Article Response: 'Sensory Integration Therapies' Lack Evidence, AAP Says

I recently read a news article: 'Sensory Integration Therapies' Lack Evidence, AAP Says. Recently the American Academy of Pediatrics has announced that there is little research-based evidence for Sensory Processing Disorder (SPD) and sensory integration therapies designed to address SPD. The article is well written. It begins with an anecdotal personal story about a now-grown child with SPD who greatly benefited from therapy. The article goes on to review the lack of quantitative research in the field. However, the author interviews experts in SPD who discuss the work going on right now and progress being made and so overall the article is very well balanced.

My response to this article is personal - not professional. I am not an expert in SPD in any way. When Ava had just turned two, she was an essentially speechless and fearful child. The few pseudowords she had been attempting were being abandoned as she turned to gesture to communicate. She was scared to go to daycare and would only play at playgrounds and indoor playplaces when they were empty. As an SLP, I focused in like a laser on the delayed speech and attributed everything else to side effects of her being unable to communicate.

We began speech therapy and she made great progress at first. Her phonemic inventory expanded. After using communication boards and sign language as a bridge for a few months, her dependence on gesture began to decrease. She began using words and then word combinations. I was elated. Then there was a significant plateau.

I finally began to pay attention to some other issues. Even though we were getting lots of verbal communication at home, she was still silent at school. At a noisy playground she wouldn't leave my side. At a relatively quiet playground, she'd go play only until another child approached her. Then she'd retreat. She loved the bath, but hair and face washing was terrifying for her. Brushing teeth was a nightly screaming and wrestling match. She was an extremely picky eater and getting worse fast. She was also extremely sensitive about touch. She always, even as an infant, preferred to eat with silverware rather than her hands. She wouldn't touch (and definitely wouldn't eat) messy foods. She wouldn't fingerpaint or otherwise engage in messy media. It wasn't until I brought up some of these issues at an IFSP meeting that our case manager and speech therapist noticed the huge red flags that were, in retrospect, extremely obvious. At that point we got an OT evaluation and began receiving services to address sensory issues.

The change in Ava following six months of sensory-based therapy was nothing short of life altering for our family. Ava is still a picky eater, but well within a typical range for a 3 year old. She plays normally on a playground and interacts typically with her peers. She enjoys participating in art activities even when that involves fingerpainting or helping me mix up a salt dough with her hands. We can wash her hair and brush her teeth without pinning her down while she screams. And those things are just items on a checklist.

Fundamentally, she is no longer overwhelmed by her world. It is a profound relief to watch my daughter experience her world comfortably rather than through the defensive shield she was trying to erect to try to protect herself from overstimulation. Not coincidentally, her communication improved at the same time. She began to use her speech in school and in social settings. The additional practice and carryover skills resulted in functional improvements and also broke the plateau in terms of learning new speech skills as well.

I know we are not the only family to experience profound changes as a result of therapy designed to address sensory issues. I talk to other parents who have had similar experiences regularly. I sincerely hope the specialists in this area continue to do quantitative research and begin to publish.

My recommendation at this time would be that an OT evaluation couldn't hurt. If sensory issues are an issue for your child do a trial period of therapy with an occupational therapist experienced in the area of SPD. Judge for yourself whether or not you are seeing changes. For us, I knew significant changes were in the works after about 2 months of therapy and we were discharged after six months of therapy. Post-therapy, Ava interacts with her world in a much more typical fashion. I also continue to use some techniques and strategies taught to me by our OT to maintain that progress (particularly in the area of eating). That six months of sensory therapy with an amazing OT was absolutely one of the best things we've done for Ava and I have no regrets or doubts about the therapy's effectiveness.

No-Cook Oatmeal Playdough Treasure Hunt

Today, during our occupational therapy session we made oatmeal play dough. It is a no-cook recipe and requires only three ingredients.

Oatmeal Play Dough Recipe

1/2 cup oatmeal
1 cup flour
1/2 cup water

Step 1
Our purpose in making and playing with the oatmeal playdough is to decrease Ava's tactile sensitivity by having her use her hands with a messy activity. So we began by putting a half cup of oatmeal into a mixing bowl and letting her explore the dry oatmeal with her hands. She enjoyed the oatmeal and took several tastes of the oatmeal.

Step 2
Then we added the cup of flour into the bowl. Again, Ava explored the flour with her hands and tasted it. Then she thoroughly mixed the two dry ingredients with her hand (one hand is in a cast, so we were doing this activity one-handed).

Step 3
Next we poured in the half cup of water. At first we just observed it. We watched the water pool on top for a few minutes and some oatmeal float on the top like tiny boats. We talked about how they would be perfect boats for ants. Then the water was slowly absorbed into the dry ingredients and we began to mix with our fingers. The mix was extremely sticky. This is part of why it makes such a great occupational therapy activity for children who are ready (if your child is still demonstrating extreme tactile defensiveness this isn't the right activity). Once the mixture seemed evenly sticky we removed it from the bowl and started to work with it/play with it on the table. (Note: Over the next 10-15 minutes, the oatmeal continued to absorb the excess water and the texture became much less sticky.)

