TherExtras

Increments

Progress can be made in increments over time.  Change can be realized after many bits accumulate.  Absolutely cliché, one-step-at-a-time finishes the race.  Sometimes it’s tough to believe in the results when the effect at each increment is invisible.  I’ve spent loads of time trying to convince parents of young children with motor delays to stand their child daily.  Placing a child in a stander requires a lot of effort, but the incremental or daily effort leads to the child taking those first steps.  Without those incremental daily efforts, sometimes as long as years, the potential for those first steps can be lost.  In the same way that brushing teeth provides an incremental but necessarily repeated effort, failing to clean teeth over time results in cavities.

Striving for incremental behaviors has been a consistent theme in my life as a therapist.  Early in my career I realized that treatment two times per week would not reduce or prevent joint contractures in a child with cerebral palsy.  Twenty to thirty years ago, the term Home Program was the high moral ground for therapists and parents.  Therapists excelled if they could write the perfect Home Program – determined by whether the parent actually implemented the Home Program.  Parents who did not follow the Home Program were the bane of therapists whose patients did not demonstrate gains in therapy.  Therapists who gave Home Programs were the bane of parents in the throes-of-cure-or-care.  How in the world can she expect me to do range-of-motion exercises 3x/day?!  Isn’t that her job?!  Both the parents and the therapists believed in therapy; both were expecting something close to cure; both bought-into the 2x/week dosage; and both blamed each other if the child did not progress.  They were in a Catch-22.

 

Sometimes the smallest change in behavior can make the biggest difference in a child’s development.  Early in my career I figured-out that identifying those small changes in any particular family situation with any particular child with any particular diagnosis was important to providing effective therapy.  Teaching an attentive mother to change the way she held her baby – something she did many times a day – was effective for helping the baby to develop head and body control; far more effective than minutes of handling on a ball twice-a-week for months at a time.  What was most effective about the 2x/week therapy sessions was the relationship that developed between the mother and the therapist.  By gaining the trust of the mother during repeated therapy sessions over time, she was more receptive to suggestions from the therapist to change how she cared for her child. 

 

The classic problem-solving required by a therapist is to create treatment and recommendations with the best potential for change, including recognizing a family situation where a Home Program will not be implemented.  I would likely not recommend a standing program for a child that lives poverty with a mother who is a fourth-generation teen-parent.  I have to make a judgment as to when to introduce such a complex activity into the life of a family that struggles to feed itself daily.  Equipment recommendations are another potential foible by therapists who make the decision based on the child’s condition as opposed to whether the equipment will actually be used by the family.  In the case of a standing program, an indicator that the family is not ready for a $1000 piece of equipment might be that they do not don the child’s orthoses daily.

Home Programs should fit easily into the lifestyle of the family in order to be effective.  Repetition is the third critical aspect for achieving effective incremental behavior.  Like endless rain into a paper cup is the perfect analogy for effective incremental therapeutic behavior, and it is the clever name of one of my favorite blogs. Susannah provides word-increments causing me to repeatedly LOL.  And Terri recently reminded me how important laughter is when helping people understand the needs of special children. Humor is not at the top of my personal toolbox, so I rely on the innate talent of others and the solid nature of my opinions.  I digress.    

 

Incremental behaviors repeated can become habit.  The advantage of habits over the Home Program is that they are performed with less thinking, with less planning, with less energy – like brushing teeth.  An occupational therapist uses the term sensory diet for children who are diagnosed with a sensory processing disorder.  By thinking of sensory experiences as food – individually chosen and daily sustenance, they become habit and much easier for the parents to implement in their daily lives.  Parents should not expect to keep the same habits for all the years of childhood.  The perfect analogy continues to apply in that once the cup overflows, it’s time to get a new cup.  Once the child develops head and body control, it’s time for the therapist to suggest another incremental behavior to support the next targeted milestone.

 

 

Housekeeping:  Read the blogs of other parents of children with diagnoses - linked in my right-side column.  I read all of the blogs listed.  These bloggers are as diverse a group as you could imagine.  They share the same joys and struggles you do. 

To Meme or Theme?

I’ve been engaged in a game of cyber-tag called meme by Lon at No Limits 2 Learning.  I’m happy to respond by posting this meme.  A meme is explained at The Daily Meme.

The Rules…
1. The rules of the game get posted at the beginning. 
2. Each player answers the questions about themselves.  Please use the option for changing a question to one question only. 
3. At the end of the post, the player then tags 4-5 people by posting their names, leaves them a comment on their blog that they’ve been tagged and asking them to read the player's blog.
4. Let the person who tagged you know when you’ve posted your answer.

