Postural control in children with sensory processing disorder

           Postural control in children with sensory processing disorder

In order to meet the environmental demands in an effective way, a child must be able to assume and maintain stable positions, move without losing balance and have adequate postural control to support movements of hands and legs. This becomes essential for a child to be competitive and successful at his/her performance areas such as play, home and school.

Postural deficits that are often associated with vestibular and proprioceptive dysfunction include a group of components as follows.

1. Low tone in extensor muscles

2. Poor postural stability

3. Poor co-contraction

4. Poor equilibrium reactions

5. Poor tonic flexion in neck muscles.

Example of poor postural control: A teacher complained about child that each time the child was asked to pick up materials from bag that was placed under the chair, the child had to get up from chair, turn around, sit down to pick up  things and repeat the same procedure to get back to chair. The child lacked the postural control that was required to remain seated and retrieve the materials from the bag. This is a typical example of inadequate postural control.

Home and school behavior:

-          Finds difficulty sitting still

-          Appears clumsy

-          May be lethargic/ lazy or be slow at day to day activities

-          Looses balance and falls often

-          May seem weak due to poor proprioception

-          May seek intense vestibular input yet avoid challenging vestibular activities while on play ground with peers present

-          Drops things often from hand

When children exhibit cluster of postural difficulties, they are most likely to have difficulty in processing vestibular and proprioceptive sensation. Hence intervention should be emphasized on activities that provide enhanced vestibular and proprioceptive sensation that simultaneously challenge posture. Those activities should address the following 4 components of posture.

-          Postural extension

-          Postural flexion

-          Postural stability

-          Balance

A. Postural extension: Activities given on prone position, i.e., child lying on tummy, gives good effort to extension position. These include,

-          Lying prone on flat swing and do activities like fixing puzzles, dropping coins etc using hands

-          Lying prone on gym ball and reach for toys overhead to allow lifting head and neck against gravity

-          Lying prone on elbows and playing with toys or blowing candles placed in front can be given for kids with low muscle tone

-          Lying prone from a higher surface such as cot or barrel/ bolster and weight bear with hands on floor will allow good co-contraction for shoulder and neck muscles and performing activities using one hand in this position will provide good opportunity for weight shifting.

-          Lying prone on a wedge with neck and arm unsupported to net a ball into a basket overhead is a highly challenging task for developing tonic extension.

-          Activities can be done lying prone on scooter board, hammock or lycra swing

B. Postural flexion: Activities given on supine position, i.e., child lying on back, where head and limbs are aimed at moving towards the abdomen gives good effort to flexion position. These include,

-          Lying supine on an inclined mattress or wedge and raising head and trunk to reach target held by the care giver

-          Lying supine with a little pillow under head and playing kicking ball

-          Lying supine on floor and propelling swing through legs

-          Sitting on a disc swing, hammock or lycra swing and picking up objects from floor

-          Hanging on trapeze to swing and cross over an obstacle

C.  Postural stability: Creating activities with postural rotation and weight shifting helps the child attain postural stability through facilitating mobility superimposed on stability.

-          Rotation can be given through activities such as rolling inside a barrel, swinging at all directions with change in body postures as in reaching for toys overhead and under swing etc

-          Weight shifting can be given using any piece of equipment that move or any activity that involves reaching at various positions such as kneeling, standing, quadruped, one leg standing, squatting, bending etc.

  D. Balance: The ultimate goal of postural control is to maintain body balance when there is a movement threat to the body or support surface. This can be achieved through reaching out from various static postures to elicit subtle equilibrium reactions and progressing to activities that can be performed by placing the child on any unstable equipment such as swing, gym ball, balance board, balance beam, bean bag, spin disc, see saw, etc. Care should be taken that activities to develop balance should progress from static to dynamic postures and should never be a threat to the child.

Group therapy for children with autism

Group therapy at THULIR

For a child to be independent and successful in his/her social environment such as home, school, peer group, etc, the child must possess social skills like communicating, sharing, waiting, turn taking, apologizing, requesting, thanking, competing, being aware of other’s needs and having age appropriate play skills. In order to develop these skills in children receiving occupational therapy at our centre, we started conducting group sessions.

Four children, two boys and girls, aged between 5 and 7 years with similar cognitive levels were taken for group therapy. All four children (referred to be in group 1) were diagnosed under autism spectrum disorders, and specifically had sensory processing issues related to bilateral integration and sequencing, and three of them had tactile defensiveness.

At the level of initial assessment, children

·         Were able orient to time, place and person,

·         Were able to follow simple commands

·         Knew basic concepts like colours, alphabets, numbers, shapes, categories of objects, etc and were going to mainstream school.

