Is Water Play Therapy?

Turning a little red wagon into a splash table...what fun! This week I suggest activities for children pre-K & older, but as you can see toddlers really enjoy water play as well.

Dear Melissa,
My son LOVES coming to therapy when it is Water Week at the clinic. But is this all just fun and games or is he really working toward his therapy goals? And if all of that fun is really therapeutic, then how can I recreate these opportunities at home? 

OK, after a relatively cool summer, it has officially turned HOT! Last week at Children’s Therapy TEAM’s Fayetteville Clinic, we had our annual Water Week. Don’t worry, our Bentonville clinic has one scheduled soon! The kids absolutely love it, and we "big kid therapists" love it too! It is a great, messy, wet, fun way to help kiddos achieve their therapy goals. The kiddos have a blast without even knowing that they are working! And THAT, my friends, is the hallmark of any good therapy session. 

Sooo...grab some neighborhood kids or some cousins, put them in their swimsuits and head to your backyard! You can have your own backyard water day with very little cash. You don’t even need a pool to keep cool this summer and the kiddos won’t even know that they are working on their back-to-school skills! 

The following are many of my favorite therapy games:  both during water week and with my own kiddos at Casa De Foster. 

1. Water Balloons: Yes, you can simply toss a balloon back and forth to work on eye-hand coordination. You can also toss it back and forth while taking turns counting, saying ABCs, or listing items in a stated category (e.g., colors, things you wear, fruit/vegetables). This helps improve response speed and attention to task. I also love to quickly pass water balloons to play “Hot Potato” for improved response speed. Another idea: line up a group of kiddos and pass water balloons overhead and between the legs to work on motor planning. Tired of the mess that the water balloons leave in your yard? Have the kids search the yard to pick up the pieces to work on visual scanning skills. They can also use tongs to pick up the pieces for improved fine motor skills. Yea, water balloon therapy!

 2. Wet Sponges: Tired of filling water balloons? Grab a bucket and some sponges and any of the above activities could be done with simple drippy sponges. In addition, wringing out sponges is a great way to improve hand strength. You can also have relay races. The teams will race to dunk their sponges in the buckets across the yard and run back to squeeze out their sponge and pass it to the next player. The team who fills up their bucket first wins!

3. Sidewalk Chalk: Chalk is fabulous for finger strengthening and offers the perfect way to work on handwriting without actually writing! Wait, your little one doesn't know how to correctly hold the chalk yet? Try breaking the piece in half (so that it is only 1-2 inches long) and have her write on a vertical surface such as a brick wall or fence. This is magical at promoting proper pencil grasp.

4. Relay Races/Obstacle Courses: Run through the sprinklers, zigzag through cones, jump over sticks, crab walk, skip, gallop...use your imagination! Obstacle courses are a great way to work on motor planning skills and sequencing. Want to add some more pizzazz to your obstacle course? Give the kiddos a “secret message” asking them to retrieve certain plastic alphabet letters by the end of the obstacle course; this helps them to work on attention and letter recognition. Need more adventure? Give the kids an ice cube in their hands and see how many times they can run through the obstacle. 

5. Water Squirters: Did you make a mess with all that chalk? Time to wash it off! Squirting traditional water guns strengthens the index finger for handwriting and aiming at a target is great for eye/hand coordination. The small squishy water squirters are also good for strengthening little ones' fingers. In addition, the two-handed water cannons work on sequencing and bilateral hand coordination; the child has to pull out the handle of the cannon to suck up the water and then push the handle back in again to shoot out the stream. 

5. Relay Races/Obstacle Courses: Run through the sprinklers, zigzag through cones, jump over sticks, crab walk, skip, gallop...use your imagination! Obstacle courses are a great way to work on motor planning skills and sequencing. Want to add some more pizzazz to your obstacle course? Give the kiddos a “secret message” asking them to retrieve certain plastic alphabet letters by the end of the obstacle course; this helps them to work on attention and letter recognition. Need more adventure? Give the kids an ice cube in their hands and see how many times they can run through the obstacle. 

6. Water Table: You can either fill up a kiddie pool with water or simply use a large flat storage tub to make a water table. Fill it with water and throw in some plastic sea creature toys. It is a great way to work on pretend play! Preschoolers can use plastic cups to work on scooping & pouring. Picking-up sea creatures with small nets is also a great way to work on eye/ hand coordination and bilateral hand coordination. 

7. Shaving cream: Shaving cream therapy is often a messy task indoors, but who cares if it’s messy outside? The kids can locate small plastic objects hidden in a bucket to improve fine motor skills. They can also use their index finger to draw or write messages in shaving cream. The water play is very motivating for most kiddos! However, many children, especially those with sensory sensitivities, will find the shaving cream, grass on their bare feet, and/or splashing water very uncomfortable...even scary! Feel free to take your time and provide gentle encouragement for participating in these tasks. If it is still too overwhelming for your little guy, encourage him to watch others having fun with these activities; this can be a great first step in lowering sensory defensiveness. And, as always, DON’T FORGET THE SUNBLOCK! 