Step 4
To extend the activity and continue to keep Ava's hand engaged in the dough we played a buried treasure game with the ball of play dough. I took several glass marbles and gems and a penny and hid them inside the play dough. Then Ava would dig around in the play dough to find the treasures.

Overall, the activity went extremely well. The oatmeal play dough has several advantages.

1. It is a no-cook recipe.
2. It is made with a small number of inexpensive, easy to find ingredients.
3. It goes through a variety of textures (dry, wet and sticky, traditional play-dough like).
4. The end product is pretty stiff making it a great medium for increasing hand strength as a bonus.

One Activity - Many Skills

I've been wanting to do this cork/pushpin activity ever since I wandered across the idea.

Pinning Shapes

Disclaimer/Warning: Only use this activity with children you are sure aren't putting things in their mouth any more. And even then, closely supervise.

I found cork squares at Joann Fabrics for about $2. Use a marker and draw shapes on the coasters. You could use cookie cutters to trace simple shapes. (I did dots, but if I were to do it again I would just trace lines.) Bring cork, pushpins, and the children to the table.

Introduce pushpins to children. Explain that pushpins are for grown-ups and children only get to use them during very special activities because they are sharp. Remind them that if they ever find them at any other time they should carefully bring them to a grown-up to put them away. This introduces basic safety rules and also has the side benefit of making the children very excited about the activity.

Let them use the pushpins to fill in the shapes.

Skills/Objectives addressed here:
Vocabulary/Concepts: Shapes, colors (we only had red pushpins, but if you had many colors you could address colors and patterns), patterns
OT: Fine motor / pincer grasp / hand-eye coordination
Speech: Use this activity as a motivator. The child gets to push a pin in after every X repetitions.
Pragmatic: Listening to directions, turn taking, attention span, eye contact

Hospital Visits as a Measure of Progress?

Ava and I were back at the ER Friday night for croup again. Friday was Michael's birthday. I sent Daddy home to spend the evening trying to make Michael's (small family) birthday celebration as much like it would have been as possible.

Cons: Well, those are pretty obvious. First, Ava couldn't breathe and needed a steroid to calm things down. Second, it was happening on Michael's birthday.

Pros: It was a mildly interesting fact that I was spending the evening in the exact same hospital that I had been in four years earlier.

Also, it gave me a chance to really see how much progress Ava's made with her sensory issues since our last trip to the hospital (almost exactly 7 weeks ago). Wow! The difference was amazing.

Last time Ava screamed when they weighed and measured her. She screamed when they took her temperature and measured her oxygen levels. She screamed when they took her blood pressure and examined her. She screamed when taking her medicine.

This time she was great. She was a little nervous and wiggly, and cried a little occasionally, but overall she handled everything fairly well. She was even charming with strangers. She was being cute and trying to be funny and enjoying the attention. This is the same child that used to act like direct eye contact from a stranger was an assault. Oddly enough, this trip to the ER was a huge way to track some pretty amazing OT progress.

(And we were sent home without an overnight stay or breathing treatments necessary, so this trip was much more successful than the last one. Hurray for not waiting until things were absolutely critical this time.)

The Weekly Review: Week 32

Blog Post with an Outstanding Description

This week Amalah wrote about a situation at her son's school where several parents of children with special needs felt they needed to advocate for their children. This post contains an outstanding description of the variety of personalities and responses that make up that population of parents and how they all ended up in the same place anyway.

Weekly Blog Post that Made Me Want to Cook:

Weelicious.com featured a crockpot vegetable lasagna recipe a while ago. I liked the idea so much I decided to try it. It was so easy and turned out really well. And, all four members of the family liked it. That's a major success around here.

Weekly Entertaining OT Activity:

This week our OT arrived with three things. She brought powdered sugar, peanut butter, and honey. We didn't measure anything, so I can't give you an exact recipe. We put several tablespoons of peanut butter in a large bowl (for each child) and let them taste the peanut butter with their fingers for a while. Yummy and good sensory experience rolled into one. Then we put some honey (a tablespoon or two?) in another spot on the bottom of the bowl and tasted that with our fingers too. We talked about how the peanut butter and the honey tasted and felt different from each other. Finally we sprinkled powdered sugar (lots) on top of both and let the children taste that too. Then we encouraged them to pat the sugar down into the honey and peanut butter using their hands. Patting turned into pushing. Pushing turned into stirring with a finger. Stirring with one finger turned into mixing enthusiastically with both hands (tasting frequently all the while). Eventually, with much stirring and adding lots of powdered sugar the mixture reached a play-doh like consistency. We made peanut butter play-doh. Lots of fun, yummy, and a great sensory experience. The end.

