Emily's OT Evaluation and Assessment Report

A lot of you have been asking questions about some of the diagnosis information I've received from the occupational therapist. Since most of this is new to me, and foreign in many ways, I thought I would include part of her assessment report for you all to read. Indeed, many of you have a lot more medical background than I, and perhaps you can help me understand some of the things that seem to be going on with my little stinkerbelle.

The following excerpt was taken from the "Early Intervention Evaluation/Assessment Report" dated 2/19/10 and 2/23/10.

"Clinical Observations:

Musculoskeletal: Emily presents with range of motion within normal limits and adequate strength to complete basic gross motor tasks of carrying a toy across the room and pushing a door open. Muscle tone appeared in the low end of a typical range as evidenced by tendency to assume a "w" sit pattern for floor play and palpation.

Fine Motor/Grasping: Emily demonstrated functional ability to manipulate objects with both hands using age appropriate distal prehension... (this continues but it was all normal)

Visual Motor Integration: Emily reportedly loves puzzles and was able to place 3 puzzle pieces correctly in a form board when placed in random order. She was able to build a tower of 6 cubes agter demonstration and minimal assistance to begin (i.e. counting first 2 blocks placed). Emily was unable to imitate vertical or horizontal lines with marker and paper. When asked to snip with sissors, Emily touched the scissors to the paper but was unable to produce cuts.

Communication: Emily demonstrated inconsistent eye contact with the therapist which may have been related to high level of visual distractions in the therapy room. Once acclimated, Emily several times took the therapist hand, leading to a toy she wanted and pointed and looked, verbalizing "this this". When given additional processing time, Emily on several occasions would repeat back a word when modeled by the therapist, i.e.; "ball, green, clean up, swing, down, up". She had difficulty initially expressing what she wanted without modeling and would try to use other means to express i.e. pointing, gesturing, leading the therapist, etc. but would become quickly frustrated if she did not get what she wanted.

Sensory Processing: Sensory processing refers to the way an individual registers, modulates, and uses incoming sensory information for appropriate use (adaptive/functional responses). Adaptive responses are seen in how an individual reacts to stimuli (i.e. Movement, visual, touch, etc.), events (i.e. transitions, open spaces, room or schedule changes), and toys or utensils (desire, avoidance, preference, etc). Organization of sensory information is needed to adapt to, deal with, or respond adequately to environmental demands.

Emily has significant difficulty transitioning out of desired activities, waiting for a desired activity or toy. She often results with creaming, tantrums or aggression towards her mother. Her mother reports that they currently use time outs in her room for 2 minutes with her door closed. They have begun to incorporate transition songs learned from her musical therapist Angie for goodbye with success. When extremely upset, she will reportedly use her silky blanket for soothing and suck her thumb.

Auditory: The auditory system receives, organizes, and utilizes auditory information to facilitate communication and cognition. Integration of the auditory system with the vestibular system and proprioceptive system has affects on the central nervous system functions that include arousal, attention, motor functions, spatial awareness, and motor responses.

Significant difficulties noted in this area both in the understanding of more than 1 step directives, and ability to prioritize sounds in her environment. Per the sensory profile, Emily's family frequently has to speak loudly to gain her attention or touch her; she frequently takes a long time to respond, even to familiar voices, and frequently appears to be ignoring her mother when she is talking. It was also reported that this has improved a little since beginning therapy over a month ago. She seldom startles to sounds and seldom appears affect by busy or noisy environments.

Visual: Per the sensory profile, Emily almost always enjoys looking at moving or spinning objects and almost always prefers fast-paced brightly colored TV shows. Her mother reported they have removed all TV's from their home because she will persevere on watching and will become hyper-focused and not engage with others with the TV is in the house.

Vestibular: The vestibular sense responds to and provides information related to the changes in head position, gravity, and movement. Vestibular input plays a role in the integration of an individuals's balance, extensor muscle tone, and equilibrium responses. It affects the ability to use both sides of the body together, and coordination of head, neck and eyes moving together. It also has an affect on the processing of auditory-language information, and behaviors related to the arousal system.

