Posted on Leave a comment

The importance of a comprehensive assessment

Thank you to the families who gave consent and our secret blogger OT for this contribution.

“A little while ago, two mums approached me and both asked about assessments for their children. Both were young adults, academically highly able and struggling with their self-organisation and motor skills.

Both young people consented to an assessment and completed, through self-report, the Adult/ Adolescent Sensory History (AASH) questionnaire. They were also assessed with the Sensory Integration and Praxis Test (SIPT). The SIPT is a standardised assessment with normative data for ages 4 through 8 years, 11 months. On this particular assessment tool, sensory integration and processing skills scores plateau at around this age, though the test is still informative for people beyond this age, who should have achieved.

The young lady assessed has a diagnosis of social anxiety and has low confidence, while the young man is quite a confident character. She has a history of bumps, trips and spills, and will tell anecdotes of these with great humour; while he prefers to focus on what he does well in conversation.

I love the AASH, the reports it gives highlight each sensory system, differentiate between discrimination and modulation difficulties and addresses motor planning, sequencing and social/ emotional aspects of sensory integration and processing needs.

It uses clear, non-patronising language and activities appropriate to adults and adolescents. It shows up really clearly a person’s (or their caregiver’s as necessary) perception of their sensory integration and processing needs and how these affect their day to day life. In this instance, the young lady highlighted many sensory processing needs.

Screen Shot 2020-04-23 at 11.05.40.png

The young man reported almost no difficulties, his only score in the primary sensory systems section was mild proprioceptive difficulties. When questioned as to the accuracy of his answers, he tended to reply “well, nobody likes that, do they?”

Screen Shot 2020-04-23 at 11.05.48.png

Having scored the AASH checklists, I completed a SIPT with each person. The SIPT is a battery of 17 tests which assess a person’s sensory integration and processing including perceptual-motor skills through tasks with standardised administration and normative data against which to compare an individuals test results. Guess which person showed more significant difficulties in the direct assessment? 

On the SIPT assessment scores between -1 and +1 standard deviation are considered typical, above +1 are strengths and scores below -1 are of clinical significance and require support and will benefit from direct intervention.

The exception to this being Post Rotatory Nystagmus in which a low (below -1) or high score (above +1) indicates significant difficulty inhibiting response to vestibular information and often relates to a low Standing and Walking Balance score.

Here are the young lady’s SIPT results:

 

 

Screen Shot 2020-04-23 at 11.06.17.png

Definite movement, balance and body awareness difficulties but also some areas of significant strength, particularly around her visual skills and imitation, which she uses to compensate for her body awareness difficulties.

Here’s the young man’s chart:

Screen Shot 2020-04-23 at 11.06.33.png

Strong visual skills, compensating for significant challenges in the other areas.

This experience taught me so much. From the AASH scores, I was expecting the young lady to have much more problems in the SIPT than the young man, their conversation about their lifestyles confirmed this expectation. Still, then the assessment showed so clearly how much of that was related to confidence.

An evaluation based solely on checklists is not enough. It tells you what a person perceives to be their difficulties, guides the direction of evaluation and adds experiential evidence to the overall assessment.

A good questionnaire is evidence-based and norm-referenced, but it always needs to be triangulated with direct observation and where possible structured and standardised assessment. These tools can tell you so much about the respondent’s confidence and resilience and what they find easy or difficult in day to day life. But I have learned it is a mistake to rely upon one alone when assessing somebody’s sensory integration and processing skills and needs”.

Posted on

CPD Update: Neurodevelopmental Soft Signs: Implications for Sensory Processing and Praxis Assessment—Part One

An interesting read, this AOTA CE Article links sensory integration and processing difficulties and higher functions linked to occupation and participation. 
A table in the article links types of neurodevelopmental soft signs (NSS) in Occupational Therapy evaluation and underlying brain areas implicated in the literature, commenting that
“Integrating clinical observations of NSS with advanced brain-based research expands our understanding of the sensorimotor scaffolding that leads to higher functions of behavior organization, communication, and cognition.”
To access/buy a copy you can find out more here:
Posted on Leave a comment

Choosing Wisely ® and ASI – a fantastic initiative from AOTA – it got me thinking about why people think sensory is easy and just anyone can do it.

Just like a parent can decide a child has a cold and needs Calpol, a sensory rich home environment can help support development. However just like a child may need a Dr, Dentist or other specialist if they have a more serious illness, what some people need is specialist intervention.

