What Am I Doing Here? What Motor Skills Should We Be Working On With Our Students With Autism

Guest Blogger: Kathryn Biel

I’ve had that moment lately. I’m not proud to admit it. Every few years, I work with a student who makes me feel this way. I have no idea what I’m doing with and for the student. Before you go judging me, stop and think if you’ve ever felt this way. For me, it’s with severely autistic students. The kids who can walk and move around. In my experience, they’re usually pretty strong, which we all note as they’re hitting and kicking and throwing objects.

My usual way of thinking doesn’t work, and I’m at a loss for what to do.  

My role is to ensure safe and efficient access to the educational process. One of the challenges with working with moderate to severely impaired people with autism is breaking through, and assigning intrinsic value to an extrinsic idea. Lots of time, I get these kiddos with goals to improve ball handling skills. I had one student once that we worked on this goal for a number of years. Finally, I said to the parent, “I can throw a ball at him for 24 hours a day, 7 days a week. Until it matters to him, we’re not going to see significant improvement in his throwing skills.” Perhaps a crude way to put it, but it was the truth. Improving ball handling skills was important to the parent, not the student. Finding what matters to the student is what challenges me.

I can often address stair climbing skills as it is such a rote skill, especially when paired with counting that it becomes ingrained quickly, providing the necessary strength and range of motion are present. After that, I struggle. Why is it important to the student that he or she stands on one foot? While these measurable skills are often delayed or lacking as compared to same-aged typical peers, often their balance is functional.

I find it challenging to increase the movements and activities in the student’s repertoire. They like what they like and they don’t like new things. This, however, can lead to secondary impairments as the child ages, especially when combined with a diet lacking in variety, as is often seen. Motivating a student to move is one thing. Motivating an overweight student to move becomes entirely more difficult.

Then, there’s toe walking. How aggressive are we being in treating it? Are we letting it occur (while monitoring range of motion) to provide sensory input? Is toe-walking alone an impairment that restricts access to the educational environment?

I struggle with working with the student who flits from object to object, activity to activity, never quite getting the functional use out of anything. These 30 minute sessions drain me, and as much as I like the child, I am filled with dread when I think about them. I know that any “plan” I make is likely to be tossed out the window as soon as the session starts. Do I just follow the child’s lead and try to make functional what I can? Do I engage in a battle of wills in order to get the student to do what I want him or her to do? I know what I’m supposed to be working on. I know why it’s functional. But my student doesn’t. How do I help my student become invested in what I am trying to work on? How important is it that I make this already challenging student faster and stronger and more agile? What do I need my student to be able to do to be functional? Am I looking at functional for the whole world or functional for his or her world?

If you’ve ever felt lost, or wanted to know what motor skills we should be working on for our students with Autism, check out Kym Doherty’s presentation, Addressing Motor Issues in Autism: What’s Realistic and Relevant? at the Sixteenth Annual Therapies in the School Conference.

~Kathryn Biel, PT, DPT

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Physical Therapist Practice in the ICU

Dan Malone just published (as first author) a paper in the journal Physical Therapy (Volume 95, Number 10) October 2015 titled “Physical Therapist Practice in the Intensive Care Unit: Results of a National Survey”.

The group sent out a survey to members of the Acute Care Section of the APTA addressing staffing, training, barriers and protocols to determine perceptions about providing rehabilitation in the ICU. The survey identified barriers to providing ICU rehabilitation as: insufficient staffing (the primary reason), lack of training, departmental prioritization policies and inadequate consultation criteria. Other barriers included sedation of the patients and scheduling conflicts related to the timing of medical procedures.

The type of training for this setting most frequently cited in this survey was “informal training” relying on mentorship and department-based competency requirements. The article mentioned that there are very few cardiovascular and pulmonary residencies and critical care fellowships currently credentialed by the American Board of Physical Therapy Residency and Fellowship Education to train this at this high level.

The survey group was given 6 hypothetical cases that might be encountered in this setting and was asked to recommend treatment frequencies for each diagnosis. Interestingly, none of these cases received recommendations for daily physical therapy. Although each of the cases was deemed to be “medically stable”,  ambulation was not recommended for the majority of patients. More therapists working in an academic setting were apt to recommend early mobilization/ambulation than those working in a community hospital setting. The conclusion drawn was that physical therapists working in acute care and ICU environments need further training to recognize the need for safe early mobilization.  

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Why is Sensory Such a Mystery?

GUEST BLOGGER: Kathryn Biel

We’ve all sat in those meetings. The one where the Committee Chair, or the pre-school director, or the classroom staff, or the administration says those dreaded words.

“We don’t treat just sensory.”

“OT is for fine-motor and visual-perceptual skills.”

“We don’t provide sensory diets.”

If you’ve never heard these cringe-worthy statements made, consider yourself lucky.

I get it. Sensory issues are tricky. Truth be told, I feel lost with them. I feel like I understand a fraction of what there is to know about Sensory Processing Disorder (SPD). Admitting this is difficult, considering my own child has SPD. But I know, if I’m mystified, then others out there must be equally as lost.

I know they are.

Classroom teachers’ eyes glaze over at the mention of a sensory diet. Shall we count how often the sensory diet recommendations are carried out? I’m guessing we can do it on one hand. It’s not for lack of trying on the teachers’ parts either. Resources are stretched too thin. Training is too sparse. It’s easier just to refer out to OT to get the job done. It doesn’t work if it’s treated with a “one-size-fits-all” approach. Heck mention of the Wilbarger protocol alone sends shudders of terror down my spine. And let’s be frank–our kids barely get time to eat and have recess. No one has time to brush someone every two hours, not to mention how socially off-putting this can be to other children. (NOTE: While writing this, a teacher came in and asked about a standing desk to try with a student. The student is currently using a T-stool but a classmate has started picking on her for it.)

