Wednesday, December 10, 2008
His parents had him on a low-dose medication and were not certain about what to do next. I suggested going back to his doctor for a new approach. The boy was given an increase in his meds dosage, and finally, he was able to focus. His OCD settled down enough to do the more powerful interventions in my toolkit (IM and sound therapy), and now we are off and running again. We've been making incredible progress with social skills, modulation and play skills. Hooray!
I think that meds are a God-send for certain children. For my small buddy, it's the difference between running in circles much of the day versus significant interaction with adults and peers.
Will he be on them forever? Can't say, of course. I truly hope that he gets a reduction of symptoms with the next round of therapy ... and then maybe meds can be revisited.
Thursday, November 20, 2008
One thing that Samonas has that others do not, is a series of disks (the CQ series) that can be played over stereo speakers. One of my colleagues uses them in the school setting with her kids once per week and sees gains.
Another feature I like is even more important. The Samonas people will tell you all about the high quality music recorded in pristine settings by joyful musicians.... that's important, but even more so is the feature of web-based monitoring. After clients get their listening CD, they log into a web site every day or so and provide a rating of how it's going. Based on that day's feedback, they are told how many minutes to listen the next day.
To understand why this is important one needs to know that with some other programs, therapists give the one-size-fits-all instruction: 30 minutes, twice per day. There is no room for nuance here. It belies the fact that these therapies truly are powerful, and for people who are sensitive (typically, the people who need them), they can have powerful effects. I have seen adults and children have unwanted emotional reactions at inoportune times.
One can use the Samonas disks without the web log-in. I like the fact, that therapists are being instructed in how to grade auditory therapy ... just as they currently grade their other therapies.
Levels of Intensity
Finally, there are many levels of intensity in the Samonas program. A therapist finds out what level to start a client at by giving them the intro (A.R.T.) CD and monitoring the effects using web-based reporting. Once the client is matched to an intensity level, listening disks are chosen.
There are a myriad of other features, and more to come. I am impressed with the program, and confident that it will serve my clients well.
Keith is an 11 year old boy with developmental delays of uncertain origin. He was raised until the age of 4 in a home with alcohol and drug abuse as well as domestic violence. Keith’s head shows scars from serious head injuries from his early years. He was eventually removed from his birth home and provided a safe, loving home with relatives who became his legal parents. Once in school, Keith struggled in regular education classes. School Testing at the age of 9 years 6 months had shown that he was 2-4 years behind on visual motor, visual perception and motor coordination skills (Beery-Buktenica Test of Visual Motor Integration). He was provided extra help by a classroom aide, but did not qualify for supplemental services such as occupational therapy.
When Keith walked in the door for his OT evaluation at age 11, he had the look of a puppy who has been mistreated. He walked slowly, with slouched shoulders and shuffled gait. When he spoke, his words were barely audible. Dried blood on his very short fingernails showed that he had the habit of biting his nails down into the skin. He demonstrated a poor pincer grasp, weak grip and poor strength. He was unable to lift a plastic chair to move it closer to the table. Keith’s mother said that he was unable to don shoes or socks or dress himself, and showed little initiative for play or social interactions.
When asked to jump on the trampoline, he sat in the middle and mumbled, “I can’t”. He was encouraged to try, and jumped 1” high, 10 times. Clinical observations showed that he had poor tone overall, poor strength, good reflexes, and poor coordination. An informal handwriting test showed poorly formed poorly spaced letters. The Sensory Profile indicated a definite difference from peers in the areas of auditory and vestibular processing.
Keith’s first sessions were child-directed and sensory-based as a way of providing motivation. Within 2-3 sessions, Interactive Metronome (IM) was introduced. He was unable to identify a beat, and so hand-over-hand and patty cake methods were used exclusively for 4-6 sessions, and as-needed, thereafter. Keith was allowed to sit on a therapy ball. Although he bounced on the ball while clapping, making the task harder, it provided him with stimulation and he was better able to attend to the rhythms. Keith received IM 1-2 times per week for approximately 3 months mixed-in with sensory integration (primarily vestibular and proprioception) and ADL interventions.
Keith’s progress was dramatic. Within a few weeks, his mother told me, “The boy who came in here for the evaluation 2 months ago no longer exists.” Her son now begged her to go to the park to play. He attempted social interactions. He was attempting to dress, bathe and groom himself. During the fourth month of therapy, IM was still incorporated into therapy. Keith performed 200-500 repetitions prior to ADL and handwriting interventions to increase motivation for those tasks. He made tremendous progress with initiative, ADLs, sensory processing, social skills and confidence. Keith developed a good pincer grasp and was able to fully dress himself including buttoning a dress shirt. He still had difficulty with tying shoes. He had made very good progress in bathing and grooming, in that he could perform the tasks, but sometimes did an incomplete job. Keith’s sensory motor skills were noticeably improved. He gained an intuitive sense of what his body seemed to need and requested suitable activities both in the gym and at home. Often, those activities included vestibular and proprioceptive components and so he was learning to satisfy his sensory input needs, as well. The activity and play made him stronger, and his grip improved so that he could help move equipment in the gym. His confidence improved to the degree that he was able to initiate social interaction with other children in the clinic, and he relished playing with them.
