Roles and Goals of Pediatric OT

Dear Melissa,
My 3 year old son is in physical therapy for falling a lot and general clumsiness. His physical therapist said that my son may benefit from occupational therapy as well. What is occupational therapy and how is it different from PT?

As I tend to do many of the new occupational therapy (OT) evaluations here at Children's Therapy TEAM, I seem to get asked this question almost weekly.

My 1-line layman's answer:
Physical therapy does legs and walking; occupational therapy does arms and activities.

Now granted, there is quite a bit of overlap between occupational therapy and many of the other disciplines: physical therapy, speech-language therapy, vision therapy, psychological counseling, behavior therapy, teaching and coaching, to name a few. Our profession often ends up being the “catch all” for any missing pieces of the puzzle to help an individual become as independent as possible.To better illuminate this, I begin with the most overarching Pediatric OT role and goal...the OT's role in helping a child achieve independence goals.

Goal of OT is Independence
So what is the basic function of occupational therapy? In short, promoting independence in individuals across the lifespan. And the terms “independence” and “individuals” are the 2 key words. As the American Occupation Therapy Association (AOTA) puts it:  Occupational therapists ask, “What matters to you?” not, “What’s the matter with you?”

And guess what? It is still April and April is OT month!
The field of occupational therapy was actually founded at the end of World War I in order to use “activities” or “occupations” as a treatment modality to help wounded veterans re-acclimate to daily life, both mentally and physically. Still today, we OT’s use a variety of activities to help our clients achieve the occupations that are important to them.

AOTA defines the role of occupational therapists and occupational therapy assistants as “helping people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities (occupations).” But what does this actually look like with our clients? Well, here at TEAM we work with children. That is the under 21 crowd. Occupational therapists DO work with a variety of different populations, but for this blog, I will focus on our pediatric clients. Let me break it down into a few age groups, and explain just a few possible roles of your OT in each.

A few examples of Pediatric OT Goals: 

Birth to 3 years: 

• Beginning hand use
• Using each arm/hand in play
• Using both hands together
• Crawling
• Engaging in play and pretend play with a variety of toys

3 to 5 years

• Holding a pencil/marker
• Cutting paper
• Dressing/undressing skills
• Eating properly at the table
• Playing and engaging with peers
• General school readiness

6 to 12 years

• General classroom participation
• Following directions from the teacher
• Playing and engaging with peers on the playground and in afterschool activities
• Handwriting
• Organizational skills to function in both classroom and home settings
• Time management

13 to 21 years

• Money management
• Simple meal preparation
• Simple housekeeping (laundry, cleaning, etc)
• Shopping
• Driving
• Job readiness
• Engaging with peers in meaningful leisure activities

Now I totally made up those age brackets for simplification purposes, but I wanted to emphasize how the role and goals of occupational therapy change throughout a child’s lifespan. And these are only general ideas. Again, occupational therapy is concerned with the goals of the individual family/child. For example:

• Some families/schools feel passionately about a child writing in cursive; some families feel that manuscript is just fine.
• Different families have very different leisure activities that they enjoy together:  playing sports together, attending plays/movies, going to museums, dining restaurants, attending sporting events, snuggling and reading books, hiking, swimming, playing on the beach, and the list goes on and on.
• Some families/individuals want to learn basic cooking skills, others want to focus on ordering take-out or simply heating up meals in the microwave.

Each of these activities listed above has a completely different skill set required and it is the job (and joy!) of the occupational therapist to evaluate the difficult splinter skills for each task, help the individual improve his/her skills, and become as independent as possible!

Want more information on the different roles of OT, PT, ST (occupational therapy, physical therapy, and speech-language therapy)? Stay tuned! In the next several weeks I will interview therapists in each discipline and ask what he/she looks for as “red flags” for a child benefiting from those services.

Resources:
American Occupational Therapy Association, Accessed March 2016
Children’s Therapy TEAM, Northwest Arkansas

Medicaid Fund: A Call to Action

Note: In light of recent legislation in Arkansas, threatening to de-fund therapy services for children with special needs, please feel free to cut and paste any or all of this post. Please call, email, or write your senator in SUPPORT Arkansas Medicaid funding, which provides so many of these services for children of Arkansas. Arkansas Senators’ Contact Information, Online Petition

Dear Mr./Ms. Politician,
(Particularly those of you who represent my home state of Arkansas)

I am a pediatric occupational therapist who has worked primarily with children on the Autism Spectrum for over 12 years. In this span of time, I have worked with countless patients and their families. I can cite dozens of “success stories” that demonstrate the importance of early intervention…how time and time again, early intervention has molded a child from a screaming, non-verbal two-year-old into a delightful, successful, sometimes fantastically quirky, kindergartener.