But then there’s flip side–we can’t expect children to learn until their sensory systems are modulated. Sure, some information can get in here and there. These kids are smart and will find a way. But smooth, coordinated learning, not to mention social interaction–in other words, success–will be impacted in children with an undermodulated or overmodulated nervous system.

Just because we know these issues are there doesn’t mean there’s an easy solution. From a therapist point of view, providing a sensory diet seems like a good solution. But we all know the reality of this. The cookie-cutter approach doesn’t always work. So, what else can we do? How can we meet our children’s sensory and social needs?

Like most therapists (and those awesome Tiger parents), we know it’s time to think out of the box. Sometimes, the answer is easy. For my son, Jurassic Park, with its roaring T-rex was too loud. We had to leave the movie. When the Jurassic World came out, we had a new plan. That pair of headphones (the cheap version of Beats)–they block the sound too. And my 11 year-old looked like any other kid with his iPod in the pocket of his hoodie. Thinking outside the box while fitting in. We’ve been doing this all along. Or we should be.

OT Doreit Bailer explores a problem solving approach to sensory issues in her seminar, No Longer A SECRET:  A Theoretical, Practical Approach to Helping Students with Sensory and Motor Challenges Experience Success at the Sixteenth Annual Therapies in the School Conference.

~Kathryn Biel, PT, DPT

 

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NEW COURSE – Connective Tissue Mobilization

Education Resources is thrilled to be able to offer this new course:

[caption id="attachment_2817" align="alignleft" width="100"]Patricia West-Low Patricia West-Low[/caption]

Connective Tissue Mobilization for Pediatric Therapists presented by a new member of our faculty; Patricia West-Low PT, MA, DPT, PCS 

Research and clinical evidence suggest that connective tissue changes may contribute to postural malalignment and movement dysfunction in children.  This course is designed to introduce pediatric Physical and Occupational Therapists to the scientific rationale for basic practices of connective tissue mobilization.  Through structural alignment observation, and hands on practicums, participants will gain the ability to identify and treat connective tissue restrictions resulting in structural misalignments, which interfere with efficient functional movement.  Participants will learn approaches to neuromuscular re-education to improve muscular control and coordination. Treatments specific to children with neuromotor impairment, musculoskeletal injury, post-surgical scars, and torticollis will be explored.  Case examples will be presented.

 

December 4-5, 2015 – Canton, MA

March 4-5, 2016 – Cedar Knolls, NJ 

April 2-3, 2016 – Orland Park, IL

Any questions or thoughts? Let us know.
Post your comment here or contact the office:

800-487-6530 info@educationresourcesinc.com

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Hands-On Therapy

It’s that uncomfortable moment in our professional development where they talk about not touching students. You know, that you shouldn’t really hug or touch students, and specifically not below the waist and above the knee.

I know the point of the training (and am not in any way minimizing the need for our children to be safe in school), but I can’t help but feel that it doesn’t apply to me. My hands are frequently on my students. Because it’s my job.

Whether it’s providing joint compression or deep pressure or joint mobilization or myofascial release, I need to be using my hands. My hands, and actually my whole body for that matter, are a tool in my toolbox. They help to provide the necessary modality to address impairments that are leading to dysfunction in my students. This dysfunction is the focus of my treatment. Especially in school-based therapy, the goal is to improve function.

Take, for example, the child who enters Kindergarten with great functional goals, like reciprocal stair navigation, ball play, cutting, and manipulating the zipper on his backpack. Yes, these are all the things a Kindergartener should be doing or working toward. But in this case, the child has a right hemiplegia, has not worn his hand splint or AFO in months, and basically does not use his right side (other than in ambulation). He is plagiocephalic and has a history of extensive abdominal surgery.

Range of motion limitations prevent the child from putting his foot flat on the floor. Muscle tone issues prevent spontaneous ease of use. Limb-neglect is present. Motor control and motor planning also stand in the way.

Based upon the child’s presentation, it’s apparent that extensor development is lacking. This impacts mid-range postural control and is another complicating factor in his overall functional deficits. While outside modalities (such as medical management and bracing) are often needed, we have some tools in our toolbox to start addressing some of these concerns. Going back to the developmental sequence, using an NDT frame-of-reference can help to address some of those skills that have been missed. Developing extensor and then flexor control through prone and quadruped will improve balance and stability for fine and gross motor tasks.

For example, positioning in prone prop while attending to an activity, for this child, can provide the following benefits:

  1. Development of strength and endurance in the upper back, scapular, and neck extensors.
  2. Elongation of the hip flexors and abdominal muscles that are often shortened due to frequent sitting.
  3. By flexing the non-involved leg (in this case left) slightly, weight bearing through the right hemibody is occurring to improve proprioception.
  4. Shoulder girdle strengthening.
  5. Right shoulder proprioceptive input through joint approximation, which can help maintain capsular integrity as well as decrease muscle tone through weight bearing.
  6. Work on visual tracking, convergence and divergence.
  7. Extension of the head and neck activates the reticular activating system, which increases attention and arousal.

But, passive positioning, especially in this case, isn’t quite enough. Hands-on techniques such as joint mobilization, range of motion, PNF, and myofascial release are often needed to inhibit muscle tone and lengthen muscles to achieve neutral alignment. Once in neutral, strengthening and motor control can be developed.

While we often think about these techniques as clinical skills that aren’t used in school, they’re often a valued resource in improving overall function within the school environment. If you’re interested in learning more about how to use NDT and MFR to treat moderately to severely involved children in the school environment, check out Barbara Hodge’s seminar, The Moderately-Severely Involved Child: Integrating NDT and MFR into a School-Based Program at the Sixteenth Annual Therapies in the School Conference.

~Kathryn Biel, PT, DPT

 

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