Mark is a 12 year old boy with high functioning autism who returned to occupational therapy after a break of several years. Although Mark was doing well in school, he was unable to fully dress himself or bathe himself. In terms of neuromuscular control, Mark had poor overall tone, poor postural control, and significant motor planning issues. He walked with a very wide gait (total deviation of 80 degrees), had poor handwriting, and lacked the ability to plan and execute movements with his arms and hands that would allow him to reach the top of his head and flex his fingers to wash his hair. In addition, he chewed his food in the front of his mouth and for this reason preferred a soft foods diet. Mark’s social skills were quite limited. He rarely looked at others while speaking and limited his conversations to single words.
Given the range of problems Mark faced, it was decided that a course of Interactive Metronome (IM) would reduce the time in therapy. Mark did IM twice per week for 30 minute sessions. He started each session with a few minutes in the ball pit to help him relax and self-organize. He then did 10 minutes of IM, took a short break on a swing or trampoline and then a final 10 minutes of IM. As his skills improved (and he moved to phase 4 of the IM program), he did 20 minutes of IM and then practiced dressing skills or handwriting.
Progress with IM
The program of IM had profound effects on Mark. He developed a self-awareness and motivation that led to greater independence. First, he figured out how to regulate the shower temperature. Next, he tried to wash his hair on his own, although he still lacked the correct motor-planning for that task. He took an interest in outside activities and began to talk about what he did. He displayed a good sense of humor. He saw gains in motor planning and postural control. He learned to dress himself entirely with the exception of buttoning pants at the waist and tying shoes. He learned to chew with his whole mouth. His wide stance improved, so that his feet were better aligned by 5-10 degrees.
After 19,000 repetitions, therapy took a new direction. It was time for Mark to learn a variety of new skills through exercise and repetition. Mark was aware and motivated, but with his new sense of humor, he was also very playful. It was difficult to keep him on task to perform the more difficult work of exercising his body to make additional gains. For example, when asked to lay over a therapy ball to work on posture, he would fall off the ball and roll on the floor and giggle. When asked to pretend to wash his hair by moving his hands together on top of his head, he would pat the sides of his head with extended fingers, as if to say, “there, all done.”
Core:Tx proved to be the solution for getting him to perform exercises correctly. Its game-like nature engaged him, and he paid attention to the instructions rather than acting-out with silly behaviors. On the first day he performed scaption (shoulder/rotator cuff) exercises. As he attempted to keep Core:Tx’s red ball within the square, he made smooth movements with his arms to the top of his head, using full range of motion, for the first time. He was proud of himself and after two sessions, he developed the motor planning to successfully wash his hair independently. He currently uses Core:Tx in both physical therapy and occupational therapy to address postural control, lower extremity motor planning and gait issues.
A new product showed up in my office a few months ago called Core:Tx. It's a computer-game based exrecise program with a strap-on wireless sensor that detects movement. The "player" has to perform an exercise (like leg squats) and match the speed and range shown on the computer monitor. The game encourages smooth movement along a full range of motion. It's cute, and it catches the attention of a 12 year old boy.
That said, using Core:Tx with a boy with autism is a daunting prospect. It's hard enough to engage children with autism without the additional burden of strapping on a monitor, teaching a "game", demonstrating exercises and getting compliance. As it turns out, I had recently done a program of Interactive Metronome (IM) with one particular lad, and so he was ripe to try this. IM alone did not give him the functional gains he needed. Core:Tx was just the right level of work and play to pull off a successful intervention. And it worked very quickly, too. I'm very pleased with the results. See the next entry for the story.
Saturday, October 4, 2008
A big factor for the change is that a small flood destroyed all of my research articles on peds and autism. But the change would have come in any event, since I am shifting my practice into teens and adults away from children. The title of this blog just doesn't do justice to where my practice is heading. I will continue to work with clients whose main concerns are self regulation or the symptoms of autism and so I will continue to have material for this blog.
On the Brain Tune-Ups site, I will continue to write about Interactive Metronome, Therapeutic Listening, Samonas, stress reduction, etc. And I'll publish the results of the adult study there.