Want even more fun water ideas? Follow the links below. 
Kids Activities: Outside Water Play
Parenting: 11 Water Games and Outdoor Activities for Kids
The Stir: 8 Awesome Water Games for Backyard Fun on Hot Days

Share your questions and ideas at share@childrenstherapyteam.com

Too young to diagnosis Autism?

Dear Melissa,

At 18 months, is it too early to diagnose Autism? 

Let me start by admitting that this blog is a bit more serious than the last few. Although this topic takes on a very serious tone, I must make a confession:  

I LOVE children with Autism. Period.  

It is my passion. It is what I do.  

Children with Autism see the world in a delightfully unusual way, and I love it. However, the world of Autism is largely unknown, and many people are scared. With the CDC reporting that 1:68 children in America now have a diagnosis of Autism Spectrum Disorder (ASD), most of us know at least one child (or adult) with this diagnosis. This also has many parents in a panic. 

How do you know if your child has Autism? This is the tricky part. Unlike diabetes or a broken arm, there is no simple blood test or x-ray to make a definitive diagnosis. Many clinicians speak of “Autism-like symptoms,” but what does this mean? And at what age do you know you have a problem? 

The CDC states that by 2 years of age, a diagnosis of Autism Spectrum Disorder given by a medical professional is “highly reliable.” They also report that an accurate diagnosis of ASD can be made at 18 months or even younger. In my personal practice, I have seen several cases of children who come to me for a 14-month evaluation for something other than Autism (e.g., food aversion, not walking), and it was obvious that these children had Autism. These children went on to receive an ASD diagnosis by a physician around 2 years of age.

What should parents look for? Possible “red flags” for Autism include:
>Not responding to their name by 12 months.
>Not pointing to objects of interest by 14 months.
>Not playing “pretend” games (e.g., tea party) by 18 months.
>Avoiding eye contact and preferring to be alone.
>Delayed speech/language skills.
>Repeating words/phrases over and over (echolalia).
>Demonstrating obsessive interests.
>Flapping their hands, rocking body, spinning in circles, or other unusual repetitive movements.
>Unusual reactions to the way things smell, look, taste, or feel.
>Any significant loss of skills that were once mastered.

Now, I am a firm believer that kiddos are just quirky. Aren't we all? If you have a child that displays a single one of these characteristics for a month or two and then basically grows out of it, there is no need to worry. A typically developing child may think a movement (such as spinning) is really neat for a month or two, and then move on to the next fascination (such as obsessing over trains). However, if a “red flag” behavior persists for more than a month or two, definitely consult your pediatrician. For me, the biggest concern is the loss of any skills that were once mastered by the child. This is most certainly a reason to have a discussion with your pediatrician, pronto!

A good question to ask is "does my child repeat a particular behavior because it is a great way for him to engage with me?"  For a parent of a young child with Autism, the answer to this question will likely be no. Children with Autism tend to not be highly relational with their preferred activities. In contrast, a typically developing child may choose to repeat activities over and over to gain his parent's focus and attention.   

Early intervention and treatment of Autism is vital to creating the most functional outcomes.  On an upcoming topic I will discuss the importance of receiving early interventions and the treatment options available to parents.  

Resources:

Screening and Diagnosis, CDC 

Signs and Symptoms, CDC 

Early Warning Signs, UC SanDiego 

Autism Symptoms, Mayo Clinic 

Diagnosing Autism, American Academy of Pediatrics 

Barefoot in the Backyard?

Dear Melissa,
When my kids run to the backyard, I often have to remind them to put on shoes. However recently I wondered if the sensory experience of warm grass on their feet on a summer day is actually an important right-of-passage for a child. What are your thoughts? 

Yay!  It’s Summer! Time for long leisurely evenings playing outside with the kiddos. But you bring up a very important question: Should we make them wear shoes, or not?  I personally LOVE the feeling of soft grass between my toes!  It’s a feeling I can’t get enough of.  In my mid-twenties I spent a year living in New York City. When I got back to Arkansas, I was most excited about walking barefoot in my own backyard!  But I too fall into the habit of always telling my children to put on their shoes when they go outside.  Should I do a double-take and tell them “Wait, it’s warm, go barefoot”?  

There are benefits to going barefoot which include:

1.  Allowing your feet to feel a variety of sensations: soft grass, prickly grass, smooth pebbly rocks, sand, etc... Your skin is your largest sense organ. Take advantage of it!

2. Going barefoot provides less support than a tennis shoe. This can cause the muscles of the foot to work harder and therefore become even stronger. 