However, I will not give you individual success stories (though they are numerous and awe-inspiring). In this long, drawn-out election season, I too, have grown weary of the individual hardship/success story of someone far away, in another state/town, that doesn’t affect me. Therefore, I will spare you the flowery special-interest stories.

Mr./Ms. Politician, please let me give you the facts. Just some hard numbers on how the economics of Autism affect you. Yes, you. You, the individual politician. You and your personal family. You and the tax-payers who you represent. These current numbers support what I have observed with my own eyes time and time again on a much smaller scale. I have often argued with my friends at the dinner table, that spending tax dollars NOW on early intervention services reduces the level of special services required over 13 years, once the child enters the public school system. I have argued that spending dollars on early intervention services can actually mold individuals from requiring a lifetime of disability services, to creating an individual who is actually a tax payer.  So once again, let me give me the financial facts on how the economics of Autism affect all of us.

FACTS:

• The lifetime cost for an individual on the Autism Spectrum averages $2.4 million when an intellectual disability is involved, and $1.4 million when an intellectual disability is not present. (Autism Speaks)
• The bulk of childhood costs for Autism are for special education and for lost parental income. During adulthood, the highest costs relate to residential care and lack of employment. (Autism Speaks)
• A study in 2013 in Washington state found that, though costly, early coaching paid for itself within eight years by reducing the need for extra help in school. (Economist)
• A study published in 1998 in Behavioral Interventions found that if children receive “early intensive behavioral interventions” from 2 years of age until they start kindergarten, the cost savings range from $187,000 to $203,000 per child for the ages of 3-22 years.
• “Well-designed early childhood interventions have been found to generate a return to society ranging from $1.80 to $17.07 for each dollar spent on the program.” – when looking at children with  socioeconomic hardships and/or developmental delays. (RAND Corporation, 2005)

Please, Mr./Ms. Politician. Don’t take my word for it. Don’t even rely on what is “the right thing to do.” Simply think of the cold, hard cash, the simple dollars and cents. Think of balanced budgets. And then, please, do what is financially (and morally) in the best interest of your own family and the families of your constituents. Continue to fund Medicaid. Continue to fund early intervention services. It only makes “cents.”

Thank you,
Melissa R. Foster, OTR/L
Occupational Therapist, Children’s Therapy TEAM
Mother of 2 wonderful children
Tax-payer
Lover of children with Autism

Resources:
Beautiful Minds: Wasted. (April 16, 2016). The Economist. Retrieved from www.economist.com/news/leaders/21696944-how-not-squander-potential-autistic-people-beautiful-minds-wasted/fb/te/bl/ed/beautifulmindswasted

DeMillo, A., What you need to know about Arkansas Works. (April 3, 2016). Associated Press, KTHV. Retrieved from http://www.thv11.com/news/health/what-you-need-to-know-about-arkansas-works/117809310

Jacobson, J.W., Mulick, J.A., Green, G., Cost-Benefit Estimates for Early Intensive Behavioral Intervention for Young Children with Autism – General Model and Single State Case. (1998). Behavioral Interventions. 13, 201-226.

Karoly, L.A., Kilburn, M.R., Cannon, J.S., Proven Benefits of Early Childhood Interventions. (2005). RAND Corporation. Retrieved from http://www.rand.org/pubs/research_briefs/RB9145.html

Lifetime Costs of Autism. (June 9, 2014). Autism Speaks. Retrieved from www.autismspeaks.org/science/science-news/lifetime-costs-autism-average-millions

Reduced Playtime Concern

Dear Melissa,
My son is in kindergarten this year, and it seems as if so much of his school day is focused solely on academic work. When I was in kindergarten, it seems as if we were focused on dress up, story time, and finger painting. Where did all of the “play time” go?

