areas!
 
For references: http://www.connectexperiencewrite.com/references.htm

Michele Parkins MS, OTR & Carrie Davis MS, OTR
Co-founders of Connect Experience Write, a developmental handwriting program using music and movement to teach pre-writing skills and letter formation connectexperiencewrite.com

Stacey Szklut MS, OTR/L, presenting Session A - Enhancing Sensory Integration Perspectives for Intervention: The Art of Clinical Reasoning contributed this piece on sensory diet.

The term diet often conjures up a visual image of someone who is overweight, or elicits a visceral reaction about our own state of ‘weightiness’.  But a sensory diet is fun, natural, intuitive, and incredibly useful!  It consists of sensory based strategies used throughout the day, often unconsciously, that help us maintain a calm and organized state, encourage attention and focus, and support our ability to fall asleep and wake up without difficulty.  Although the terminology may be new to you rest assured that you already have a variety of sensory strategies in place.  

• When you wake up in the morning the strong smell and taste of that cup of coffee begins to alert you well before the caffeine hits your blood stream. 
  
• Turning out lights and climbing under a nice warm quilt encourages sleep. 
  
• The next time you are at a meeting notice the strategies people are using to stay focused and attentive. 
  
  • How many have legs or arms crossed, or are resting their chin on their hands?  These strategies provide our body with touch pressure that is calming and organizing (like a hug, massage or a warm bath). 
    
  • Who is drinking from a cup or water bottle, or eating a chewy snack?  Exercise to our mouth is one of the most powerful sensory tools.  
    
• Speaking of exercise, this is considered the panacea by sensory experts like myself.  Regardless of whether you are tired and lethargic or stressed and anxious a little exercise can help you feel more grounded and organized, even if you just stand up from your desk and stretch for a minute.

It is extremely important for children to use sensory organizers throughout the day, especially when needing to sit and focus at school. Simple strategies like crunchy snacks, water bottles and movement breaks encourage more optimal learning.  Many children we see at South Shore Therapies need stronger and more frequent sensory strategies to focus, stay calm and organized.  
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Stacey Szklut MS, OTR/L is owner and Executive Director of South Shore Therapies in Weymouth and Pembroke. Ms. Szklut is nationally known speaker and frequently contributes articles and book chapters for professional magazine and college text books.  Visit her website at www.southshoretherapies.com.

Did you know?
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1. Your breathing pattern has an impact on your nervous system.  The impact can be positive with a proper breathing pattern.  (Abdominal distension, 3-D lower rib cage expansion followed by apical filling)  With a proper breathing pattern, your exhale is longer than your inhale and this drives the autonomic nervous system into a parasympathetic state.  This then allows you to focus, stay calm and relaxed.  For children and adults alike, this state allows work to get done.    If your breathing pattern is poor (example—breath holding, using accessory muscles excessively) the ANS can be driven into a parasympathetic state with a “fight or flight” response.  This is a tough state in which to be productive.
2. Your breathing pattern has an impact on you circulation.   You know that blood flow to the tissues is important for healing.  Breathing can affect circulation via the ANS.  If the sympathetic nervous system is stimulated via your breathing pattern, the blood vessels are constricted.  If the parasympathetic nervous system is stimulated, vasodilatation of the vessels occurs increasing the blood flow to the tissues.
3. Your breathing pattern has an impact on how efficiently you use your musculoskeletal system.  The muscles of respiration have a dual purpose—respiration and postural stability.  With the contraction of the respiratory diaphragm upon inhalation, an increase in intra abdominal pressure occurs.  This action is important for several musculoskeletal relationships.  It provides passive stability to the “core” of the body allowing other muscles to be able to take a “break”.   The muscles that might need a break are the cervical muscles, the paraspinal muscles or the pelvic floor muscles.  When the diaphragm relaxes, the abdominal muscles engage and contract providing active stability.   Therefore, a proper breathing pattern is very instrumental in facilitating core stability.  In turn, core stability is needed for the production of efficient movement.  Research is bearing out that the transverse abdominus contracts before the deltoid when doing an arm movement.   An efficient breathing pattern is also being linked to pelvic floor health and in turn to bowel and bladder function. 

 
 
The workshop “Air is Good” will focus on assessing breathing patterns and strategies to improve a poor breathing pattern.  Prior to attending the workshop it would be very helpful for you to review the anatomy of the respiratory system and chest development.

​Would you see this kid as a neck issue kid? Learn how to treat these in the upcoming course at the 3rd RAIR Symposium. This young man had an undetected cranial base compression.  He was referred due to biting his lower lip most of the time and having articulation problems.  The problems were easily corrected and core issues addressed after treating his neck compression. The action picture demonstrates the child using ORAL CORE exercises for gaining head, neck, core, oral control as a team. Starting things over to get all systems in sync is most efficient.

The TARGET is a comprehensive format for collecting and organizing assessment data from tests, observations, histories and questionnaires.  This format helps the therapist see the relationships between original concerns and underlying causes, prioritize areas that need addressing in treatment and plan the sequence of treatment. Goals can then be generated together and progress tracked together.  The TARGET is composed of 4 pages, each of which is a category of like areas of function. They are titled:

• Page 1 is Modulation
• Page 2 is Postural Development and Outcomes
• Page 3 is Learning how to Learn and Remember 
• Page 4 is Integrated Brain Activity, Emergent Processes and End Products.
  

The following case demonstrates issues and concerns on all 4 pages and reflects the assessment and treatment planning outcomes.

Case Example
E is a 6.9 year old beautiful little girl with a smile on her face most of the time.  Her history includes an unremarkable pregnancy and delivery at term.  There were no major issues other than difficulty attaching to and remaining attached to the breast.  This was reportedly difficult until she weaned herself at 8 months and switched to a sippee cup. No particular problems were noted until her preschool teachers told the parents they had some concerns about her language organization and some speech concerns.  They also noted her motor skills were a bit awkward and she avoided the slide, climber and swings on the playground.  Peer interaction was minimal (her preference was to play or sit in class by herself) but all thought that was because of her speech and language issues.
By the first grade these concerns remained and an OT consult was recommended which was followed by assessment and recommendation for a treatment intensive.  A speech and language evaluation was also recommended and she began receiving services about the same time an OT intensive was scheduled.