By the way, my clinic's website is http://www.braintune-ups.com/
Wednesday, July 23, 2008
After 6 sessions, we are finally able to run a structured obstacle course in our open gym without both boys making their own agenda. But we worked hard to get them modulated in our environment. I think that our successful formula during the first 5 sessions was this: for the first 1/2 hour, we gave them free play - but with limited options. For example, 3 on a bench swing, 2 in the ball pit, then switch. This let them blow off a lot of steam, but in a semi-controlled manner as they rev-up in the ball pit and then cool-down on the swing. The next 1/2 hour was spent at a table top activity, and so was quite structured. At the end of the hour, they were able to march off to speech (and snack) and sit (relatively) quietly for another hour.
I can't say that combos are my favorite part of the day - I am completely worn out, but I am very glad for these children to have the opportunity to work through modulation issues under adverse conditions.
Monday, July 7, 2008
Dr. Taylor describes the right brain's organization as a parallel processor ... that is, it has it's pulse on all the senses, but has no structure to make sense of the input it receives. For example, she talks about hearing "wah, wah-wah, wah-wah", rather than "Hi, my name is Joe". Another example, she had difficulty distinguishing numbers on paper. She couldn't discriminate figure/ground.
She described the left brain as a serial processor (a typical computer) that is able to analyze, organize and communicate. She says that the left brain has the sense of self (ego?) whereas the right brain is cosmic / in touch with energy. This is all very interesting, quite fantastic, and depending on your religion and training, may make a lot of sense. It did for me.
I wonder if autism doesn't have some sort of right/left brain connection .... I've seen a number of children without verbal skills who struggle with reality and appear to be content in their inner world of songs, touch, lights, and spinnng (right brain with left brain missing). And then there is true Asperger's Syndrome, which seems to be all left brain.
Dr. Taylor has a book, "My Stroke of Insight", that covers this same ground in depth.
Sunday, June 22, 2008
It is interesting for me to see and compare the difference in working with adults versus children. The poor folks who were sensory kids, but did not get therapy are now sensory adults who have self-adapted to the world around them and may still have a lot of difficulties in coping, adapting and interacting. The therapies that I use with children work with adults. The biggest problem is simply reducing the accumulated baggage that an adult has from years of dealing with physical, mental and sensory issues in the form of praxis, autism/Asperger's syndrome, and/or overall poor inter connectivity to the world and other people. Having access to psycho-therapy will help.
I am expecting to see fewer adult clients with autism than I do in my pediatric practice, but this will be offset by clients with traumatic brain disorder (TBI) and aging-related problems including stroke. I expect the same number of sensory-related issues and the issue of self-regulation will still play out strongly. For outcomes: those with auditory issues will be able to relax and be less volatile, those with vestibular issues will appear to be smarter and will probably act-out less. Those with social issues will lose fear of social situations and pay attention to social rules. Folks with TBI will find increased organization.
I'm not sure what to expect with teenagers. Probably a mixture of everything but stroke. And probably plenty of clients with autism.
My study of the adult parents of children with autism is near completion. There are still 2 post-tests to complete and then we can look at the results.
These sensory kids may or may not have autism - and it seems that a lot of them are on a sort of continuum from "typical" to "high functioning autism". My first step is to give the children strategies to keep their cool. I recommend earplugs (with a pediatrician's approval), or headphones in noisy environments. There are chewy necklaces and pencil grips that can provide them with oral input and serve to limit the vocal tics. Then I discuss ways to self-calm using breathing and focus on breathing. With one bright child, I explained what fight or flight means and suggested that she provide herself with self talk by telling herself that she is safe and that her reaction to noise is just an over-reaction by her body.
These strategies help, but not all children can use them independently. My next stage of therapy is twofold - vestibular stimulation and a listening program. We have Therapeutic Listening at our clinic.
Given that the vestibular and auditory "organs" are in close physical proximity, it is common for a child with auditory issues to have vestibular problems as well. I look for dizziness or fear, and treat it by finding the plane (lateral, vertical, horizontal) and type of movement (rotational, linear, stationary, head down, etc) that makes the child dizzy or fearful. I then acclimate the child to the difficult positions and types of movement by alternating them with safe movement (usually linear swinging). I count out loud so that the child knows when the movements will start and end. This helps to remove fear. I have them check themselves for dizziness, and report on progress. These types of vestibular problems usually heal in just a few 15-minute sessions. It is harder to accomplish with a child with moderate-severe autism because they may not pay attention to what I am telling them (or may not initially trust me) and so go into a state of fear. The trick with them is to go slow and back off if it looks like it's going to backfire.
I am still new to listening programs, but have seen progress with my kids and my colleague's clients, too. Therapeutic Listening (TL), as I mentioned in another post, has 4 classes of CDs: self regulation, time and space, praxis and connectivity (to the environment). I use the self-regulation CDs to help reduce the fight or flight response and the time and space CDs to help with correcting the auditory imbalance itself. After that, I move to the connectivity CDs to try and help re-integrate the child into his/her environment, with the hope that it'll help with social issues.