3.  And, going barefoot just makes you feel good! 

However, as with everything in life, there are risks. Some precautions to consider:
1. Footwear is typically required by licensed childcare providers, so potential barefoot benefits will have to be limited to times when it can be safely supervised by parents.   
2. Survey the environment and avoid the following:
     a. areas that may be too hot, such as concrete or dark pavement surfaces
     b. areas with the potential for glass, metal or other sharp objects
     c. high-traffic areas that stay moist (danger for fungi and warts)
     d. areas with animal or human feces (danger for hookworm)
3.  If a child has decreased sensation in his/her feet or has feet that do not heal well (such as in diabetes), then the risks outweigh the potential benefits. 
4.  If your child has foot or walking problems, ask your physical therapist first to help you weigh the pros/cons of going barefoot.

What do you do if your child doesn't like to go barefoot?  
Many children with sensory sensitivities HATE going barefoot. These children are often irritated in other areas, such as the feel of clothing, food tastes and textures, and grooming tasks such as combing hair, brushing teeth, bathing, and clipping fingernails. Helping your child to enjoy the grass between his toes is a way to help him decrease his overall touch sensitivities. Here are a few ways to help your child “baby step” her way towards becoming comfortable on bare feet:

1. Take shoes off in the house. 

2. Expose her to different shoe styles.

3.  Gradually progress through outside surfaces - first smooth porch, then smooth driveway, then soft grass, then different textures of grass, etc.

4. If you don’t have access to a safe barefoot outdoor space, create one inside! Spread out different textures of rugs/mats, various blankets/quilts, or even bubble wrap!  This also makes  a great rainy day activity! 

Now if you will excuse me, I’m off to run barefoot in the yard with my kiddos!

Do you let your kiddos go barefoot outside?  I would love to hear your comments/concerns!

Resources:

American Academy of Pediatrics: Hookworms 

American Physical Therapy Association: Move Forward PT 

Barefoot Benefits for Kids of all Ages

Medical Specialists who Support Children being Barefoot

Watch your Step, New York Times 

iPad Time: How much is too much?

Dear Melissa,

"I feel like we are raising a generation of children who spend hours upon hours a day living in an altered iPad reality. What are the recommendations for iPad usage for children with special needs?" 

This question is tricky. If you Google “iPad recommendations for children with special needs,” you are BOMBARDED with tons of fabulous apps. There are almost no articles exploring the dangers of being so absorbed in electronics that children forget to interact with the real world. The simple answer is everything in moderation, but the full answer is much more complicated than that!

First of all, I always like to look at the literature. I don’t trust what someone writes in a blog (except this one of course). I want the hard facts. However, that is precisely the problem here. There are no hard facts. The iPad is so new that researchers have not yet studied large samples of children with disabilities and measured how they responded to these devices over time.  National Public Radio (NPR) recently did a wonderful story on this exact topic. But even they were hard pressed to locate research studies on more than a dozen kiddos. 

So, I guess I am forced to give my opinion. The American Academy of Pediatrics (AAP) reports that the average 8-10 year old spends 8 hours per day engaged in various forms of media. These include TV, phones, video games, and, yes, iPads. This is too much! I totally agree with the AAP that screen time should be avoided for children under 2 years of age and limited to less than 2 hours/day for older children. The AAP has numerous research studies showing correlations between greater amounts of screen time and the following: 
1) increased rates of obesity, 
2) decreased attention, 
3) increased behavior problems, 
4) decreased academic performance and 
5) poor sleep. 
These findings included samples of “typical” children as well as studies involving children with ADHD and Autism Spectrum Disorders. 

But there are exceptions to every rule, and this is where it gets tricky. The iPad can be a magical device for children with various special needs. It is highly motivating. It can be used to practice handwriting, increase fine motor speed, practice counting money, improve typing skills....it slices, it dices…but wait! There’s more! It is used as a communication tool as well!  The communication aspect is especially important for a child with Autism, as he needs to have at least SOME form of communication...that is not screaming!  If an iPad does the trick, then so be it.  But it is not magic fairy dust. Just like the augmentative communication devices of old, it still requires many hours of education to master as a communication tool.

I also hear parents praising little Johnny for doing all of these splendid things on the iPad and claiming that he can spend 8 hours/day on it because "they are educational games!”  But again, everything in moderation. We would all agree that a child reading a book is fabulous and worthwhile, but if he is reading in his room for 8 hours a day, when is he socializing?  When is he outside playing and developing gross motor skills?  When is he learning to tie his shoes?  Same with the iPad.  I don’t care if a child can sort the jelly beans into colored jars on that popular iPad app if he can’t help the family by sorting forks from spoons in the silverware drawer!    

I would love to hear personal experiences and comments on this topic!

For more information, please follow the links below: 

NPR article:  iPads In Special Ed:  What Does The Research Say?

American Academy ofPediatrics Policy Statement on Children and the Media

National Association forEducation of Young Children & Fred Rogers Center for Early Learningarticle:  January 2012

Mayo Clinic: Children and TV