The Weekly Michael

Michael's continued theme is exploring destruction. Please tell me this is a phase. This week he deliberately pulled up his floor vent and stuffed random objects inside (multiple times). He popped Ava's balloon - with his teeth. He pulled a well attached canvas wall print off his wall and then pulled the 3M wall hangers off both the wall and the picture as well. He attempted to cut a hole in the side of a bottle of glue with his scissors (right in front of me). I have actually told him that he needs to stop and think about whether his actions will destroy or harm something before doing it and decide to stop if the answer is yes. The next time he destroyed something he just informed me that he had forgotten to think.

Ava this Week:

Baby Kitty has been replaced. At the store the other day Ava passed by a bin of $4 baby dolls. She found a pink one with a kitty embroidered on its bib and a pacifier in its mouth. She cradled that doll in her arms for at least half an hour before we left and asked so nicely if she could take it home. I couldn't resist. Certainly not for four dollars. Mama Kitty and Baby Kitty are still in bed with her, but Bitty Baby (as we call her because she's small) takes the place of honor tucked in Ava's arm as she falls asleep.

Wilbarger Deep Pressure and Proprioceptive Technique (Brushing Technique)

I have to admit, when our OT first introduced the "brushing technique" to us I thought it seemed a bit questionable. And yet I think it is working wonders.

First, some background. Ava seems to have a fair amount of tactile defensiveness. Prior to beginning occupational therapy she hated tags in her clothes. She never allowed me to fix her hair with barrettes or hair bands. She barely tolerated brushing her hair. For months, brushing her teeth involved pinning her down and brushing them as she screamed. She panicked every time she needed a band-aid. She is an extremely picky eater and her pickiness seems to be related to food texture. She doesn't like to get her hands messy and even as a very young toddler taught herself to use utensils rather than have to touch her food. Art activities were only tolerated when a paint brush or some other tool kept the paint from her hands.

Several weeks ago our occupational therapist gave me a surgical brush and showed me the brushing/deep pressure technique. At first it felt awkward and I was self conscious. Ava was a bit intolerant at first as well. After only a few sessions it became something we both enjoy. I tell her it is time for brushing and she hops right into my lap.

Now, you are supposed to do the technique every 90 minutes to 2 hours all day long. We don't. We do the technique twice a day before nap and before bedtime. I am going to try to incorporate it right after morning dressing as well. However, even with a twice a day schedule I have noticed changes.

Ava now lets me fix her hair. She is more tolerant of a wide variety of clothing situations. She is more adventurous with touching art materials, sticky foods, and muddy or dirty things. She's allowing band-aids without much of a fight. For Ava, the brushing technique has worked wonders.

She's also having a bit of a speech and language and social developmental spurt and I'm not sure that is all coincidence. I think that she's feeling more comfortable in her own skin and less overstimulated by her environment. That translates into more mental resources left over for communication.

So what is the Wilbarger Deep Pressure and Proprioceptive Technique?

This technique of brushing the skin and joint compressions was developed by Dr. Patricia Wilbarger, an occupational therapist and clinical psychologist with 30 years of experience working with children with sensory processing issues. The technique involves running a soft surgical brush (it reminds me of the brush the hospital uses to clean newborn babies) over the arms and hands, back, and legs and feet of the child with a firm pressure. The brushing is followed by a sequence of gentle joint compressions of the fingers, elbows, shoulders, hips, knees, ankles, and spine. The entire process takes only minutes and is often soothing and enjoyable for both parent and child.

Here is a link to a youtube video of an OT using the brushing technique with a young toddler. The video is pretty different than the way we do it. Our way separates the brushing from the joint compressions and is smoother, slower, and more relaxing.

Instructions for the Wilbarger Deep Pressure and Proprioceptive Technique (brushing technique)

Before I explain how we do the technique I should say that this is just the way that we do it as shown to us by our particular occupational therapist for our child. The technique may vary in other situations. Also, I highly recommend that you only perform this technique after being shown how to do it by a certified occupational therapist (which I am not).

Brushing
Use a soft surgical brush. Use pressure firm enough that the bristles on the brush bend. You may do the technique through clothes. My daughter often seems to be a little hot and sweaty and the technique seems to be easier to administer through clothing. Never brush the tummy or face.

We sing a song as we do the technique. At first I would modify the "This is the way we wash our hands, wash our hands, wash our hands. This is the way we wash our hands so early in the morning." song. The first verse would be, "This is the way we brush our arm, brush our arm, brush our arm. This is the way we brush our arm, brush our arm with Mommy." (and so on for each body part). Now I just sing the numbers 1-10 to the melody of a lullaby. It is soothing and peaceful and helps us keep a calming rhythm during the entire technique.

Sit down with crossed legs and invite your child to sit in your lap. Their back is towards you. Begin on whichever side of the body is most comfortable with you. We begin on the right. With a firm pressure, stroke up and down the full length of each body part in the sequence described from 3-10 times (as many as your child will tolerate) moving smoothly from one section of the body to the next.