The self-regulation CDs appear to make a person more passive - which can be good or bad. I tried a week's worth myself and had a friend do so, too. We both became noticeably calmer, but more passive. I stopped standing up for myself. I certainly don't want that to happen with my clients. So, when I see that symptom, I move to a third stage - Interactive Metronome (IM). Perhaps not a full program, but certainly enough to break the passivity and induce a shot of confidence. With one client, I moved in and out of TL and IM in the hopes that he would find an easy place to settle. It appears to have worked and he is discharged. I'll check back in a few months to see if he is still doing well.
Wednesday, June 18, 2008
Friday, May 16, 2008
She made significant gains in her parent's eyes and it also registered on the Sensory Profile (SP). She now accepts hugs from her family without tactile defensiveness (talk about huge!). On the SP, She gained 10 points overall (from 497 to 487). Her Touch Processing score moved from definite difference to probable difference and the Sedentary Factor moved from probable difference to typcial.
Thursday, May 8, 2008
Tyler is an 11 year old boy with high functioning autism who attends regular education and special education classes. Before his IM program, he displayed low tone, poor motor planning, and poor attention and organization skills. He also demonstrated poor overall motivation. Tyler could not tie his shoes. He had difficulty playing the typical games of children his age that involved motor planning, rules and social interaction. Tyler had language skills but engaged in very little communication. For example, he did not acknowledge his mother when she asked him what he wanted to eat or requested that he clean up his toys.
His mother’s stated goals for Tyler’s IM program were improved organization and motivation skills. Tyler’s personal goal was to be able to compete with family members when they played Wii. The IM long form pre-test indicated average to severely-below-average scores for Tyler. He was given a four-week, 12-session program with adaptations for low tone in his lower extremity (therapy ball), tempo modification and use of the visual mode. He began with 800 repetitions and by the twelfth session was able to maintain 1800 repetitions that included 30 minutes of continued focus.
Initially, Tyler showed poor motivation and tried to find ways to take frequent breaks. Introduction of a therapy ball during an early session increased his overall compliance. After 3 sessions, he independently taught himself in the space of one day to tie shoes. He also began to learn new gross motor skills in the gym. More important, he began to demonstrate a noticeable sense of pride in his accomplishments and to work diligently in the program. After two weeks, his mother said he was acquiring better focus, as well as improved attention, memory and sense of responsibility. He also beat his brother in a game of Wii. After three weeks, his mother said, “I was blown away. I asked him to pick some things up, and he said, ‘Sure, Mom, I’ll get it in a few minutes.’” She went on to say, “He had never done that before!” Tyler completed the program with above-average scores. Four months later, his gains including his newly-developed reciprocal communication skills remained intact and are growing.
Monday, April 21, 2008
There are 2 modes of training: Interactive (alone) and Workshop (in a group). As usual, there are tradeoffs.
If you have access to the IM equipment, then doing the interactive training is a great option. For $225 (or so), you are sent an excellent training manual with 12 lessons, each 30-90 minutes in length, of hands-on training. Most people complete the training in 4-6 weeks. The beauty of doing this is that you will experience the effects of using the product 2-3 times per week for several weeks. The OTs in my clinic found that doing our own course of IM helped us to get our own gears in sync and allowed us to move forward with projects. (For me, it was my blog.)
The workshop is very vaulable for the instructor contact. (I'm sure I missed a lot by not attending the workshop!) and you learn how to facilitate IM in just 48 hours. (And of course, you can then do your own hands-on training later).
Be aware that the IM equipment costs over $3,000. For that price you get hardware (that hooks to your computer), software, headphones, and hand and foot triggers. In addition to the initial equipment cost, the company charges about $6-8/hr for use of the system. You buy blocks of time from IM so that you can treat your clients. In fact, the real cost for a client's session is much less than $6-8, because the IM clock runs only during active clapping.
By the way, the trainees who purchase the Interactive course are given enough minutes to complete the course.
Friday, April 18, 2008
Therapeutic Listening and Interactive Metronome have overlapping territory in the area of motor planning - although each product works in a unique way. There is rhythmic feedback with IM in which the person actively attempts to increase their rhythmic precision. (See my entry about this, or check out the IM site.) TL is a passive system in which the person receives modulated auditory stimulation through rhythm and music. The therapist can add active components to TL therapy in the form of sensory stimulation, play or exercise.
A third program I have checked into is Samonas. I'll devote a blog to this at some future date. It comes from Germany and is a very high quality listening program that would appeal to adults as well as to children. There are 5 levels of CDs offered. Levels 1-4 require direction from a trained therapist. An introductory set of CDs is available to the general public. The recorded music and nature sounds are gorgeous. I tried a level 1 CD for 15 minutes and felt some powerful broad effects that included auditory refinement, emotional release and energy. I was pleased with it. Samonas offers a series of Listening Programs for the general public specifically aimed at areas including emotional, social, communication, organization, motor planning, etc. The Samonas web site can be very confusing. You can find web-based training programs for professionals at this location. They will be offering live training classes in the fall in New York and Florida. I'll write more when I get the details.