You are not alone! A recent blog from the American Occupational Therapy Association comments on just that. The following statistics are reported by researchers at the University of Virginia (Education Week):

Academic skills:

• 31% of teachers in 1998 believed students should learn to read in kindergarten, compared to 80% in 2010
• 35% of teachers in 1998 believed it was important for children to enter kindergarten knowing how to use a pencil and paintbrush, compared to 68% of teachers in 2010  
• 29% of teachers reported that children should know their alphabet before starting kindergarten, whereas 62% of teachers in 2010 think children should enter kindergarten already knowing the alphabet  

Play skills:

• 87% of classrooms had a dramatic play area in 1998. In 2010, only 58% of classrooms had a dramatic play area. 
• 92% of classrooms in 1998 had an art area in the classroom, compared to only 71% of classrooms in 2010. 
• 58% of kindergarteners participated in dance or creative movement at least weekly, whereas only 48% of kindergarteners had movement in 2010.  

And, it’s not just the academic institutions who are on board with more play skills development. The Lego Foundation (yes, THOSE Legos that we always fear stepping on bare-footed in the living room) was established 29 years ago and is funded with 25% of Lego’s post-tax profits. In a very recent article published in The Guardian (a British daily newspaper AND the world’s 3rd most read newspaper), the Lego foundation promotes play to help children devise, tell, and act out stories years before they are capable of writing these stories down. Play allows for the establishment and practice of these creative foundations, so that the child is capable of actually writing down stories when their writing skills catch up. Specifically, their research promotes a play-based approach to learning until the child reaches 8 years of age. Sound like child’s play? Well, Cambridge University has just created a “Lego professorship.” They are working with institutions like Harvard, MIT and other well-known, prestigious institutions, for the intention of providing concrete, academic proof on the educational value of play.  (The Guardian, March 15, 2016)

As a pediatric occupational therapist, it is my job to focus on the occupations of each individual child. In only one generation of life, the traditional occupation of a 5 year old has quickly converted from creative play and movement to sitting at a desk and completing academic work. We have become a nation so focused on test scores and academic achievement, that pretty soon, our children will have no creative life experiences to read and write about.

And it is not just the OT’s who feel strongly about the role of play in a child’s development. The Journal of Pediatrics (2007) reports the following: “Play is so important to optimal child development that it has been recognized by the United Nations High Commission for Human Rights as a right of every child… even those children who are fortunate enough to have abundant available resources and who live in relative peace may not be receiving the full benefits of play. Many of these children are being raised in an increasingly hurried and pressured style that may limit the protective benefits they would gain from child-driven play. Because every child deserves the opportunity to develop to their unique potential, child advocates must consider all factors that interfere with optimal development and press for circumstances that allow each child to fully reap the advantages associated with play.”

So play is not just “child’s play”. Play is a RIGHT of every child. And, according to the Journal of Pediatrics, the specific benefits of play reported include:

• Play allows children to use their creativity while developing their imagination, dexterity, and physical, cognitive, and emotional strength. Play is important to healthy brain development.  
• Play allows children to create and explore a world they can master, conquering their fears, while practicing adult roles, sometimes in conjunction with other children or adult caregivers.
• When play is allowed to be child-driven, children practice decision-making skills, move at their own pace, discover their own areas of interest, and ultimately engage fully in the passions they wish to pursue.
• In contrast to passive entertainment, play builds active, healthy bodies. In fact, it has been suggested that encouraging unstructured play may be an exceptional way to increase physical activity levels in children, which is one important strategy in the resolution of the obesity epidemic.

As alluded to in today’s parent question, this trend of reduced play time has even affected our kindergarten children, who have had free play reduced in their schedules to make room for more academics. A 1989 survey, taken by the National Association of Elementary School Principals, found that 96% of surveyed school systems had at least 1 recess period. Another survey, a decade later, found that only 70% of kindergarten classrooms had a recess period.  

So, we know our youngest elementary school students are receiving less recess time. AND, we know that play is important for proper development of our children. So what do we do about it? This is the tricky part. It will take a multi-dimensional approach, but we must become advocates for our children.

• Insist that a child never has recess (or any other “non academic” time) taken away as a consequence for negative behavior. 
• Talk to your teachers and principals about your child’s schedule. Share with them the literature on the importance of play. 
• Feeling brave? Join your own school board or run for PTA offices to help change public policy. 

If we all work together, we can re-introduce play into our childrens’ lives!