Sensory Integration therapy requires years of training, first just to become a therapist and then the advanced training needed to accurately assess, develop a personalised intervention plan and then carry out the intervention. We might all know when tonsils need removing, but few of us would do it at home. Telling someone about how tonsils get removed or how sensory integration happens is very different to actually doing it, and doing it safely and so that the outcome is as expected. Sensory integration therapy is not just about swinging on a swing or bouncing on a ball – it is about so much more. And is definitely not about just about wearing headphones and having a bouncy cushion.

The superb article from AOTA’s CHOOSING WISELY programme – see link below – got me thinking. I get weekly emails from people offering to treat other people’s children without training, offering Sensory Profile assessments by mail from a questionnaire when they are not even a therapist.

Share this blog and have interesting discussions with clients, colleagues and line managers. As relevant here in UK and Ireland as in US. This really confirms what we teach in our modules and promote as an organisation; including the best standardised norm referenced tool currently at our disposal – the SIPT. No or limited assessment waters down efficacy. Standardised assessment (when possible) structured clinical observations and thorough clinical reasoning using a clear process are imperative. Data driven decision making.

https://www.aota.org/AboutAOTA/Membership/Tools/Periodicals/choosing-wisely-sensory.aspx

Posted on Leave a comment

Assessment tools are just that – tools in our toolbox!

We should use and value our specialist skills – promoting our profession – information from one assessment tool is not a comprehensive assessment. We should act with integrity and only practice what we are skilled in and trained to do. This can and must include postgraduate training and we should value this investment in our own skills to deliver a great service to our clients. I felt ashamed of my own profession today, and here is why.

selective focus photography of three disney princesses figurines on brown surface

Today I chatted with a parent I was introduced to on social media. They had paid almost more money than I earn in 2 days in private practice for a 10-page report written after the parent returned a completed Sensory Profile to a therapist via the mail. Then after a 45-minute meeting where the child played on the floor while the therapist interviewed the Mum, the report and recommendations were written.

On the back of this report, the child who lives far away from the assessing therapist is now about to undertake:

brown makeup brushes

  1. Balance exercises every morning which the Mum was training to do over the internet. These include standing on one leg eyes open and eyes closed, and, hopping eyes open and eyes closed along a line.
  2. A brushing programme; which Mum will be soon be trained to do over the internet – this needs to be done every morning and every night.
  3. Using a sensory diet sheet and the child will follow 5 activities off this sheet each day with her TA at break-time while her friends are out on the playground.
  4. Using a wobble cushion at lunch to facilitate eating new foods.
  5. An after-school calming plan – spinning on a wheelie board and jumping on a trampoline for 10 mins.

The final recommendation was getting sensory therapy from a ‘Sensory OT’ if these things didn’t work. I am apparently one of the closest ‘sensory therapists’, so I got a call. The therapy has not worked. Where do I start? What is a ‘Sensory OT’? Am I one of these?

I have to be professional. So I started with educating the parent about our profession and how we practice.

Screen Shot 2018-07-03 at 08.41.10Then I told her about Jean A Ayres and about Ayres’ Sensory Integration and Practitioner Education including the ICEASI. I had to dispel some myths she’d been sold that sensory diets are not related to Ayres’ Sensory Integration – exploring the history of the theory’s development, explaining how the theory should be used to inform assessment and clinical reasoning even when we can only provide advice and strategies – but that these should still be individualised following a comprehensive assessment.

Screen-Shot-2018-07-03-at-08.16.50.pngThe approach used and charged for is not what I recognise and not what encompasses best practice – best practice in occupational therapy, wherever we work, involves using assessment tools; some standardised and with norms or some just structured questionnaires that collect and collate our clinical observations. Then we listen and hear the client’s voice/story via their narrative and then using this to confirm our clinical observations. Then using the best possible evidence we should work alongside clients to develop goals and set a way to measure if what we then do makes a difference – improving participation in daily life.

ASI WISE RCOT 2018 Poster ASI Beyond ChildhoodOur recent poster at Royal College of OT Conference in Belfast shows the 2015 Schaaf and Mailloux data-driven decision-making process.

This is not a process restricted to Ayres’ Sensory Integration, but one that should guide best practice in any area of clinical practice; judicious collection of data through assessment to inform clinical reasoning that will allow the setting on individualised, personal goals to inform intervention planning and implementation – with careful measurement of outcomes alongside reflective practice.

This is our profession – working with people in partnership, alongside them in conversation and while using assessment tools in the assessment is expected, we choose tools specific to the person, the referral reason using our clinical reasoning. This is our expertise and what makes our jobs a profession.

The Sensory Profile, like all assessments, is meant to only guide and inform clinical reasoning. Otherwise, we could just hire number crunching computer programs that use algorithms to assess plan intervention and write reports instead of OT’s.