Sunday, April 6, 2008
As for the Sensory Profile, most were typical. But 2-3 showed sensory issues.
To get a feel for the therapy, I tried it out on myself. I tried it under 3 conditions:
1. At night before bed for 2-3 nights. This is per the instructions from the REI site. I slept deeply, awoke with deep calm and felt like I could handle anything.
2: During the day, during very stressful occasions. I didn't notice anything while it was playing, but within 30 minutes, I was very cranky, and snapped at someone. Later, I became even more irritable. Was it the music or the stressful situation? I am typically very easy-going and handle stress well. The next morning, I was calm and happy.
3. Several times for a few minutes throughout the day under stress-free conditions (on a Friday while treating children in the clinic) . Seemed fine at the time, and all weekend I've had a wonderful sense of calm and perspective as I deal with another stressful situation.
My conclusions: use it when the client is in a good mental state for just a few minutes at a time or at bedtime.
One of my clients,, Tommy, has what appears to be an undiagnosed case of ADHD. I am doing 15-20 minutes of Interactive Metronome (IM) with him once a week as part of his OT session. Since the IM can be very arousing, I thought to counter it with the Calming Rhythms. Jeff Strong told me that other therapists are using this same approach. I gave Tommy's mom the CD and instructions and suggested she try it at night over the weekend. I warned her to watch out for acting-out behaviors. Can't wait to hear how he did.
I think that this will be a good option for my hyperactive kids. By the way, if you want to try it, Jeff Strong offers a free demo download at his site.
4/18/08 Update: 3 parents tried the Calming Rhythms CD for 10 minutes just before bedtime for a few nights. One boy made noticeable decrease in hyperactivity. A second mom reported no change. The third boy, Tommy, liked the rhythms, however, his mom reported that he got up in bed and danced to them ... not exactly what we were hoping for ... but she planned to try it for another night or two and report back.
Thursday, March 13, 2008
In order to be effective, myelin must have exactly the right amount of sheathing around its neuron's axis. Too much or too little and the signal's timing gets messed up. Pretty critical! It turns out that neurons have a constant ratio (.6) for the thickness of an axon to the thickness of myelin sheathing wrapped around it. Somehow the developing brain cells are able to place the myelin down to the exact prescribed thickness. Except, of course, when they get it wrong, which they do with various developmental disorders, cerebral palsy, ADHD, language disorders, autism, bi-polar disease, schizophrenia and so on, including pathological lying(!).
The brain puts the myelin in place slowly over the years starting in the back (shirt collar) at an early age to the front (temples) by age 28-30. The brain forms and prunes itself until the sheathing is done, and then things are pretty well set - barring the phenomena of plasticity, which is a much subtler process. By the time a child turns 4, the myelin has been fully wrapped around the neurons in the visual cortex (so that is the optimal time to have vision therapy complete - but we rarely note problems by then!)
The author explains that the lack of sheathing on the pre-frontal cortex - executive function - is what prevents teenagers from making mature decisions -- that area is still developing and the lack of myelin means that the timing in the area is just not working yet.
The implication for practice with children is that there are critical times for completing therapies. Just as a person learning a second language after age 11 will retain an accent whereas a 10 year old child will not, there are developmental (and other) issues that can be repaired, adapted, etc. if caught before the final myelination takes place. Intensive practice in certain ways (Fields uses learning a musical instrument as a child for the example) will increase myelin thickness (probably because the axon grows wider, too), and this may allow for an impacted area to correct itself.
We can see why early intervention is critical. The author did not identify the critical age for various regions in the brain other than those given above. We will be waiting with baited breath for more particulars!
Fields also discussed the role of insufficient myelination in the pre-frontal cortex (during the teenage years) on the onset of bi-polar disease and schizophrenia. He described the failed process and the role of mutated genes.
Good article - can't wait for greater detail.
Sunday, February 24, 2008
There has been substantial research done on IM for children. (The article cited below finds that IM "appears to facilitate a number of capacities, including attention, motor control, and selected academic skills in boys with ADHD.) There are a few studies on the effects of IM on adults in rehabilitation recovering from varied disabilities such as stroke, TBI and loss of limb. None of the studies I've seen address softer issues such as stress, organization, or well-being.
I have launched a small research project studying the effects of the IM protocol on parents of children with special needs. It's a convenience study being done at Building Bridges therapy Center, where I work. I am asking the question: Does IM help parents of children with special needs become better organized such that they are better able to accomplish their goals. And does this is turn help reduce their stress levels? These parents operate at a very high level of challege and stress (lots 0f OT journal articles have documented this).