This is kind of fun, but I’m concerned that participating in the meme makes the post all about me.  You’ll likely see in my answers below that I am trying to get back to the theme of my blog within the meme.  (I made a rhyme!)  If this meme does not entirely satisfy your curiosity about me, the page More Personally contains more details of my life before blogging. I also want to point out that naming this post was a bit of a challenge.  Here are a few rejected titles:  I Meme for You, I Meme for Lon, Lon Meme’d Me.  I felt it appropriate to make references to Lon’s meme.  There is a price for meme-ing me. 

Here are the questions:
1. What were you doing 10 years ago?
During May, 1998 I was employed full-time as a faculty member in a graduate physical therapy program and preparing to move from a rental house into the one we live-in now. 

2. What are five things on your to-do list today?
What an easy day you had, Lon.  I want make the point that the activities on our to-do lists are the stuff of our lives.  This is known as occupation, and is the basis for name of the Occupational Therapy profession.  My occupation today ….. Drive my child to school.  Work in the yard – includes prepping a garden bed and spreading a bag of mulch by hand, scooping and moving bunny poop (used a shovel for this) from under the hutch to the front lawn to spread as fertilizer, mowing two parts of the back yard, and setting-up sprinklers on both lawns.  I have to work in the yard in the morning as the high temperature today was 90 degrees.  Shower.  Eat.  Make phone calls and work on my pc – answering email, and composing this meme.  Pick-up my child from school.  Shop.  Prepare dinner.  Spend time with my family.  Work on my pc – read other blogs and finish this meme to post.  Tomorrow will be completely different as I can’t spread any more bunny poop until the bunnies make some more. 

3. What snacks do you enjoy?
Dark chocolate.  Dark chocolate.  Dark chocolate.  I snack once a day. 

4. What would you do if you became a billionaire?
I would create, fund, endow a non-profit organization.  I have a lot to learn to do that. 

5. What are your bad habits?
Not coincidentally, I plan to write a post on habits.  Occupation segues easily into habits.  I don’t do anything bad habitually.  My habits could improve but I’m going to leave it at that.  Feel free to over-analyze that, Lon.  Regarding Lon’s other bad habits…..I believe exercise or purposeful movement is the panacea for health.  I used good body mechanics while scooping bunny poop, and that qualifies as exercise.  The translation of moving poop to healthy occupation is one of the benefits of being a physical therapist.  Referring to Lon's third bad habit, my spending habits match my husband’s and we work to together to maintain the lifestyle we want for our children and plan for all our futures.  The likelihood that we will someday be billionaires is very, very, very low. 

6. Where have you lived?
I have lived in Texas, Oregon, Washington State, Pennsylvania, West Virginia, and then back home to Texas.  For futurer meme'rs, I replace this question with:  What is a basic tenet you live by?  My answer:  nothing happens by chance. 

7. What are the five most interesting jobs you have had?
Teaching graduate students is lot like the job Lon had - working in a zoo.  I’ll leave it at that.  In the over-30 years since I started my first OT affiliation (clinical experience before graduation) I have had thousands of patient and caregiver interactions.  My jobs in four different states, mostly with child clients and their families, mostly in the public schools are the fodder for this blog.  During summers while earning my bachelor’s degree I waited tables at restaurants along the San Antonio River Walk.  Expanding the meaning of job beyond employment, the most interesting occupation I’ve had is mother.  At my core, I am a wife and mother. 

8. Who do you tag to continue the meme fun? 
This was also a challenging question for me to answer.  I'm an infant in the blogosphere, and few others know me.  These people will at least recognize my name.  I tag:  Nancy at Olive Leaf Ministries; Dad at Kintropy in Action; Julie at Shanan Trail; Terri at Barriers, Bridges & Books; and Susannah at Like Endless Rain in a Paper Cup.   Thanks, Lon!

‘round here they call it Fiesta!

Blog Carnival is a new term in my vocabulary – I’ll have to add it to the blog Lexicon I’m gradually building.  The city where I live takes-on a carnival atmosphere every April.  Fiesta traditions began almost a century ago and the city goes all out to entertain visitors and showcase the city.  Lon has done a wonderful job of sponsoring two monthly editions of the Assistive Technology Blog Carnival.  According to Lon, “A carnival is supposed to travel around from town to town and set up somewhere different to amuse and entertain the residents of a community.”  One of my posts was included in the AT Blog Carnival this month.  My post is kind of like a vegetable peeler among Cuisinarts.  If your child uses assistive technology you will find some new online resources through an amazing group of individuals at the AT Blog Carnival. 