1. Right arm and hand. (Both sides.)
2. Back. (Have child lean forward so you have room.)
3. Left arm and hand. (Both sides.)
4. Left leg and foot. (Both sides.)
5. Right leg and foot. (Both sides.)

Joint Compressions
You've now worked your way around the body in a circle with the brushing. Set the brush down and move right into the joint compressions. These are difficult to describe in text, which is why it is so important to have an OT demonstrate the technique for you. I will try.

1. Right elbow. Bend elbow 90 degrees supporting elbow from bottom with left hand and holding the wrist with your right. Gently push elbow down into your left hand 10 times.
2. Right shoulder. Straighten child's arm. Place left hand on top of shoulder still holding wrist with your right hand. Hold arm away from body and push straightened arm towards the shoulder 10 times.
3. Right hand's fingers and thumb. Gently squeeze each finger and thumb between your thumb and finger (one at a time) starting at the base of the finger and sliding towards the tip. Do this once per finger.
4. Left elbow. Same technique as before.
5. Left shoulder. Same technique as before.
6. Left hand's fingers and thumb. Same technique as before.
7. Left hip. Cradle the left hip from the bottom with your left hand. This is kind of like having your child sit on your left hand with the left side of their bottom. With their leg bent bring their leg towards their tummy almost like they are going to hug their legs. Place your right hand on their left knee and press down toward their hip 10 times.
8. Right hip. Same technique as before.
9. Knees and ankles. With the child still in your lap place both feet firmly on the floor with their legs bent at a 90 degree angle. Place your hands on top of their knees and gently press down towards the floor 10 times.
10. Back. Set them down on the floor right in front of you and have them cross their legs and sit up straight. Place one hand on their chest and the other on their back and press gently towards the floor 10 times.

Ava just melts into my arms by the end. It is a really peaceful time where we are completely focused on each other and we both enjoy it. The trick is to find the time in a busy day to work it into your routine.

Wishing for Another Year (Upcoming Evaluation Anxiety)

In quiet moments I am beginning to experience a sense of unease about upcoming changes. In five and a half months Ava will age out of early intervention. Before then she will be evaluated by our local school district to determine if she will continue to qualify for services.

Things are going so well right now. Ava has been making steady progress in speech. We finally identified a need for OT and are just now beginning to receive those services as well. The combination of speech and occupational therapy services is powerful and she is making progress.

I am both profoundly grateful for that progress and somewhat fearful of it at the same time. I am happy that Ava's ability to communicate is improving and her frustration is decreasing. I am happy that she's making progress towards her feeding goals. I am delighted to see her become a bit bolder with sensory exploration and a little less overwhelmed in environments that used to be overstimulating for her. At the same time, I am afraid that she will have made just enough progress that she will not qualify for services at the next level.

I feel like we are standing before a diverging path. One path takes us down a road where we can continue intense intervention through these early years and maybe, just maybe find ourselves in a place where she no longer needs extra help later on. I desperately want that path for her.

The other path involves being denied services. We will try to provide her with as many services as possible without help from the school district but it won't be the same. I worry that the second path will involve less intense intervention that results ultimately in her needing extra help for a much longer period of time.

I know it isn't that simple. I know there are always options even if they aren't the ones I want most. I just feel like this transition from the early intervention program happens so quickly. Many children are just settling into a program of services when they "age out" and have to go through another round of testing. Then, even if they do qualify, they go through another round of getting to know new therapists when the old ones were working perfectly well to begin with.

I find myself wishing that early intervention went just a year longer. Of course, I'm sure I'd still dread the transition even then, but at least she would have had the same set of therapists for 18 months rather than for 6 months by then.

It Was An Innocent Idea - Honest

I decided to recreate the success of the shaving cream in the water table day. Except this time I thought it would be fun to bring the water table up to the increasingly complete deck. I just thought the kids would enjoy the change of scenery and I knew I would love to sit on my swing while watching them instead of perched in a lawn chair in the yard down below batting away gnats. Also, for another change of pace, I decided to try cool whip (or some generic brand that was cheaper) instead of shaving cream.

First, let me say that the children did have a wonderful time. From their perspective, an hour flew by in absolute bliss as they flung first cool whip, and then water all over most of the deck. However... I don't think I completely understood how difficult it would be to remove cool whip from the wood after it had been sitting there a while. I innocently assumed that it would spray away easily with the hose. It took a bit more effort than that. Let's just say that my husband wasn't delighted with the experiment when he heard about it that evening.

As much fun as the children had with the activity, I found it interesting that they were much less bold without a friend over to model playing in it with her hands. They mostly used spoons and other various kitchen implements to play in the cool whip. They also ran over to the hose to rinse their hands and bodies off frequently. Baby steps I suppose. I need to invite friends over for these sensory activities more often.

Speedy Progress Right Off a Cliff

So Ava continues to do well with her feeding hierarchy. She's pretty much just accepted that she has to take a bite of the food she doesn't like in order to receive more of the food she wants.