Per the profile, Emily almost always enjoys physical and rhythmical activities (i.e. being bounced, swinging, rocking or car rides), almost always becomes upset when placed on back for diaper changes and almost always resists having head tipped back during bathing. In the evaluation, Emily frequently jumped from activity to activity and did not engage for very long with trampoline jumping or swinging, especially when movement was imposed by the therapist.

Proprioceptive: Proprioception allows awareness of the position of muscles and joints. Proprioceptive input provides us with information as how far to reach, with how much pressure, timing, etc. It also provides us with feedback as to where we are in space and our relationship to things outside of ourselves.

Emily reportedly takes risks in play without regard for personal safety inclduing climbing on things, etc. She was reported by her development therapist to often engage in proprioceptive seeking activities.

Results/Implications: Emily's strengths include a supportive family and mother who appears interested in the therapy process and in helping her daughter, age equivalent grasping skills, good strength, functional mobility and interest in engaging with adults if motivated by activity and clear expectations are set. Her challenges include atypical sensory processing which impacts her ability to prioritize sensory information and respond appropriately to it, specifically proprioceptive, tactile and auditory. Emily appears to have trouble modulating her responses to input and either under-responds (not noticing) or over responds. Her over responses pose a safety risk for herself and others and limit her ability to problem solve situations adequately. In addition, Emily present with visual motor skills below age level which may be impacted by her difficulty following adult directed tasks and processing verbal instructions.

Emily presents with signs indicative of mixed responsiveness to sensory input and atypical modulation of responses. These significantly impact her ability to engage appropriately in home and community tasks with her family and peers. In addition, she resorts to non-functional behavior within her activities of daily living including toileting issues and food intolerances. Emily's visual motor integration skills are recommended to be re-assessed as her sensory process is addressed to determine accuracy of age equivalency."

PECS

Once again its been awhile since I've written, and as always, its because there are just more things to do around here than there is time in a day. Nora and her Brownie troop are keeping me busy, my new online class and its 15 students are keeping me busy, and of course Emily's therapy is keeping both Emily and I busy.

In the last two weeks, Emily and I have started using a tool called PECS both in Speech Therapy and at home. PECS stands for Picture Exchange Communication System. It was developed as a means for autistic children to communicate their wants and needs by handing pictures of different items to an adult or other caregiver. A side effect of using this system is that many children start to learn the words associated with the pictures, thus leading to verbal communication. Since Emily is a visual learner, we are hoping that by using PECS we will be able to cut down on the tantrums associated with her lack of verbal skills, as well as teach her some important vocabulary.

At first, as mentioned in a prior posts, Emily was not very keen on using this system. She has been pointing and grunting at the things she wants for over a year, and she didn't want to change her routine. When learning the system in Ms. Shelly's office, she had several major meltdowns, and I suffered the loss of a tuft of hair that she yanked out of my head. When I introduced the pictures at home, the look she gave me was one of pure disgust. She hated the PECS book, and she kept throwing it and its pictures right back at me.

Of course I probably should have watched the DVD video explaining PECS before trying to use it. After Ryan and I watched the show, I realized I was approaching the whole thing wrong. I needed a secret weapon: Root Beer. So the root beer picture went into the book. Then I showed Emily that if she handed the picture of root beer to me, she would get her tiny mug filled to the brim with brown foamy goodness. It only took her about 20 minutes to figure out the whole system. Now she is able to "tell" me what she wants to eat when she's hungry and what toy she wants to play with simply by handing me a card. I love PECS. She has learned several new words including book, root beer, raisins, animal crackers, and fish (for gold fish).

This has lead to a new set of issues, however. Now that Emily has a means of expressing her wants, she thinks she will automatically get them. I'd tell her "no" or "all done", and then I'd put the picture back in the book. The problem was that she would retrieve the picture, and hand it to Nora or the dog! Of course I had a good belly laugh when I realized she was trying to get root beer from Lacey, but then Em got angry when the dog didn't deliver. I've taken to hiding the PECS pictures of things she can't have too much of, like fruit snacks. She doesn't take no for an answer. I am thinking we need an "all done" bin to get the idea across that the PECS book isn't her personal all you can eat buffet. Until then, I suppose she can keep asking the dog for a snack, and who knows? Maybe Lacey will help her out after all.