I’ve spent the better part of my online time for the past five days reading posts gathered for another blog carnival – Blogging Against Disablism Day, BADD, May 1.  There’s another new word for me, disablism or discrimination against persons with disabilities.  This group of posts does not have an entirely carnival atmosphere.  I encourage you to check-it-out for yourself, but will let you know that a few of the posts are true ‘carnies’.   Most of the posts are by adults with disabilities, most acquired but a few who grew-up with a disability and few more who are either parents or siblings of a child with a disability.  The carnies are the hard-core bloggers who post almost daily, write with passion and seem intent on drawing an emotional response.  The comments left by others are equally interesting, and in large part serve to affirm each other that they too have experienced that feeling of discrimination, or depression, or anger. 

If your family includes a child who is recently diagnosed, if you’re not sure you want the perspective of adults with disabilities, give yourself permission to look at the carnival from a distance.  I am more amazed than amused by the BADD carnival – at the sheer volume and the immense variety (er, diversity) of people participating.  I’m amazed in the same way when looking at a carnival from a distance - the lights and the Ferris wheel, screams from the roller coaster, pings and rings of bells, the shouts of barkers.  Come to think of it, BADD does have a carnival atmosphere.

Teachable moment more like teachable springboard

A wonderful resource for parents is Exceptional Parent Magazine.  A story on EP’s companion website eparent is useful for giving a clear picture of the kind of decisions teachers make daily.  The story also shows the importance of prior decisions and potential outcomes of decisions made in the moment.  “Wednesday” is Pizza Day” by Barbara Bazeghi is the story of how a teacher manages Andy’s response to an unexpected change in routine.  For Andy, rectangular pizza “is unacceptable. This is tragic. This is beyond comprehension. The melt down begins.”

Andy’s teacher already knows that he can be set-off by change before rectangular-pizza-Wednesday.  Long before Ms. Bazeghi has already shown Andy how she responds to his melt downs.  Prior to this event, she has been consistently supportive, perhaps even comforting, but not immediately providing round pizza to calm Andy.  Andy must board the bus “shattered” on rectangular-pizza-Wednesday.  Then his teacher works with the cafeteria staff to have a back-up round pizza next Wednesday.  Ms. Bazeghi also writes a “Pizza Social Story” including a rectangular pizza and reads the story with the children the next day.  Initially, Andy protests at the shape of the pizza in the social story.  In the end we learn that on the next Wednesday Andy accepts pizza on French bread!   

After rectangular-pizza-Wednesday this teacher had to decide how to both prevent and respond to another melt down on the next Wednesday.  Her choices were influenced by the practical implications of a melt down and the opportunity to push Andy a little further along in his adaptation to life.  Andy’s move forward is indeed “sweet” and “small in size [compared] to a regular student.”

This story subtly depicts a couple of characteristics about the particular school Andy attends.  The teacher has the freedom and ability to creatively teach towards a child’s individual needs.  I’ve met teachers who are so bound by program structure that they cannot, or believe they cannot respond to a teachable springboard like the one on pizza day.  I’ve also observed teachers that have only one standard for responding to a child’s melt down – a kind of consistency that is more like rigidity.  Engaging the cafeteria staff for Andy’s benefit is another laudable decision made by this teacher.  The staff learns that some children adapt more slowly than others, and sometimes there are simple practical means for accommodating a child’s inability to adapt quickly.  Promoting acceptance of a child’s differences often spills over into the community around the school.  This is advocacy at its best.   

The teacher’s social story gave Andy words for what he experienced.  The social story expanded Andy’s understanding of the word ‘pizza’.  The story and the time lag before the next Wednesday gave Andy time to
cement his learning from the experience.  The social story was effectively a cognitive behavioral technique or gave Andy to tools to use cognition to modify his behavior.  The social story empowered Andy to move ahead.  This is special education at its best. 

Most school age children know that the shape of food does not affect its taste or meaning as food.  When do most children learn that concept?  Likely, most children learn similar foods come in different shapes early and before they have the language to express the difference.  This is similar to learning that objects unsupported by a visible structure fall to the floor.  Infants learn this from their high chairs before they learn the word gravity.
Andy’s response to rectangular pizza is evidence that he missed learning that at a typical age.  The fact that his teacher recognized the opportunity and effectively assisted him in learning was “sweet”, too.  This example gives credence to the term delayed development.

Coinciding with his delayed learning, Andy has an extreme and emotional response to a change in his life. Accommodating change is one of those innate abilities that become part of what we call personality in most people.  Andy’s melt down is likely a ‘nature’ behavior or he is ‘wired’ to respond in that way.  However, his teacher shows how response to a natural trait can be influenced through (carefully planned) experience. 

Andy could have been served rectangular pizza in a restaurant with his parents and produced a similar melt down.  I wonder if his parents are prepared for that eventuality.  Parents make decisions daily, too.  Can you identify a teachable springboard in your child’s life?  Why do you think some children are highly reactive to small changes?    

Music

Speaking of singing, listen to the wonderful voice of my friend Shaney by clicking the play button under Errata in the right side column.