Her technique so far has been to pop that food in her mouth and let it sit front and center on her tongue as if I had put something horrendously nasty in there. She grabs her milk and swallows it down as if it were a pill-tasting it as little as possible. In the name of substantial progress, I was letting the fact that she was treating perfectly yummy food like dirt go.

Well, yesterday morning, in the middle of our weekly OT session I had set her plate up with small pieces of sausage. They were the size of large blueberries. A bowl of cheerios to use as a reward had been set to the side. She asked for cheerios. I told her she'd need to eat a small bite of sausage first and I stepped away from the table to grab a knife. Usually I cut a tiny sliver off the larger piece of sausage for her to try.

Well, when my back was turned she popped the entire piece of sausage in her mouth and tried to swallow it whole by gulping several large gulps of milk. I turned around to see her choking back up all the milk and finally (thankfully) the piece of sausage too right back into her lap.

I calmed her down, cleaned her up, and told her I was proud of her for trying such a big piece. I then tried to explain that we can't swallow such big pieces without chewing them first. I'm pretty sure she didn't really get it.

So now we're working on teaching her to put food in the side of her mouth and to chew it up in an exaggerated way. We're teaching the technique with foods she likes first. Once she's really good at it, I'll have to insist she actually chew the things she doesn't like before swallowing them and getting a reward.

I'm pretty sure that this next step forward is going to be a big struggle.

Therapy and Hierarchies of Difficulty

In general, therapy consists of breaking complicated tasks down into a hierarchy of components and then working on those components from easiest to hardest. So in speech therapy we start with sounds in isolation, then at the syllable level, then at the beginning, middle, and ends of words, then in phrases, then in sentences, and finally in conversation.

In OT we've been working on getting Ava to try new foods. Prior to OT, the only options I could think of were to try to make her try a bite (ha, ha) or to just put it on her plate and hope that eventually she'd try it if she were hungry enough and if everyone else around her was trying it. Well, nothing was working. She was never hungry enough to try something out of her comfort zone. She didn't respond to playing (let's play airplane type activities). She didn't respond to comments that her brother was doing a good job trying it. She didn't even respond to bribery (eat just a little and I'll give you a treat).

Our OT introduced a hierarchy for getting Ava to try new foods. I never would have thought of it on my own, but it is working.

The lowest level is just getting her to touch the food. I used tricks like asking her to test if it is too hot for me while pretending to be busy pouring a drink so I couldn't do it myself. I wasn't asking her to eat it yet - just to touch it.

The next step was to get her to just give it a kiss. She didn't have to eat it, just kiss it. Now this required a combination with bribery. We needed to fill her plate with something she didn't like and something she did like. She didn't get more of the food she did like until she gave the other food a kiss. This step took a little longer, but eventually she realized that giving food a kiss was not a big deal.

The next step was to give the food a little lick (if it is solid - this would't work with a pudding or anything like that). So when she wouldn't eat sausage, I could put a piece on a fork and she'd lick it. Again, we have to bribe her to do it for a second serving of something she likes.

The next step is to eat some of the new food. Sometimes we cut it into a very, very tiny taste and put it on a fork for her. She'll put it in her mouth and wash it down with a big gulp of milk. She doesn't actually chew it, but still it is a big step in the right direction.

Other times we use a food mill. You can put food in it and the children can help grind it up by turning the handle. We tell them they're making "magic" food. Then she can try a small taste of the magic food before she gets to eat something else.

A month ago Ava would absolutely refuse to touch or even consider trying anything outside her comfort zone. She honestly preferred to go hungry. She rarely ate more than 1 out of 3 things on her plate. A month ago our OT introduced the hierarchy (touch, kiss, lick, tiny taste, regular bite...) to us. Now I can get Ava to at least taste a tiny amount of a new food at least 80% of the time. It is a huge change and I'm so proud of her. It's amazing what a little knowledge and some new strategies can do for a situation that seemed impossible to change.

A Flurry of Activities

We had a friend over for a playdate Wednesday and I decided to fill our water table with shaving cream (outdoors). The children had a blast. The modeling of a typically developing peer is so powerful. They had their hands in it and were covering the glass of the french doors with it. When our guest began painting her arms and legs with it we decided to strip them down to their underwear. Before all was done, our guest looked like a snowman front and back and Ava had covered her entire belly and most of her legs. It was wonderful. Two weeks ago we had to persuade her to touch the shaving cream with a fingertip. All the credit goes to the great modeling of her friend.

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They came back for a bonus visit yesterday and my bright idea this time was to redo the pudding activity, but this time in an empty bathtub for more exposure and easier cleanup. We put the two girls in the bathtub with a bowl full of pudding I had colored with green paint and told them to have fun painting. I gave them paintbrushes because I was hoping that there would be no way Ava could avoid getting covered in at least a little of the pudding even with the paintbrushes to help get her started. Well, they quickly ran out of pudding and I grabbed some washable fingerpaint and we just continued the fun. Every time the walls filled with paint I would simply shower them off and the girls would begin again. They were in there at least an hour. It was great.