·         Were not having social skills like, greeting others without prompt, listening to others, etc

·         Had problems in maintaining eye contact

·         Lacked group skills like waiting, taking turns, or play with peers,

·         Were not able to accept or tolerate other children’s company.

Hence group therapy was planned carrying the above mentioned problems as goals which include one activity from each of the following categories.

1.      Children were asked to greet each others, parents and therapists by names with eye contact

2.      Warm up activities such as jumping on trampoline, breaking soap bubbles, tapping balls/balloons ,etc were given  were children were expected to stay within the given boundaries which helps to develop tolerance to touch, were asked to give chance and wait for others turn which develops sharing and waiting.

3.      Activities like holding hands and jumping across rope, jumping together within hoola loop, crossing over obstacles in a line,  walking together inside lycra swing, doing animal walks like crab walk, bear walk, frog jump, etc, together in a line, were given. This helps to develop skills such as doing activities together in a group, tolerating other’s touch, waiting for others to complete their task and join the group, waiting for commands and control impulsivity..

4.      Activities like singing rhymes, doing action imitations, spelling words, counting numbers, reciting alphabets, were given were each child was asked to perform these tasks in turns  in front of other kids and parents. This helps to develop eye contact, reduce social hesitation, and improve self confidence.

5.      Activities requiring exchange of puzzles or toys among each others were given to provide opportunities for verbal communication. Concepts such as “give me”, “take it”, “thank you” and “welcome” were taught.

6.      Activities like target throwing, ball catching, board games with dice, actions on commands etc were given to develop game concepts in children.

7.      To teach sharing, snack time was present at the end of all sessions were each child was asked to share a piece of given snack to each other and eat once all of the get their share.

8.      At last, children were taught to say “bye-bye “to each others, parents and therapists by their names.

Each of the group session would last for one hour including 7 to 8 activities from the above mentioned categories with two minutes breaks between each activity. After 8months of group therapy children are now able to

·         Greet each other without prompt

·         Recognize the absence of other child

·         Enjoy the presence of other kids and show emotional attachment

·         Show tolerance to touch better than before

·         Understand turn taking and able to wait for others turn without prompt

·         Initiate activities like rhymes action imitation etc

·         Verbally use “give me” , “take it”, “thank you” and “welcome” appropriately without prompt

·         Point out when others did not wait or take turn appropriately

·         Share and eat without prompt

·          Listen and follow instruction and learn simple new games

The future goals of the group session would be to improve verbal communication, to introduce concepts of competition, winning and losing, to improve listening skills and to develop age appropriate play skills.

Study Finds ADHD Improves With Sensory Intervention

http://www.sciencedaily.com/releases/2005/05/050513103548.htm

News - Occupational Therapy for Autism

An article on"Autistic children's ability to perform everyday tasks improved by occupational therapy" was released by Medical News Today on 27th November 2013. The following URL will link to the original article. http://www.medicalnewstoday.com/releases/269371.php

How to teach colours to children

Colour recognition is the ability to identify and name basic colours. Colour recognition is important in recognizing objects around us and it is a precursor to language in the context of naming and using adjectives. Recognizing colours or other general concepts like shapes, numbers, alphabets, etc. develops in a child in the order of sorting / matching, identifying, naming and generalizing, where, in the context of colour concepts,

·        Matching denotes the ability to match similar coloured objects

·        Identifying denotes the ability to identify a colour when it is named

·        Naming denotes the ability to name a colour when asked

·     Generalizing denotes the ability to understand the similarity of colours in varied objects

Matching:

Initially, in teaching colour concepts, only one or two primary colours must be taught at all levels of matching, identification naming and generalization. To begin with teaching colour concepts, the child is given activities that involve matching. For example, collect objects of similar shape or size but different colours like yellow and red beads or yellow and red coins. Take two cups, one in yellow and one in red. To teach matching, the child is expected to drop the red coin in the red cup and the yellow coin in yellow cup. Encourage positive responses and correct the wrong attempts. Once the child masters this, include more colours like blue, green, black, white etc.

Generally, children tend to easily achieve this level of matching and parents would begin to proceed to next level- identification. But practically, the transition between matching and identification must be including another phase which involves matching of same colour with objects that are varied by size and shape. We, in our centre, took 15 children with varied cognitive abilities to teach colour concepts. Among them, 11 children could do matching of all primary colours efficiently but could not progress directly to identification.

After matching red and yellow coin in red and yellow cup respectively, the children (individually ) were instructed to pick red coin when named and drop in the red cup (this is identification). All of them were able to leave yellow coins and pick up red coin and drop in the red cup. But when red and yellow coins and red and yellow beads were mixed and presented, children were able to pick up red “coins” but not the red “beads” when instructed to pick up red. This implies that children paired the word “red” for only “red coins”. They could match colours for only those objects that are similar in shape or size. So, before moving to identification children must be trained to match colours of both similarly sized or shaped objects and differently sized or shaped objects.