Brownie Troop 64 is off and running...

From 2010_02_First Brownie Meet

And I do mean running. I am still out of breath!

But let me begin at the beginning. After the excitement of becoming the new leader for the Brownie Scouts in our troop, it began to dawn on me that I really didn't know what I was doing. I asked Nora repeatedly for information about her other meetings, and determined they knew the Girl Scout Promise, bringing the snack was a big honor, and that everyone liked to do crafts. As someone that hasn't quite grown out of crafting, or snacking for that matter, I could appreciate what these girls needed. That information, along with some helpful tips found online from other Brownie leaders, helped me plan out our first agenda. And yes, I did type up an agenda just like I was back in college leading the art history student organization.

I made a cute poster with the GS Promise, the GS Law, and the GS Motto. The Motto, Be Prepared, was the theme of the meeting. We talked about what it meant to be prepared if it was rainy, sunny, or if someone got hurt. We played a band-aid relay race game that didn't really work, considering it is hard to have a relay race in a room that is only 12 long and full of tables! We made friendship bracelets, most of which have probably fallen apart at this time due to my inability to tie durable knots with an audience watching. Despite the fact that some of these activites did necessarily work out as I'd hoped, I think we all had a good time.

The thing that stuck me most about these girls is how excited they are! They were just bursting with enthusiasm. I asked a question, and I had nine hands waving in the air, "Pick me! Pick me!" They all seemed to warm up to me very quickly, more so than to Mr. Ryan, who was in the room trying to keep Emily from totally destroying the place. Overall I think it was a success. At the end we formed a friendship ring, holding hands and passing a squeeze from girl to girl. They liked that, and seemed happy that we would be meeting again in two weeks.

To see photos from our first meeting, click this link: http://picasaweb.google.com/duck560/2010_02_FirstBrownieMeet02#

A few helpful links

For my parenting readers out there, I personally found these articles helpful and wanted to pass them along. Enjoy!

Two simple ways to be a happier parent: http://health.yahoo.com/featured/84/two-simple-ways-to-be-a-happier-parent/

Keeping children's toys from overwhelming a room: http://unclutterer.com/2010/02/11/keeping-childrens-toys-from-overwhelming-a-room/

PS I am not adverse to the idea of putting out a hit on the extra toys...

Therapy update

Changes are headed this way in terms of Emily's therapy. I am so happy to see that she's progressing, but like any good teacher (or therapist), the time has come to push Emily to the next level. So far she's not too keen on what she sees.

For the past two weeks, Emily's music therapy has been ok. She wasn't talking as much as she had been, although she is still playing her instruments and singing with a lot of gusto. She is getting better on the guitar, which is just plain cool. However, it's hard for me to sit, unseen, in the other room and listen to the other kids speak up. She does ask for crackers and juice, but she hasn't learned many new words to share in a social context since. She certainly doesn't speak up for herself when asked who wants to go first, but since the last shall be first and the first shall be last, I'm hoping she's practicing a spirtiual path. Maybe?

Speech last week was just a diaster. Oh my tantrum time. In order to get Em to communicate a little more one on one, Miss Shelly introuduced a picture card system. Instead of having Emily resort to pointing and grunting at things she wants, like the cabinet with the snacks inside, she is going to learn to hand me a picture of what it is she wants to eat. This is going to help her learn to express what she wants and pay attention to the person she is communicating with, rather than focusing soley on the object of her desire. We tried this in the office with some Fritos. To say she hated it is an understatement. She pulled out all of her tricks, the hair pulling, the hitting and scratching my face, throwing herself on the ground in a fit. Luckily the floor was softer than I had anticapted.

She didn't like it, but that doesn't mean we are going to stop trying. She was frustrated by the extra step, the step involoving the other person. Miss Shelly decided we are going to make a book with the picture cards inside of it, and we are going to have pictures for food, toys, people, and places. Once this system catches on, she will be able to both "talk" to everyone through the pictures, and I will be able to "tell" her about her daily schedule and activites so there isn't such an element of surprise. That should help with some of the transition issues we've been having as well. (Transistion issue is code for throwing tantrums whenever we have to leave one place to go to another place).