[This blog was written a while ago, with some details changed to protect the family, but at their request and with their permission. It was written just after my father in law fell and then sadly did not recover. I was very sad anyway, but after this conversation, I was really very very sad and I waited to make sure I still felt as concerned and as sad after some time had passed.]

 

 

 

Posted on Leave a comment

Neuroscience and Sleep

Submitted by guest blogger Ruth OT

Before I trained to be an occupational therapist, I studied neuroscience to masters by research level. It is so helpful in my work to have that underpinning knowledge of some of the things going on in the brain and how these affect behaviour. However, I don’t miss growing neurons in petri dishes and counting them.
Our kids are not great sleepers, to understate it considerably. We have had more sleep advice than anyone has any business accessing. It’s been variably effective. In the UK, there are several charities who offer sleep advice for children with special needs (Cerebra and Scope to name but 2), alongside advice from our children’s centres and child and adolescent mental health services (CAMHS). They’ve all been helpful, they’ve all prioritised the importance of a good consistent bedtime routine, on minimising distractions from sleep and on knowing your child’s sleep patterns. We have filled in more sleep diaries that you can shake a stick at (incidentally, this is the most effective way to make sure your child actually sleeps I have found! It’s amazing how well they sleep when you’re filling in a sleep diary to prove they never sleep).
I have promised myself I will stop reading sleep advice because I only get frustrated when we still don’t sleep, but here are some things we have found helpful (some nights at least!) and a little bit of the neuroscience of why.

Melatonin
One of our children along with many autistic people I know is taking melatonin at bedtime. The doctor tells us frequently that this is expensive, and we’d prefer to avoid medication as much as we can on general principle, so it’s worth knowing a bit about what melatonin does and how to boost it without medication.
Melatonin is a substance which the brain makes from the neurotransmitter serotonin, mostly in the pineal gland. The pineal gland is a tiny gland right in the middle of the brain and close to the visual centres of the brain. It starts making serotonin into melatonin when the light reduces, stimulating sleep onset. I don’t know whether my kids’ pineal glands are less efficient converters of serotonin to melatonin or whether their brains are less sensitive to the melatonin produced, but I just need some sleep so here are some ways we try to boost melatonin production.

Light and Screens
If melatonin is made when the light dims, it stands to reason that emphasising that light change is important, so we make sure they get lots and lots of daylight when we want them to be awake, and none when we want them to be asleep. This is not always easy in Northern England and involves a lot of getting wet and muddiness. We play outside every day we possibly can. When we can’t, we are lucky enough to have a big conservatory which we use as a playroom, and we have daylight effect lightbulbs in key rooms of the house which we use in daytime then switch to lamps in the evening. We have found that physical activity in the day can help with sleep, but if it’s all indoors such as soft play centres and swimming pools, it’s nothing like as effective as a walk outside no matter how wet the walk may be!
We have a no screens after the evening meal rule when sleep is particularly tough. Focusing visually on an (often bluish) glowing screen will inhibit melatonin production if you’re struggling to sleep, turn the technology off, it really does help.
We have blackout blinds behind blackout curtains and we close the doors of all the rooms that don’t have that every night (actually in our child who takes melatonin’s bedroom, we’ve made wooden boards which fit exactly into the window area over the Velcro blackout blind. Yes, I am serious…).

Serotonin
If melatonin is made from serotonin, it also stands to reason that it’s a good plan to have a lot of serotonin available to be converted. A large proportion of the antidepressants available have their effect by increasing the amount of free serotonin in the brain, this may explain some of why depression can affect sleep patterns. If you think mental health difficulties may be influencing sleep patterns, please talk to your doctor about this. It can be a vicious cycle that poor sleep exacerbates depression and depression then makes sleep more difficult, it is important to break that cycle.

Food
There are certain foods which contain tryptophan which the brain then makes into serotonin. I know some parents who swear by these in evenings, these include cherries, nuts, seeds, tofu, cheese, red meat, chicken, turkey (you know how we all fall asleep after Christmas dinner?), fish, oats, beans, lentils, and eggs. Just be aware that strong flavours and smells can be very alerting and so be less helpful than you’d think. Also, many of these can be allergens.

Movement
It’s also good to know that serotonin and melatonin levels rise with proprioceptive activity (movement against resistance, which helps the person to understand their own body more clearly), so including (not too vigorous) movement against resistance as part of the bedtime routine can really help- moving against the water in a warm bath, followed by squeezing yourself in a soft towel would be one example, or carrying a good sized box of bedtime stories up the stairs to bed. Movement of the head can also stimulate serotonin release in the brain and help sleep, just avoid spinning and sudden changes in speed or direction as these will counteract the effects.
Doing all of this does not mean you will get a good night’s sleep (I think we got about 2 hours last night!), but it might just improve your chances.