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We had an old baby gate. It was the huge kind you can use to make a play yard. Or, in our case, to protect the little ones from a huge brick fireplace. We're no longer using the gate. I set the gate up in play yard formation and used some old blanket and baby wraps to make a tent, or cave. The kids loved it until they destroyed it. Here's a picture I managed to take before the destruction.

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One last fun activity we did this week was to take some bowls of water, paintbrushes, and ice out on the deck. The children had fun "painting" the wood with the water and just exploring pouring water and playing with ice cubes. We were out there for at least an hour two separate times this week. We went through three huge bowls of ice cubes each time, but it was completely worth it.

OT and Pudding

Our occupational therapist showed up yesterday morning with a box of pudding. I'm not a huge fan of pudding myself, so I'm pretty sure my children have never made pudding before. They might have been served some at school or at my parent's house. Perhaps they've tried some at a buffet. We've never had any here at home though.

Our goals for the day were to work on feeding (she came at breakfast time) and to continue to work on sensory exploration. While I made breakfast (eggs, sausage, and dry cheerios) the OT made vanilla pudding with the children. The children enjoyed tasting the dry mix, measuring and pouring in the milk, and stirring the pudding. Then we let the pudding set while we ate breakfast.

Ava likes dry cheerios, tolerates a little egg, and traditionally won't touch sausage. That was exactly the mix that the OT requested. First we got Ava to touch the sausage in exchange for some extra cheerios. Then we persuaded her to kiss a piece of sausage in exchange for more cheerios. Finally, we did manage to get her to lick it in exchange for some cheerios. She did not eat any. However, a month ago, I couldn't even get her to touch something she refused to eat so getting her to lick something is significant progress.

After breakfast, our OT wanted the children to fingerpaint with the vanilla pudding on construction paper. We got all set up. Everyone chose their favorite color construction paper (orange for Michael and pink for Ava). Then the OT put a dollop of pudding on each piece of construction paper. Both kids took one look and absolutely refused to touch it.

The OT modeled making a sun on her piece of paper. The kids were still not tempted. She used some cheerios to give her sun a smiley face. Still no takers on the activity. She offered them a paper towel to help keep their hands clean. Nope. Then I remembered a comment from one of my readers about how her son would only play with shaving cream if there was a bowl of water nearby (Thanks Gentle Blue!). I went and got two bowls of water and finally we were able to get started. Michael went first and Ava started tentatively with one finger. We made dots and lines. We tried unsuccessfully to get handprints. Ava washed her finger off in that bowl of water after every single dot or line.

I got Ava to play a game where I would draw something with the pudding and then she'd "erase" it with her finger. She always enjoys that game. I tried to continue the playful atmosphere by dabbing some pudding on the back of her hand. It was a big mistake. She had a meltdown. We had to clean her hands off instantly and she refused to participate or even stay at the table after that. I felt terrible. Instead of the experience ending on a slightly positive or neutral note, I pushed her too far and it ended really negatively. Lesson learned I suppose.

It is fascinating to see the variety of rather common household substances (shaving cream, cornstarch and water, instant pudding) that the OT is using in therapy. It's been good. I've been very pleased with how things are going so far.

OT and Oobleck

We had occupational therapy again today. Today we spent the entire time with oobleck. For those of you who are unfamiliar with oobleck, it is a simple homemade substance that is made by mixing one part water with 1.5 to 2 parts cornstarch. It makes a substance by suspending the cornstarch particles in the water. The substance is pretty unique. It behaves like both a liquid and a solid. When under pressure it behaves like a solid. Otherwise is behaves like a liquid. So you can pick it up in your palm and squeeze it into a ball, but when you release the pressure a bit it drips down between your fingers like a liquid.

First we put a pile of cornstarch on a cookie sheet and let the kids explore that with their hands. That alone was a bit of a stretch for Ava because of the way the cornstarch covered her hands and was difficult to wipe off. Then we began adding water and she wanted none of it. She mostly observed for the next 20 minutes or so. Michael was hesitant, but when he began to play with it he had a blast.

I just let Ava watch me play with it. The messier my hands got the more agitated she became. She actually broke down in tears at one point when my hands were covered in it and I refused to clean them off quickly enough for her. I eventually got her to poke at it a little bit in exchange for a spoon. Once she had a spoon she had fun scooping it up and watching it drip back down onto the pan. Some would cling to the spoon and I did manage to persuade her to use a finger to push the last few remnants off the spoon.

Another thing we did was get out some markers. The children could draw on the surface of the oobleck with markers and make pictures. When it got mixed up again, the oobleck combined with the color of the markers. Ava's turned pink. Michael's ended up grey because he experimented with so many colors. We did start with yellow and then blue which combined to make green. That was fun. The markers just rinsed clean.

