This week we had to make some accommodation for self-regulation and communication. Joey typically uses an eye gaze device for communication, but when he is on the ground as we need to be for physical OT work, he is unable to access this device. To give him a form of communication even without his device, we use some simple signs and give two choices holding out hands to correspond with each choice. Joey can then pick which hand/choice and have more control over the situation. He has been introduced to a variety of signs including more (mastered and easily recognized) all done (emerging), thank you (mastered and easily recognized), please (mastered and easily recognized), and help (emerging). He is encouraged to use the signs to communicate when he is visibly frustrated, crying, or kicking with his feet. This is not as helpful as his eye gaze communication device, but allows the adults helping him to understand the root of his frustration or sadness and address it appropriately.

Joey can get frustrated and show decreased goal-directed persistence (pushing through difficulties to finish a task) especially with placing the coins into the slot on his box. He much prefers to do the squigz, as he has improved in his manipulation of squigz and has more instant gratification when placing them into the box, typically getting it within his first few attempts. (Squigz are easier to grasp because they have a bulb on them where the coins are flat). This is where the help sign would be useful.

 

Week Five Areas of Challenge: Self-regulation and communication. This is becoming an area of challenge for most families as they progress further into the weeks of no school or virtual school to structure their days. We addressed it by continuing to build and remind Joey of his sign language to communicate rather than kicking or crying.

 

Week Five Areas of Success: Joey has enjoyed placing squigz in the box so much, it’s reported he even does this when he’s not in OT. Playful engagement that the child is willing to do outside of therapy is valuable to build motor memory and motor strength.

 

 

This week I decided to do a contact-free porch drop-off of a new activity for Joey, with excellent results. I wanted him to work on an alternating left/right grasp and release so I created a “rescue basket” with toys he likes and a long ribbon to pull. We included a 1.5 lb cornhole beanbag for extra weight to help grade the activity as he got more efficient.

 

The basket is repurposed from holding baby bottle pieces for the dishwasher and has a latch that pulls apart with minimal effort. It has a top compartment that is more shallow and a bottom larger compartment. The ribbon was burned on the ends to prevent fraying.

 

Initially we attempted to have him lie prone (on his belly) but he wanted to crawl, roll, or wiggle himself closer to the basket rather than pulling it with his arms closer to him. Once he attempted the task sitting up, he understood and was able to alternate arms with adult assistance. He was able to open the latch with assistance using his right hand to stabilize grasping the basket through the holes and his left hand to pull on the latch.

 

Week Four Areas of Challenge: Keeping activities engaging for the full session, even without being able to use my facial expressions and voice to their full potential. This must be balanced with goal-directed persistence, or pushing through an activity even if it is difficult instead of jumping from one activity to another as soon as it becomes challenging.

 

Week Four Areas of Success: contact free drop-off of materials for Joey to utilize during his treatment sessions. Finding and using new resources for telehealth including:

• Facebook groups Telehealth OT, Pediatric Occupational Therapists and Pediatric Physical- Occupational- Speech Therapy Telehealth.
• AOTA resource page (available even to non-members at the time of this post) https://www.aota.org/Practice/Health-Wellness/COVID19.aspx
• Books: The Telehealth OT: A guide to teach occupational therapists about telehealth, The Out-of-Sync Child Has Fun, and 101 activities for Kids in Tight Spaces

This week we used a variety of body positions while completing a familiar task. Joey liked putting the squigz in the box, but his head and neck wore out being held upright, so we tried it in tall-kneel (on knees but bottom does not touch feet) with his right arm holding his weight on the peanut ball. A peanut or stability ball is a great way to challenge the core a little more than just sitting or leaning on the ground—because it is inflated, it is constantly changing in tiny ways and forcing the body to react and utilize all the muscles to keep the body stable, rather than just a few of the large, surface muscles and not activating the deep postural muscles. The more we can get Joey’s core muscles to fire together, the stronger he will get.  This also allows him to have improved postural endurance, or ability to hold himself upright over time.

Week Three Areas of Challenge: figuring out how to give Joey challenges graded up or down without being there in person. Grading is OT talk for making it easier or harder to  complete a task depending on the level of ease and frustration the child is having in the moment. You want to hit a just right level of desirable difficulty—hard enough that he has to have his brain and body fully engaged but not so hard that he becomes frustrated and gives up on the task or melts down.

 

Week Three Areas of Success: finding different body positions to complete a task in order to build core and postural strength and stability. We don’t just do an activity at the table, we crawl, tall-kneel behind a ball, or push into both arms with his head up while on his belly.

This week, we had to get creative with the tools available to Joey at home. Typically, I am able to create new challenges or gather interesting novel items at my clinic and bring them with me to an in-home session. This, however, has changed with COVID-19 stay-at-home guidelines.

Looking at a volitional grasp and release goal (picking items up and dropping them) and a grasping goal (having thumb on the opposite side of the item as fingers, with a “c” shape of space forming between thumb and pointer) we decided to use the squigz—a suction cup based toy with bulbous

grab spots. Then, Joey’s father was able to create a box with a large hole, so we could bring in hand/eye coordination to the activity. Joey was able to sit at his lap desk in circle-sit and put the squigz in the hole, then open his fingers to release them to drop into the box.

 

 

 

 

Week Two Areas of Challenge: figuring out how to give Joey access to novel toys/materials without the therapist driving them to his house.

 

Week Two Areas of Success: utilizing common household items (box and tape) to create new games/activities to build grasp and release skills.

The basics of telehealth:

 

Due to a global pandemic, school systems have temporarily suspended classes and the CDC is recommending social distancing (6 feet) between people to prevent the spread of COVID-19. This created an area of challenge for occupational therapists across the nation with a pediatric population—how do we deliver service without exposing our vulnerable clients to COVID-19?

 

Teletherapy or telehealth is a growing field that has been in the spotlight suddenly as face-to-face interactions become increasingly more risky. The American Occupational Therapy Association defines telehealth as “the application of evaluative, consultative, preventative and therapeutic services delivered through information and communication technology.” In plain language, it’s the same therapy services delivered through a platform such as Google Meetup or Zoom with a facilitator on the end of the client being coached through the activities to prove the support that the therapist typically would live.

 

A typical telehealth session follows the same format as an in-person session with a few key exceptions—you must plan ahead with more activities than you think will fill the time, you must arrange the time/platform with the parents, and you might need to allow for a few minutes at the start of the session for the child to show you around their house or a new toy/game/item.

 

Week One Areas of Challenge: figuring out a strong, clear connection platform. Because everyone was trying to access video chat at a higher rate than before, platforms varied in their ability to handle the traffic. Clocktree, Zoom, Google Meetup, and doxy.me were all trialed, with Google Meetup coming out as the most secure with the clearest and most consistent video connection.

 

Week One Areas of Success: partnering with a strong facilitator on the end of the child is a key component to a successful session. Determining the proper amount of time for a telehealth session and recognizing that it may be smaller than the time you can have full engagement in person. The 30-45 minutes range seems to be most appropriate for elementary-aged children.