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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:
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Christmas Themed – Calm Down Glitter Bottle Timer

Thanks so much for this beautiful, simple idea sent to us by one of our families.

Have you tried making and using a glitter-filled calm down bottle timer to help your little ones? It’s easy to put a Christmas theme into them by using festive colours and adding seasonal themed sequins or beads.

With so many versions on the internet, here is a blog post from my Crazy Blessed Life with tried and tested instructions to make your own. While Mama OT explains how the bottles can work by aiding self-regulation http://mamaot.com/sensory-calm-down-bottle/

And a Christmas themed jar from Teaching Mama

Christmas Sensory Bottle

Don’t forget there is still time for you to win a copy of Love Jean by entering our Christmas time book give away. Share your Christmas themed sensory ideas with our community… by leaving a comment on one of our Christmas themed blog posts or on our facebook page … before the 15th December 2018

love jean book

 

 

 

assorted color sequins

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Messy Play 1 – What is messy play and how can it help?

Submitted by guest blogger, Ruth OT

It’s the summer holidays for most schools in England, including my kid’s schools. I’m well known for my love of messy/ tactile play, and summer holidays and messy play are made to go together.

First of all, can I just say that messy play is not just about the sensory input, it’s not a “sensory session”, it’s certainly not a substitute for “sensory integration therapy”?

All play is sensory.

All activity is sensory.

Messy play is a about normal development and learning through a playful activity using tactile experiences and experimentation. It should be fun, it can be intensely therapeutic, and it can form a part of sensory integration therapy session, but overuse of the word “sensory” for activities like this weakens the power of true sensory integration therapy.

Second of all, can I just say that messy play is not a substitute for natural tactile experiences? Messy play is not a substitute for muddy walks, tree climbing, animal handling and other important life and learning experiences. It can scaffold and enable those activities for children who find these experiences difficult to tolerate, but there’s nothing like nature and the great outdoors for kids’ sensory skills.

Here are some of the reasons I love messy play…

It teaches basic cookery skills, but nobody has to actually eat the product

Through making recipes, you can practice opening packages, pouring, measuring, stirring (and holding the bowl still at the same time) and following a recipe. But you don’t have to worry about food hygiene, if the child drops it on the floor, picks their nose, spits, or anything els. You don’t have to pretend it’s delicious. But there is still a tangible result.

It teaches flexibility of thinking and problem solving

So many times I say to kids “OK, that doesn’t look like it does on my picture, what did we do wrong?”, followed by “OK, let’s try that then!”. It’s amazing to watch our children move from “it’s gone wrong, bin it” to experimenting to try and improve the outcome. When I hear “it’s too runny, add more flour” I smile, I count this as a breakthrough parenting moment.

It can be really helpful to use non-specific language, I love seeing that look and a laugh when I say ‘you need a good amount of this’ or ‘give it a squirt of that’. I say we’re working on estimating.

It teaches art, creativity and scientific experimentation

We’ve made beach scenes out of shaving foam and cornflour gloop, farms from rice and silly string and just beautiful visual effects from any range of strange concoctions. I love that moment of “what happens if I mix this with that?”. So long as you’ve checked what you’re using properly, to make sure it’s safe, the worst that will happen is a sticky mess.

Beware of borax as a substitute in cheap homemade slime recipes!

It teaches communication

It can be a great motivator that isn’t food-based; practising choice-making, turn-taking and asking for help is really easy with a tin of shaving foam and some dry pasta. You can follow a recipe, practising reading and maths. Make visual recipes pictures of the scoops of flour and oil, with laminated recipes so the child can tick off each step they do – wiping clean at the end. Get older kids to research their own recipes on the internet and print them off ready for the session.

It teaches motor skills and tactile discrimination

Opening packets, pouring to a measure and sprinkling need I go on? And then squeezing, pressing, rolling, stretching and cutting. It’s amazing for fine motor skill development. You can hide things in a messy play tray or a ball of playdough for the child to find and choose the perfect texture. 

It exposes the child or young person to new sensations

You will make lots of smells with microwaveable soap kits, you will spill liquids, you will touch textures and the outcome is often unpredictable.

It can help with food aversions

Food-based textures and odours can become familiar through messy play. Exploration of food and food-like substances in a calm, fun activity without the pressure and anxiety of being pushed to eat can help to break down anxiety responses to foods, meals and eating.

It’s fun

Or at least, you should make sure it is. 

So, with all of that in mind, Over the next few days, I’ll give you 6 of my favourite recipes, one for each week of the English summer holidays. There are loads of recipes out there, I have a whole book of slime recipes (yes, really) but these ones are tried and tested and hopefully varied.

Hope you have fun trying them out…

pexels-photo-1148998.jpeg

 

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Dyspraxia or DCD, what term and recommendatons do you use in your EHCP’s and why?

pexels-photo-1040427“Developmental co-ordination disorder (DCD), also known as dyspraxia, is a condition affecting physical co-ordination that causes a child to perform less well than expected in daily activities for his or her age, and appear to move clumsily.”