Resources: 
Foster, M. Recess Critical for Learning, (Feb 2016), Children’s Therapy TEAM Blog. 
Ginsburg, K. The Importance of Play in Promoting Healthy Child Development and Maintaining Strong Parent-Child Bonds, (Jan 2007), Pediatrics.
Kindergarten Today: Less Play, More Academics, (Feb 10, 2016), Education Week.
Strauss, V. You won’t believe these kindergarten schedules, (June 2, 2014), Washington Post. 
Ward, L. Children should learn mainly through play until the age of eight, says Lego, (March 15, 2016), The Guardian.
Yamkovenko, S. Kindergarten Trends to Less Play, More Academics: How Does it Affect Children, (Feb 22, 2016), OT Connections. 

The Power of Words and the Empowering of Validating

During my first year working at the hospital in Central Asia, before there was a pediatric therapy department, I began seeing more and more children brought in from the countryside. The rumors had spread throughout surrounding villages and even surrounding provinces that a “foreign expert” was now available to see kids. Therefore, a growing tide of families began bringing their toddlers, elementary age, and teenage children to me. They all had one request, “Fix them.” The vast majority of the children had moderate to severe cerebral palsy. They had never received what I would term “active therapy.” But several families had spent their life savings on the falsely advertised, “brain-fixing” IV fluids that were making many a millionaire throughout the mainland. When these IVs did nothing other than make children terrified of any human wearing a medical white coat, families became just desperate enough to be willing to try therapy – a concept they generally knew little to nothing about. At least some families became willing. Others still believed that there was a mystical and immediate cure out there for CP.

It was rarely due to lack of love that parents became abusive toward their children. But lack of education and misunderstanding go a long way in creating an environment full of frustration, an environment ripe for opportunity to vent those frustrations on your one and only offspring. With certain Asian laws still actively enforced where I lived, having a child with special needs not only sealed the child’s fate in an overpopulated, madly competitive society, but it also sealed the fates of parents that would one day age into needing assistance – assistance that generally fell solely on the shoulders of that one and only precious baby. I saw fear drive parents into doing and saying things that years before they probably assumed was not possible for them.

One such moment was when a young father brought in his 4, nearly 5 year-old little boy. This son was one of those children who glow with such effervescence that I found myself completely unable to keep myself from scooping him up and wanting to snuggle him incessantly. He had beautiful, giant brown eyes, a smile that enveloped the majority of his face, and just a hint of mirth glinting off of him that made him impossible not to love. He had been born in a village hospital, and due to lack of oxygen at birth, had developed the symptoms of cerebral palsy. His lower extremities were tight with high tone, and although he was able to walk a few unsteady steps by obtrusively swinging his hips, he preferred to mobilize around the treatment room by scooting on his booty – a sight that caused his father obvious embarrassment. His dad looked at me, and right in front of his son, said, “My son can’t walk. He doesn’t even try. He is stupid and lazy. If he would try harder he could walk like other children. Make him walk.” And right at that moment, the boy, who had been attempting some steps (upon his father’s command), lost his balance and fell against his father’s legs – to which the father smacked his son hard enough to send him sprawling to the floor and told him to get off and “walk right.” The sound of that slap filled the bare-walled and tiled floor of the room to such a degree that I couldn’t control my own gasp that completed the echo. I stooped, scooped up that precious child, told the father with my words, “Please wait one minute,” (though I’m pretty sure my eyes told him something less polite) and swept the boy into the hallway while he sobbed into my shoulder.

I asked the boy if he was OK, as I could easily see a red welt forming across his cheek.  But he was fine, physically. He was from a minority group that is known for being physically tough. They live in harsh conditions, and over the years I saw patient after patient come to the hospital with horrific injuries yet having not shed one tear in pain. But, as “fine” as the boy was physically from the slap, he was just as “not fine” emotionally. He was ashamed. Embarassed. And overwhelmed by feelings of having once again disappointed his father. These are unforgivable sins in the culture of central Asia, and he and I both knew it. All I could do was to speak words of life over that little boy – and so I told him how precious he was, how his life had meaning and worth, how he was smart, and fun, and funny, and was so, so lovable. He stopped crying, reached up with both hands to squish my cheeks, and twinkled a hint of a smile at me. I took him back to his father, told the father that there was no such thing as a total “cure” for CP, and gave him the run-down for a therapy treatment plan. And with that, the father roughly picked up his son and walked out of the room – while the little boy looked over his father’s shoulder and locked eyes with mine until they exited the doorway, turned the corner, and were out of sight. The father never brought the boy back again.