Hence, the steps in matching would be:

1.     From a group of red and yellow coins, match only red coins to the red cup

2.     From a group of red and yellow coins and red and yellow beads match only red coins and red beads to the red cup

3.     From a group of red and yellow coins, red and yellow beads, red and yellow balls, match only red coins, red beads, red balls to the red cup

4.     Follow the above steps to all other colours

Identification:

Once matching is achieved for all basic colours with varieties of objects, identification of colours can be taught. Here children will be presented with objects of varied colours and varied shapes/size and asked to identify the named colours. 

Eg. 1. Present yellow bead and red ball and ask the child to pick up red

          Eg. 2. Present red ball and yellow block and ask the child to pick up yellow.

          Follow the same for all other colours. In identification, parents/teachers must name colours and child must be asked to repeat the naming during identification. This is the precursor of the next level – naming of colours. For example when the parent says “pick up red”, the child must say “red” when picking up red object. Here the child is learning to pair the name of the colour to the object.

Naming:

          In this level, the child must be asked to name the colour of the object for example when the parent says “what is the colour of the ball”, the child must say “red”. If this is not achieved, the child must again be taught identification.

Generalization:

          This involves naming of colours that are fixed colours of objects. Example generalization involves the understanding that red is common for apple, tomato, pomegranate, blood, rose, etc. in this the child must be asked to list objects that are of red colour, yellow colour and so on.

  

Article on echolalia

Autism and Echolalia (Repetitive Speech) – Questions and Answers - Craig Kendall, the author of The Asperger’s Syndrome Survival Guide

Your child is repeating movie and TV scripts all day, and showing all the signs associated with autism and echolalia. What should you do? Should you be worried? Not quite, says some language and autism experts who discuss the topic.

First of all, what is echolalia? This is when a child with autism will either repeat back to you what you have just said, or what they heard someone say earlier, or they will repeat seemingly random lines from kid’s TV shows or movies that they have heard.

This may seem, at first glance, like totally non-functional communication to you. It may seem very frustrating, because you’re trying to talk to your child and all you’re getting back is seeming nonsense. It probably will have you worried for your child’s development.

Scripting, Autism and Echolalia

But actually, if you look closer, these seeming nonsense statements are actually quite full of meaning. Kids with autism who have echolalia will often do something called “scripting,” which is repeating scripts from TV shows or movies. They do this because they don’t have the language skills or ability, yet, to come up with their own language. But, they have learned that they can express a need or a feeling by matching it to the thousands of statements they have stored in their head from watching things like Blue’s Clues, Dora the Explorer or other such things.

Emotions are easier to understand on exaggerated kids’ shows. Therefore, kids with autism may be able to understand the language easier and due to their great memories, save it for a time when they need it. This is what happens with autism and echolalia.

So, if you hear a bizarre statement that doesn’t seem to quite fit, see if you can recognize it from one of the shows your child watches. For example, one mother gave the example of a kids’ TV show where one character is tired of the other and says “I’m going to go read in the bathroom!” Her son uses it to express the feeling of “I’m done with this; I want to be by myself.”

The actual words in an echolalic statement don’t really matter. They are just placeholders for the emotion being expressed. So her son doesn’t actually want to read OR go to the bathroom – he wants to go off on his own. You kind of need to know the original show it’s from to understand what’s being said, but it’s far from nonsense language. You can ask “Where is that from?” to try to get more clues about the origin and meaning.

Autism and Echolalia – Should I Discourage this Behavior?

Many parents wonder, Should I be trying to stop my kid from using echolalia? Should I ignore him and try to coach him out of it? They want their child to be more “appropriate” and more easily understood by the outside world. But the answer is no – no, you shouldn’t. Language does not come easy for many kids with autism. Any attempts at all at language should be rewarded and appreciated.

It has actually been shown that echolalia is a positive indicator that the child will gain functional language. But, like all other things for a child with autism and echolalia, it will just come much later than their peers.

Echolalia is part of a “gestalt” system of learning language. That means language is learned gradually and absorbed from the environment, until one day it all just seems to coalesce and make sense, or at least more sense. This is as opposed to the more analytical, word by word form of language learning that most typical kids turn to by the time they’re of school age. This doesn’t work nearly as well for most kids with autism.

Autism and Echolalia – Echolalia as a Developmental Step in Building Language

Echolalia can come in two forms, immediate and delayed. Immediate echolalia is when the child repeats something you just said instead of giving a response. If this happens, be patient. At least there is an attempt to communicate. You may want to reinforce verbal skills by having pictures of different choices and feelings for them to point to. Know that if you say something like, “Do you want juice or milk?” and the response is “Or milk,” it doesn’t necessarily mean they want milk. They’re just repeating the last part they heard. Try turning it around and asking it the other way. Sometimes you’ll just have to guess.