I may also look at another factor -- SI. Since many of the children at my clinic have autism and sensory integration issues, as a result, I may assess parents for sensory integration issues using the Adult/Adolescent Sensory Profile. If indeed they do, I wonder if any symptoms lessen at the end of the study....and if not, perhaps, I could re-enlist them in another short study with a different intervention. H-m-mm.
Shaffer, R. J., Jacokes, L. E., Cassily, J. E., Greenspan, S. L., Tuchman, R. E., & Stemmer, P. J., Jr. (2001). Effects of Interactive Metronome™ training on children with ADHD. American Journal of Occupational Therapy, 55, 155-162.
(This was copied from the IM site)
The purpose of this study was to determine the effects of a specific intervention, the Interactive MetronomeÒ, on selected aspects of motor and cognitive skills in a group of children diagnosed with attention-deficit/hyperactivity disorder (ADHD).
The study included 56 boys, age 6 to 12 years, pre-diagnosed as having ADHD who were pre-tested and randomly assigned to one of three matched groups. The 19 children receiving 15 hours of Interactive MetronomeÒ rhythmicity training exercises were compared with a group receiving no intervention and a group receiving training on selected computer video games.
A statistically significant pattern of improvement across 53 of 58 variables favoring the Interactive Metronomeâ treatment was found. Additionally, several statistically significant differences were found among 12 factors on performance in areas of attention, motor control, language processing, reading, and parental reports of improvements in regulation of aggressive behavior.
Friday, February 22, 2008
Ermer, J. & Dunn, W. (1998). The sensory profile: a discriminant analysis of children with and without disabilities. American Journal of Occupational Therapy, 52, 283-290.
Here is an older study done in Kansas that looks at the factors (1-9) in the Sensory Profile for positive correlations to autism and ADHD. (The authors note that this process can be done for other disabilities, as well. I vote for Fetal Alcohol Syndrome!)
ADHD can be distinguished by high scores in Factors 1 and 5, sensory seeking and inattention/distractibilty and low scores in factors 4 and 9, oral sensitivity and fine motor perceptual.
Autism can be distinguished by high scores in Factors 4, 5 and 9, sensory seeking, inattention/distractibilty and oral sensitivity and low scores in factor 4, fine motor perceptual.
The study results had a statistical error, the assumption of homogeneity of variance was violated for the control group, and so these results must be used conservatively.
Questions for research:
1. Will these results pass muster on a larger population?
2. What does the factor profile look like for FAS, ODD, CD, etc.?
Friday, February 8, 2008
Roberts, J.E., King-Thomas, L., & Boccia, M. L. (2007). Behavior indexes of the efficacy of sensory integration therapy. American Journal of Occupational Therapy, 61, 555-562.
The authors performed a single-case study on a boy age 3 years and 5 months with sensory modulation disorder (as diagnosed by the Sensory Profile which noted tactile and auditory processing issues and sensory seeking behaviors) and delayed communication skills. He had been given a reduction in school hours due to classroom behaviors of phycial and verbal aggressive, throwing objects, mouthing objects and touching others within a classroom setting. Treatment was given in an ABAB format: 2 weeks of no treatment, 5 weeks of intense SI therapy (3 times per week), 2 weeks of no treatment, and 2 weeks of treatment. Success was gaged by teacher report of observed behaviors. The SI treatment was provided by a therapist trained by Jean Ayers.
At the end of the study all aggression and mouthing behaviors had diminished. There was a 50% decrease in teacher intensity needed to manage the child's behavior and he was engaged in classroom activities for 70% of the time, a 40% increase from the start of the study.
The child continued with once per week OT which was reduced to once per month over a 3 year period. At the age of 6 he was diagnosed with ADHD.
This is a nice look at the early stages of a boy with ADHD and the affect of intense early intervention.
See also the article by Ermer & Dunn regarding the using the Sensory Profile to differentiate typically developing children, children with ADHD, autism, and other disabilities.
Ermer, J. & Dunn, W. (1998). The sensory profile: a discriminant analysis of children with and without disabilities. American Journal of Occupational Therapy, 52, 283-290.
Thursday, February 7, 2008
Hall, L. & Case-Smith, J. (2007). The effect of sound-based intervention on children with sensory processing disorders and visual-motor delays. American Journal of Occupational Therapy, 61, 209-215.