We will have to play with oobleck several more times over the next few weeks and try to increase Ava's tolerance of it. Does anyone have any suggestions for activities with oobleck other than simply playing with it and then coloring on it? I didn't get any pictures this time, but I definitely will next time so I can share them with you.

First OT Session

We had our first occupational therapy session yesterday. It went so well. Michael was able to fully participate in all of the activities which helped a lot. After watching her brother do something first Ava didn't want to be left out so she'd try too. Our OT's plan was to alternate sensory activities with fun motor activities. The idea was that the motor activities would be a fun break between the sensory activities which might be stressful for her.

First they bounced on an exercise ball mostly as a warm up and to develop rapport. Then they dug around in a container of rice and then a container of pasta for hidden objects. The pasta was no problem. Ava liked the rice until she realized it left a white powdery residue on her hands, but she stuck with it. Both of those were relatively easy because they were dry.

Then they got a ride on a kind of padded dolly as a motor activity break. The next activity was playing with moon sand. This is some kind of synthetic sand that feels moist and sticks together. Ava started playing with it using spoons and containers and resisted touching it with her hands, but gradually as she watched me play, and her brother play, and the OT play, she got bolder. Towards the end she was using her hands pretty well, but was bothered by any residue left on her hands and by the sand that ended up scattered on the floor. She kept moving her tray to a new spot to try to find a clean spot to play in.

The last activity we tried was shaving cream. To be honest, both children were a little hesitant to get in there with their hands, but Michael tried it first. As the texture became more familiar he moved from a fingertip, to multiple fingertips, to his whole hand. Ava took a lot longer and was a lot more agitated, but we eventually managed the same progression with her as well. She needed a cloth nearby and frequently cleaned her hands off.

We would spread a thin layer of shaving cream all over the tray and then draw shapes in it. I would make a flower on Ava's tray and then say, "No, no, please don't erase my flower!" Of course, that made her just want to wipe it away, but in order to do so she had to stick her entire hand in there to rub it out.

All in all the session went beautifully. The children had a blast and will definitely be looking forward to the next visit from the OT. Ava's tolerance for new sensory experiences was definitely stretched, but not pushed too far. I'll have to put shaving cream on our shopping list this week.

OT Evaluation Report

Our OT evaluation addressed two main areas: sensory and feeding. Therefore her OT report covered those two topics.

The sensory issues were addressed through a standardized sensory profile administered via parent report. Essentially, I answered a lot of questions about Ava. The profile covers auditory processing, visual processing, tactile processing, vestibular processing, oral-sensory processing, low registration, sensation seeking, sensory sensitivity, and sensation avoiding.

Ava scored in the typical range for vestibular processing, low registration, and sensory sensitivity. She also scored in the typical range for tactile processing, but the OT commented that Ava does seem to have some tactile processing hypersensitivity (doesn't play with food, play-dough, messy art materials, etc.). She responds slightly less than normal to auditory and visual inputs. She responds more than normal to oral inputs (food). She also scored high in sensation avoiding. She withdraws in group situations, avoids noisy places, avoids foods with strange textures, resists being touched by anyone other than very familiar family members, etc.

Nothing in the sensory profile was surprising. That makes sense, because the results were based upon my own observations. I am anxious to begin therapy and see how the OT recommends addressing her sensitivities.

As for feeding issues, again, the report was mostly a summary of my answers regarding Ava's food avoidances and preferences. The only new information was that her gag reflex is not overly sensitive. Again, I am interested to see where therapy takes us. The report itself didn't reveal anything earth-shattering here either.

I am mostly looking forward to beginning her OT therapy to see what that therapy will consist of and how much it helps. I want to help her with her eating issues for obvious reasons. I need to help her with the sensory issues for two reasons. The first is social. I don't want her hypersensitivity to prevent her from being able to socialize normally. The second reason is her speech. With apraxia, the greater the processing demands, the more difficult speech is for our children. So, when Ava is in an environment that is overstimulating for her, her system is so busy trying to deal with that overload, that her speech tanks. I hear her communicate so much less when we are out, when she is at school, and when we have a lot of people around. If we can start to work on that hypersensitivity to her environment, perhaps her speech will improve in these settings.

Hurry Up and Wait

Our OT evaluation yesterday was something of a mixed bag. It took two hours. The vast majority of that was mostly the OT asking questions and listening to my answers. We filled out one test instrument that was a parent questionnaire designed to give a "sensory profile".

We did very little hands-on work with Ava. She did teach me how to test Ava's gag reflex. That went startlingly well actually. As it turns out, Ava's gag reflex is not overly sensitive. Ava was very, very anti-social. Perhaps if Ava had been more receptive, the evaluation would have been more hands-on.

The OT observed me giving Ava lunch. She requested that I serve Ava one thing I know she likes (grapes) and one thing that she doesn't love, but she might occasionally eat (egg). Now, Ava used to eat egg when she was littler. I haven't gotten her to eat it in months. Today, she ate it with very little prompting. Why do they always do that?