NHS Choices[accessed 1 July 2018] 

Sometimes the terms we use as therapists are disputed in EHCP meetings or tribunals. The following quotes have proved useful in defending my own use of the terms in reports, especially when I link the term I use to the specific assessment tool I have used to do my assessment and clinical formulation.

Gibbs and colleagues 2007 described that “the definition of DCD is very similar to dyspraxia. A survey of health and educational professionals showed widespread uncertainty about the definitions of, and distinction between, DCD and dyspraxia. Furthermore, the rationale for using one or the other term in the literature has been unclear. Therefore, DCD and dyspraxia should be regarded as synonymous.”

art assess communication conceptual

When I use the Movement ABC-2, I will tend to use the term DCD, as the tool and the research about it are clearly linked. As our local NHS paediatric services use the Movement ABC-2 for diagnostic purposes, despite its limitations.

For some referrals, therefore,  this is my tool of choice and the quickest way to ensure the child can access services because their condition is then officially recognised by teachers and the Local Authority. Thie example report is then how I report the results, ensuring I clarify the limitations of the tool, and that additional data and assessment has been undertaken to inform my clinical reasoning.

DCD Proforma

But when I use the term Dyspraxia, I am usually using it to refer to a pattern of praxis difficulties recognised in the research that we hypothesise interferes with participation in activities at home, school and out and about.

This pattern is typically identified by gathering a history of development and functional difficulties, Ayres’ Clinical Observations and the Sensory Integration and Praxis Test. I like the history form in Schaaf and Mailloux 2015 and the Sensory Processing Measure, or for adults the Adult/Adolescent Sensory History.

people in front of macbook pro

I will also use the COSA, OSA, SCOPE and MOHOST to gather information related to difficulties with participation in daily life and to set goals, and these can then also act as great subjective outcome measures. The impact of DCD/Dyspraxia on daily life is significant. Caçola 2016 described how Dyspraxia/DCD is considered to be “one of the major health problems among school-aged children worldwide, with unique consequences to physical and mental health.”

Poor praxis often means a person with little understanding of where their body is in relation to the world and so what to do next, making the plan and doing it becomes harder than for others. When this happens, our brain is unable to feel safe and secure, and so it is unlikely that the person can remain in a ‘calm and alert’ state.

children riding bicycle

For those who have poor praxis, a sudden increase in arousal often happens when a  new or unfamiliar task is presented, because the previous failures to achieve success on sensory-motor tasks will trigger and raise arousal levels. This often means the person’s body is on ‘red alert’  – reactive to the world and small confusing changes happening within their own body. This may mean they are more likely to make decisions in flight, fight or freeze mode, resulting in behaviours that challenge others. The underlying problem is the praxis deficit not sensory reactivity in response to a perceived threat. This is why thorough assessment is required.

Arousal and alertness, sensory modulation and praxis are interwoven with a complexity that is often missed by others and those new to learning about sensory integration theory and practice. Praxis difficulties that result in behaviours that challenge others are often labelled as sensory modulation difficulties, however digging deeper will often reveal praxis deficits underpin the dysregulated behaviours and attempts to get control. This is very true of our clients who have dyspraxia co-occurring with mental health difficulties. We ignore and disregard praxis at our peril. Left unaddressed, praxis deficits continue to interfere with participation in daily life, skill development and self-esteem unabated.

Watch this young person’s story about living with dyspraxia.

How is a diagnosis made?

For a diagnosis of DCD to be made, your child usually needs to meet all of the following criteria, in some areas of the UK this requires a score below a cut off on the Movement ABC-2 Test.

  • motor skills are significantly below the level expected for their age and the opportunities they have had to learn and use these skills
  • the lack of motor skill is significant and persistently affects the child’s day-to-day activities and achievements at home and at school
  • the child’s symptoms first developed during an early stage of their development
  • the lack of motor skills isn’t better explained by
    • a delay in all areas of development (general learning disability)
    • other medical conditions; such as cerebral palsy or muscular dystrophy

Usually, DCD is only diagnosed in children with a general learning disability if their physical coordination is significantly more impaired than their mental ability.

What about DCD/Dyspraxia and Autism?

In numerous studies, the links between autism and praxis skills have been reported.

In 2016 Cassidy published important findings from a study, showing that

kid s plating water on grass field during daytime

  • Dyspraxia/DCD is significantly more prevalent in adults with Autism
  • Motor coordination difficulties commonly co-occur with Autism
  • Dyspraxia is associated with significantly higher autistic traits and lower empathy in those without Autism.

These results suggest that motor coordination skills are important for effective social skills and empathy. This is clearly seen in children and young people presenting in clinics who struggle to know how to make friends, ask for the help they need and can’t understand others feelings and frustration.

What about DCD/Dyspraxia and Speech and Language Difficulties?

In 2012 Stout and Chaminade stated that “long-standing speculations and more recent hypotheses propose a variety of possible evolutionary connections between language, gesture and tool use. These arguments have received important new support from neuroscientific research on praxis, observational action understanding and vocal language demonstrating substantial functional/anatomical overlap between these behaviours.”

Listen to this Speech and Language therapist describe the links between speech and language concerns and tone, more general praxis and motor coordination difficulties.

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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.