Leah Hall conducted a study with 10 children ages 5y 8m - 10y 11m who were diagnosed with sensory processing disorder (they were rated "Definitely different" in 3 or more areas of the Sensory Profile). Children were given home programs of four weeks with a sensory diet followed by 8 weeks of continued sensory diet with Therapeutic Listening. Significant results were found at the end of the first 4 weeks and at the end of the 12 weeks. Children gained an average of 71 points on the Sensory Profile with the biggest gains in the area of auditory processing and behaviors associated with sensory processing. Children with specific issues (such as auditory hyper-sensitivities, tantrums and hyperactivity made significant gains in some of those areas, as well). In addition, significant gains were made in handwriting (as assessed by the Etch program, and visual processing (as assessed by the VMI). Parents noticed large changes in overall behavior included improved attention, social interactions, self awareness, communication and sleep patterns. One child on medication for ADHD was given a reduction in dosage.
Wednesday, February 6, 2008
For example, we have developmental scales and excellent assessments for a child's motor skills. They are quite specific, and provide a therapist working with a child with motor delays with a measure of the disability as well as indicate an enumerated set of goals to reach.
Similar OT-based tools for modulation will tell us what modulation behaviors are typical for children at various ages. This in turn will allow us to create assessment tools for children with sensory disorders (including autism) and will allow us to estimate the degree of problem a child has, as well as where they are on the developmental scale. Good assessments will give us milestones for our treatment, and allow us to determine if indeed our treatment is effective. On a larger scale, these tools will allow us to perform quantitative research interventions on large populations. (This topic is also addressed in depth in other articles within the same issue of AJOT).
We need to know precisely the qualities of modulation and their developmentaly characteristics. According to Williamson and Anzalone, the qualities of modulation for infants and toddlers include arousal, attention, affect, and attention. Can we quantify these, assess them in clinical (and other) contexts? For example, can we talk about joint attention, object manipulation, object play, etc.? I am guessing that there are many subtleties here. I hope that we can find specific assessable qualities that are general enough to give us a picture of the child (as the motor assessments do). A resource I have not yet looked at is the zero-to-three foundation's publications (with the exception of the book cited below).
1. Miller, L.J., Anzolone, M. E., Lane, S. J., Cermak, S. A., & Olsten, E. T. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy, 61, 135-140.
2. Williamson, G. G., & Anzalone, M. E. (2001). Sensory integration and self regulation in infants and toddlers: helping very young children interact with their environment. ZERO-TO-THREE: National Center for Infants, Toddlers and Families.
Monday, February 4, 2008
2. A study found that babies are more inclined to eat veggies (green bean, for example) if the green beans are followed by a treat such as peaches. This is just proof of what every mother knows works.
3. Raisins are good for the teeth ... BUT ... they can be made into a yeast starter (and so feed yeast and yeast infections!). I continue to find sugar(s), fructose and glucose a mystery. Not to mention honey!
Here is a recent success. Three mornings a week, I do food therapy during snacktime with two 8-9 year old boys in the school attached to our clinic. Billy eats very few fruits, but he likes crunchy foods. So every day, I bring in an apple or pear cut 2 slices and then deliberately crunch on one slice while I put the other near his mouth. He can't resist. He still grimaces at the apple, so I don't make him eat it, just crunch on it. He loves to do that. And once in a while, he will chew and swallow a bite (with surprise).
A month ago, I brought in tangerines. I put a slice on my tray and had the boys practice cutting the orange. To my surprise, Billy started mashing the orange with his finger playfully. I did so, too. We made a mess and giggled. Then I encouraged him to lick his finger. We played with oranges a few times that week and then went back to apples.
Last week, Billy's mom caught me in the hallway, "I just have to tell you what happened! I was on the phone in the kitchen, when Billy came in. He took an orange from a bowl of fruit, peeled it and then ate the whole thing! THEN, he went back, got another one and ate part of that, too."
Success with oranges is very sweet!
Wednesday, January 30, 2008
The diet moves through stages. First there is a 2-3 day cleanout period in which just chicken, hamburger patties, 2 cooked fruits, very ripe bananas and 4 cooked vegetables are eaten. After that, one adds more cooked fruits and vegetables slowly and then eventually adds raw fruits, raw veggies, nut butters, nut flours, goat yogurt, aged cheese, etc.
I stayed on the diet for 3 days, before I was forced to cry uncle, first from symptoms of low blood sugar and then second from fear of gall bladder complaints from too much oil. Let me explain.
I ate lots of meat, veggies and fruit. However, nothing seemed to fill me up. (I heard that one mother lost 15 pounds in the first week or so.) I am not overweight. I was starving. I ate a banana (legal) as a snack, but became very light-headed. Later I took a nap. Low blood sugar in action. Alarmed, I searched the pecanbread web site and looked for a solution. Sure enough low blood sugar is a known complication, and bananas are known to cause "drunken" behaviors. I found advice to eat blacker bananas (in which the starch was already broken down) or get more oil-laden foods into my body such as avocados, nuts and peanuts. I decided that the bananas would still have too much sugar, and so opted for the second solution.