Delayed echolalia is when the child repeats something from movies or TV, or something they heard earlier.

Eventually they get better at choosing the right script for the moment so that you might not even know they were scripting if you weren’t already familiar with the scripts. Then that turns into “modified echolalia,” where they will sometimes keep the basic structure of the script but replace it with words that are more appropriate to the situation. Names will be swapped out for the people actually in the situation; descriptions will be closer to what is actually going on.

After more time goes on, this will usually lead to some sort of spontaneous language. It will start with only a few words at a time, but eventually it will evolve into several word sentences. Scripting provides a good base for the child with autism to learn about the structure of and use of language until they have acquired enough skills to use it on their own, according to many accounts of autism and echolalia.

When Does Echolalia Occur?

Even after there has been some language development and ability to use language independently, kids with autism may still script when they’re feeling particularly stressed out or anxious. The scripts are comfortable and familiar and it takes some of the stress off of them. Also, they may be used when the kid just plain doesn’t know the answer or how to answer.

A lot of kids with autism don’t know how to say “I don’t know.” Sometimes this is teachable. Gather together a series of questions that may be commonly asked in daily life but that you don’t think they will know the answer to. Model to them how to say “I don’t know.” Prompt the “I don’t know” after each question. You may even want to reward them with a small token after each “I don’t know,” and then graduate to rewarding only when it is spontaneous. This will, at the least, make communication about some things a little easier and also more comprehensible to those not familiar with the scripts.

Typical kids and babies coo and babble when they are toddlers and just beginning to learn how to speak. They are trying to imitate what they hear and what is going on around them before they can put it all together. The only difference is, with autism, it can take longer – much longer – for this to happen.

But for many kids it WILL happen, and using echolalia is a natural step to learning language. If you are patient and reward their efforts, if you try to get into their world and respond to them, you will find that autism and echolalia doesn’t have to be quite the volatile mix that you might have thought it was going to be. 

OT intervention for autism; case example - 1

At  4 years of age, Hari  was brought to  us with the complaints of  repeating words all the time, not able to speak in sentences, not mingling much with peers, not being imaginative in play, not showing hand preference yet, not eating all kinds of food, restricts many textures and touch of others, etc. He was diagnosed before to have speech and language delay and was treated by a communication therapist for a couple of months. On occupational therapy observation and evaluation, he was found to be markedly tactile defensive and had problems in bilateral integration and sequencing. Hari was an active, happy child with good comprehension and was intrinsically motivated to play.

Our immediate goal in working with Hari was to address tactile defensiveness in order help him maintain optimal arousal level even in the tactile rich environment as in play ground or in class room   activities involving peer touch and to address oromotor issues such as problems in suck- swallow- breath(SSB) synchrony, oral sensitivity shown through non acceptance to brush teeth, put water in and around mouth, eat fruits or any other sticky soft textured food, highly restricted choice of taste, etc.

He was under our occupational therapy intervention since two and a half months having three sessions per week.  Most of his sessions started with activities of his choice modified to give large amounts of deep pressure and proprioceptive inputs followed by enhanced tactile experiences. The latter half of the session focused on improving oral motor skills followed by a ten min work out on language and academic skills.

Within this period of intervention, Hari has shown good improvements in accepting to be exposed to and play with materials like clay, wet sand, oil, rough textured mats, etc, which used to evoke high defensive reactions previously  that as expressed through high pitched voice, tip toe standing, avoidance of touch, etc. Hari’s mother reported that he has started hugging his cousins and grandparents and playing with children in groups for 5 to 10 min. He still has problems in brushing teeth, washing face, wearing slippers instead of shoes, etc, which we are hoping would get better with further therapy.  

Focus of Discussion:

                Hari is brought into our discussion especially to share our views on his oromotor skill development.  Apart from oral sensitivity issues, he had problems in sucking food stuffs from within his cheeks, using his tongue appropriately to move food within his mouth, licking lollipops and sucking in the juice with proper lip closure, etc. These problems are the results of his inadequate Suck- Swallow- Breath Synchrony which seemed to interfere in his speech too.  We used a wash cloth dipped in juice to train suck-swallow pattern with lip closure. The juice dipped cloth was kept in his cheeks and he was taught to suck and swallow the juice from the cloth without taking the cloth out from the mouth. This was later generalized to eating, drumstick, sugar cane, etc. This helped him to learn to create a negative pressure inside his mouth which resulted in better sucking, chewing, and tongue lateralization within a week of intervention.

Note:     The same technique was tried in four other children with similar problem in SSB synchrony. All of them showed reasonable improvements which show that, using wet cloth to teach sucking might help improve oromotor skills in children with oromotor integration.