And now I just wait for the results of the evaluation. It feels odd. I think somehow I thought this evaluation would provide a lot of answers and I hadn't stopped to think about the fact that I wouldn't get them right away. Silly of me. I used to do nothing but speech evaluations and so I know that tests have to be scored before the results are given. And so the next wait begins.

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In other news, we're now trying liquid oral antibiotics for the mystery ailment that's been upsetting the kittens' tummies for over three weeks now. I will be trying the first doses tonight (two different kinds). Somehow I'm not expecting this to go well at all.

All Set for OT Evaluation

Our OT evaluation is scheduled for today. My mom (who just retired last week - Congratulations Mom!) is going to watch Michael. As much as I love Michael, he is a rather overwhelming presence when around. I need to be able to focus on Ava and the occupational therapist and on answering her questions rather than on trying to keep Michael quiet and out of the way.

In one way, I am excited. I know speech pathology. I know Apraxia. Those areas are familiar and comfortable. I know very little about occupational therapy and I am excited professionally about getting to watch an occupational therapist at work. Even as a mother I am excited. Ava will finally be getting an assessment and hopefully some help to address some of her other needs. I always had some idea of how to address her speech issues, but I don't know how to help her with her sensory ones. So I am excited to be getting some help for her in that area.

When the OT called to set up a time for her evaluation we chatted for a few minutes. One of the things she asked me was if I thought Ava had a particularly sensitive gag reflex. (She asked the question in the context of her food pickiness.) I told her I hadn't really observed Ava gagging while eating because she won't even try things she thinks she won't like. So, the OT said, "Do you think she'll let me check her gag reflex?" Hahahahahahaha. Oh my. What I said, very politely, was, "We can try." What I thought was, "Hell, no!" So, I think we'll be looking at a very... interesting hour later today.

Our First, and Only, 6-Month IFSP Meeting

Unlike IEPs, IFSPs are reassessed twice a year. Our 6-month IFSP meeting was held Monday morning. I was nervous going into that meeting. Ava has made great strides and I was a little concerned they would tell me that she didn't qualify for services any more.

As it turns out, I didn't need to worry quite so much about that. I was careful to stay focued on her needs rather than her successes, but I did not exaggerate her needs. The main ones I see right now (in no particular order) are:

• The more stress she's under, the more difficulty she has communicating. So, when she's upset or hurt, that is when she tends to lose her words. Those moments are exactly the ones in which you need for her to communicate the most.
• Although Ava is making many communication attempts at home, she is reluctant or unable to communicate at school with her teachers and peers. At school she'd often rather go without than try to tell someone what she needs. At school she doesn't even try to talk to the other children in the classroom. That situation just breaks my heart and I desperately want to see improvement there.
• As an SLP, I continue to recognize the comprehensiveness of the speech delay in terms of intelligibility, but early intervention won't really write goals for specific speech sounds or intelligibility issues because there is such a wide range of normal at this age. That doesn't make it less valid, just something out of the scope of early intervention apparently.

So, we reviewed her speech progress and discussed her speech needs rewriting her goals and continuing her in speech therapy for an hour a week. If our therapist's schedule permits, she will actually see Ava at school in order to facilitate her communication and speech there. I will obviously continue to work with Ava here at home.

The big story of the IFSP meeting, however, is that we veered off into an entirely new direction. My service coordinator sent me a questionaire ahead of time and one of the questions was about my areas of concern for Ava. Almost on a whim, I wrote in a couple of non-speech items that have been bugging me for a while now. Honestly, I was expecting to bring them up and be reassured that they were within the normal range for kids her age. That's not exactly the way it went.

I've noticed that Ava is really sensitive to noise. The sound of the washer or dryer running will bother her enough while she is watching television in another room for her to leave the tv, run around the corner and down a hallway and shut the door to the laundry room. The flushing of the toilet in a restroom bothers her. Her hands clap over her ears and she recites, "loud, loud, loud" until the sound stops. Her father's electric razer will get the same reaction. We took the kids to their first movie (Winnie the Pooh) and I spent the entire time with my hands over her ears trying to reassure her that it really was all right.

Another issue is her picky eating. It is getting worse and worse and seems to be related to texture. She doesn't like to touch things that are messy and if her hands do get messy she immediately wants a napkin. She doesn't like to be touched or restrained. When other children approach her she gets really upset and reacts almost as if she's been hit. Washing her hair and face is pretty traumatic because she reacts so poorly to the washcloth and tilting her head back.

Well, to make a long story a bit shorter, we've added an hour of occupational therapy to her services. They feel like some OT might make a big difference with her feeding and bathing issues and other sensitivities.

I've never been closely involved with occupational therapy services before and so this will be a whole new area for me. I am hopeful that they can help Ava to be less sensitive and to experience the world a little more comfortably and fully. That would be such a gift to her.

All in all, a useful IFSP meeting. Next up: transition meeting and scheduling our first occupational therapy session.