Avocados and nut butters/flours were not legal in my beginner's diet, but I followed the advice anyway. I made a quick batch of hazelnut flatbread and combined with some turkey bacon (my personal cure for all that ails me) I felt better. Now, however, my stomach felt oily. I began to wonder if my gall bladder could keep up with this. I realized that I, for one, could not follow the diet as it was meant to be followed. Not all bodies can do all things. I skipped ahead and tried foods from stages 3 & 4. I added nuts, cheese and peanuts to my diet. However, I continued to have low blood sugar symptoms.
I finally had to give up and eat a sweet potato to help provide some balance. I am now re-introducing foods back into my diet (but no gluten or casein for now!) to get a better understanding of what effect each has on energy levels, yeast levels, gas, stools, etc in my body. By eating starches, I won't get the same results that others will get - and in fact, I am defeating the purpose of the diet. But I hope to mimic enough of the experience to provide support to my clients. Presumably, their constitutions are better suited to the diet than mine is.
Friday, January 25, 2008
Brenner, L. A., Turner, K. C., & Muller, R-A. (2007). Eye movement and visual search: Are there elementary abnormalities in autism? Journal of Autism and Developmental Disorders, 37, 1289-1309.
This article is an all-encompassing literature review on the topic of visual search and the ocular motor system in children with autism. Individual sections of the article describe:
1. The mechanisms involved (both vision and attention) for visual search.
2. Neuro-anatomical description of the vision system with regard to search and attention
3. Neuro-imaging studies of visual-systems on both children with autism and controls.
4. The ocular components of visual search including saccades and smooth pursuits and how they differ in children with autism.
5. The relationship between ocular motor and attention systems.
6. The impact of the ocular motor system on higher functions including face perception, joint attention and language acquisition.
This is not an easy article to read but it provides great insight into many underlying differences between the autistic and typical brain. The authors create a case for the possibility that the symptoms of autism (including joint attention, face perception and language acquisition) are the result of a defective ocular motor system. They warn that the current theory, the "lesion" view of autism in which autism is presumed to be caused by observed neural differences in many brain structures does not take developmental (and experiential) considerations into place. The authors call for research in the combined areas of ocular motor and joint attention to gather additional information in this area.
Another post in this blog will list the differences found in the brains and behaviors of children with autism and typically developing children.
There is a great deal of latitude for therapists, and I find that it works both as a modality and as an intense therapy.
Sunday, January 6, 2008
Article 1: Auditory & Attention; Tactile and Motor Planning
Myles, B.S., Hagiwara, T., Dunn, W., Rinner, L., Reese, M., Huggins, A., & Becker, S. (2004). Sensory issues in children with Asperger syndrome and autism. Education and Training in Developmental Disabilities, 39, 283-290.
A comparison of Sensory Profile assessments on 76 children ages 6 y 9 m to 16 y 8 m. Half were diagnosed with Asperger's syndrome, the other half with autism. There were no restrictions to the study based on intellectual capabilities. The purpose was to discover sensory differences between the 2 groups. Statistical significance was found in the areas of auditory processing, tactile processing, "modulation of sensory input affecting emotional responses and activity level" and emotional/social responses. Children with AS were more severely impacted than children with autism in all of the above areas.
The authors conclude
1. Higher rate of social/emotional behavior for children with AS may be due to greater capacity for language. They are attempting to interact and are doing a poor job.
2. The poor auditory processing skills are associated with decreased attention levels. Children with AS may hear just portions of verbal information and this create a confused message which they then try to make sense of. The authors go on to posit that this may lead to rigidity in behaviors because the children latch onto the portion of the message that they heard.
3. Children receive inaccurate tactile information causing a distortion in their body perception which in turn causes poor motor planning. The authors explain that this may thus explain poor coordination in children with AS.
A previous article () classified children with autism into 4 catagories. Children with high functioning autism (HFA) do not have communication problems. This would suggest that they need to be separated into a third group for this study to make sense. Another article (hmm, have to find that one...) I read found that children with AS and HFA have similar sensory issues -- and yet there truly are differences ... I for one, want to know more.
Tuesday, January 1, 2008
- Sage Publications opens up to allow free access every few months. This includes Autism, ADHD, and many, many other journals. To find out about free access, click on "journals" then see the "current free online trials" ad and also register for "email alerts".
- Journal articles from The Journal of Neurology, Neurosurgery and Psychiatry - which is at journals.bmj.com/ are available for free 1 year after publicaiton. What I do is print out the free abstract and write a reminder note to get it later.
- The entire year - 2007 - of Journal of Autism and Develomental Disorders currently has free access. I printed out 20 or so abstracts and papers. This is from SpringerLink Publications.
- I also get aricles from AOTA for the American Journal of Occupational Therapy, as well. I am a member, so do not need free access ... however, I'm not sure that they provide it!