There is something deeply powerful in words. The second half of Ephesians 4:29 says, “. . . Let everything you say be good and helpful, so that your words will be an encouragement to those who hear them” (New Living Translation). Good and helpful. Those two words alone are beneficial to remember. Yes, the power of words has a deep impact.

I don’t think that man was a horrible father, and I don’t think that he was trying to horrifically shame his son. I think he was trying, in the only way he knew how, to motivate his son to walk, to fit in, to be like others so that he had at least a chance to make it in an unforgiving society that places value strictly on performance and not on person. But he was blind to the way that he was disabling his son even more by speaking words that cripple the soul and either create or deepen spaces for crushing insecurities. Such insecurities can keep a person blocked emotionally, socially, and relationally for decades or a lifetime.

Brené Brown, a researcher on shame and vulnerability, calls shame “the swampland of the soul.” In her research, she has discovered that shame has two big lies.

• The “Never Good Enough” lie
• The “Who Do You Think You Are?” lie

The kids who we, as therapists, work with face these lies every day. They already stand out as different. They use a wheel chair, walk with crutches, look different, sound different, think different and need to go to therapy because they are different. They get compared to national “norms,” the results of their evaluations get placed on a bell curve or termed “typical” vs. “probable difference” vs. “definite difference.” It doesn’t take a stretch of the imagination to see how children with special needs, with developmental delays, or with anything that would place them in a therapy setting, could make them feel “less than.” And so it is our job as therapists to confront and counteract the lies that these children may believe. Because they are good enough. They are valuable. They are important. Just as they are.

But what about us adults? It’s hard to speak what you yourself haven’t recognized or don’t believe.

What are our triggers that make us feel “less than?” If we don’t press into these difficult emotional areas, then it’s nearly impossible for us to recognize, validate, and honor the emotions or struggles the children we work with or live with might be going through. What are the things that rub an emotionally vulnerable spot and cause us to react rather than respond? What incident or wound has been left dormant and unaddressed (because not addressing wounds “feels” safer) but has brought about the secondary effect of us becoming the “shamers” because we were once shamed.

Like I said, I don’t think the father I met at the hospital was a bad father. But he was embarrassed by his son’s lack of ability. He was fearful about the future, and he probably felt like a failure because he couldn’t control what was going on. Knowing what the culture is like there, he was also probably being told on a daily basis what he was doing wrong, what he should have been doing for his son, and how “everyone else” would have and could have done things better or differently. He was being shamed by both himself and others constantly. And since an emotion like shame hits our amygdala (the emotion-behavior center of our brain) with such force that we typically either flee or charge through like a train off its tracks, the behavioral results were less than ideal.

Shame is sneaky. Sometimes it’s something as simple and seemingly inconsequential as, if after having just given your child instructions on the next activity, he or she looks up at you and says, “What am I supposed to do?” – is your response along the lines of, “What did I just tell you?” (Shaming) or is it more along the lines of, “Let’s think about this together, really hard, and I bet you can remember.” (Empowering and Reassuring).

Or maybe your client is having quite the day of emotional overreactions and you snap at them – not because snapping at them will be beneficial to helping them calm and self-soothe, but because you glanced up and saw your co-worker roll her eyes and raise her eyebrows at your alleged inability to “get your client under control.” You felt shame – and that shame touched some deep place inside of you that wants to be known as a capable, talented, valuable individual. You felt disapproved of, you felt a lack of control, you felt “less than” – and your client faced the result of your emotions.

And so, what if, as we work together to create an environment of health and healing for the children we work with and/or live with, we also create an environment where shame has no space to reside? This takes a lot of inner work – because we can only change what we are aware of, and we so rarely allow ourselves to be aware of what is emotionally hard or painful. But the end result (not that I’ve reached the end result of my own journey…) is worth the process.

Amanda Wherry is a local and international advocate for individuals and families with disabilities. She spent nearly 7 years in a remote area in inland Asia developing a hospital pediatric therapy program with teaching in physical, occupational and speech therapy as well as NICU therapy. read more