I'm in the process now of taking photos of family and friends and homes to create the pictures in the book. I am hopeful, but I have a feeling this might be a bit of a challenge.

Occupational Therapy Evaluation

Miss Em had her last evaluation today for services through the state. Oddly enough, she qualified for occupational therapy even though she's only two and certainly has never had a job! Of course I'm only kidding, from what I gather occupational therapy doesn't pertain to what you do for a living. Rather, it deals with the way that the body takes in information from the world, how the brain processes that information, and how the body responds to the external stimulus.

As Miss Jeanie explained to me, when someone is eating a meal, there are as many as 32 separate types of information entering the senses all at once. There are smells, different textures to the food, shapes of the plates and utensils, lighting, cooking sounds or the sounds of people talking, etc. etc. It's a lot of stuff to take in, yes, yet the brain can handle it well enough. However, when this process isn't smooth, when the brain can't handle everything coming in, it affects the way that info comes back out. I think of it like the computer's CPU. When its using 99% of its power on one program, the other programs don't respond. And that is what is happening to Emily.

More specifically, she has a problem with her auditory processing. At times, she can hear verbal language and she can understand it. If you tell her she can watch a movie she runs to the computer. But she can't always respond verbally to a similar situation. For example, if I asked her to what movie she wanted to watch, she would go to the computer and point, but odds are she wouldn't be able to come up with the words, "Wiggle Bay" or "Dora". If I pushed the issue, she would throw a tantrum. I never understood why she wouldn't respond to what seems like a simple question. I thought she was being stubborn. It turns out she simply can't respond to these types of questions. She is focusing on the idea that a movie is coming, and she's too excited to get any words out, even words she knows like "Dora". When she is really foucsed on something, like a puzzle or a book, she can't even hear me. In Emily's head, I actually sound like Charlie Brown's teacher! Whon wonh whonnw...

I am not exactly sure how the occupational therapy is going to progress. Miss Jeanie and Melanie, our state coordinator, both feel Emily would do best participating in the occupational therapy in conjunction with her speech therapy. Sessions will be held back to back at the same facility. Hopefully this will help her progress quickly. She is a bright girl, and there's no reason why we shouldn't be able to make some significant strides before her third birthday.

Super Trooper Nora

In an unexpected turn of events, I have found myself promoted from mom of a Girl Scout Daisy to new Brownie Troop Leader for our local Montessori School. Wow! What a change. I really hoped that I could start working less so I could be more involved with the girls, and this is the perfect opportunity to do just that.

I think the best part about everything is the fact that it's the result of the runaway success of the troop. It seems like there are new members added every few weeks. The tipping point for Candice, the Daisy leader, must have happened somewhere around 18 or 19 girls. I got to talking to her about what would be best for everyone, and the idea to split up the girls into two groups was formed. After all, the needs of the 3 year old unofficial members are very different from the 8 year old Brownies. We both wanted to see them doing activities that really promote what the Girl Scouts stand for, namely service to others and a self-reliant attitude. Plus, splitting up the girls will allow for a little more individual attention. Currently, there are so many girls and so few adults; once they have their snack they're too hyped up and organization is out the window. Hopefully having two groups of nine will help bring a little order back to the meetings as well.

Of course I talk about bringing organization and instilling a sense of service to others...the real test will come on Thursday. That will be my first meeting as leader. It will be me, hopefully Ryan, nine girls, and Emily. It sounds a little daunting, but I think I can do it. The other teachers, the professionals, are on the other side of the door if things get out of hand. And even if I totally flop, I know I have at least one fan in my troop. Nora is totally thrilled that I'm the new leader. She has said, "Mom, I'm your trooper!!" more than once. I told her, "Yes sweetie, you're my super trooper." She thought that was funny; I don't think she realized I was being completely serious. I'll be counting on her sunny attitude and excitement more than she can know!