April is OT Month and Autism Awareness Month!

Another apology is in order for the neglect of my blog. I’ve had several blog entries “in the works” for a long time, but have failed to finish developing them and getting them up here. I’ve made a promise to myself to get back into this, and my goal is to try to publish at least once a week! So if you’ve abandoned my blog because I haven’t updated in a long time, please come back!!! It seemed appropriate to come out of hibernation to blog during April, as April is the celebration of both Occupational Therapy, and Autism Awareness! I work with, and have worked with, many children and adolescents on the autism spectrum (about 1/3 of my current caseload has a diagnosis on the spectrum), so Autism Awareness is something that is important to me. In honor of both April celebrations, here is a general overview of autism and how occupational therapists work with individuals on the autism spectrum.

First, for those unfamiliar with autism, allow me to explain what I mean by “autism spectrum.”  This is an umbrella term that refers to a group of developmental disabilities that may cause significant challenges in the areas of social skills, communication, sensory processing and behavior.  The general term Autism Spectrum Disorder (ASD) [which can also be referred to as Pervasive Developmental Disorder (PDD)], refers to the following three disorders: Autistic Disorder (also called “classic autism” or just “autism”), Asperger’s Syndrome, and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS).

Someone diagnosed with Autistic Disorder generally has significant language delays, social and communication challenges, [unusual]* and/or stereotypic behaviors and interests, and atypical processing of sensory experiences. Often people with autism also have intellectual disability, but low IQ is not a diagnostic criteria. Within the classification of Autistic Disorder, there is variation in severity and functionality, though there is no “official” distinction, many people will often refer to different levels in terms such as “high functioning autism” or “severe autism.” Asperger’s Syndrome shares some symptoms with Autistic Disorder, such as social challenges and [unusual]* behaviors or interests, but symptoms exist in a more mild form, and there is no language delay. Typically those with Asperger’s Syndrome do not have intellectual disability and generally have average to above average intelligence. A diagnosis of PDD-NOS is given when an individual meets some criteria for Autistic Disorder but not all criteria. Signs of ASD in young children may include lack of, or delay in, spoken language; repetitive use of language and/or motor movements (example: echoing or scripting what another says instead of speaking spontaneously, hand-flapping , or twirling objects); little or no eye contact; lack of interest in peer relationships; lack of make-believe play; and persistent fixation on parts of objects.

*Author’s note: I bracketed [unusual] because these words are included in literature about diagnostic criteria for autism, however, I do not like these words. I do not feel as a “neurotypical” (the term that people on the autistic spectrum often use to describe those who are not) that I have the right to pass judgment on behaviors and interests of those on the spectrum, or anyone for that matter. To the person, it not unusual, so what right do I have to say it is?! Also, in my opinion often these interests aren't even necessarily so "unusual," often people with ASD just have very specific interests that can be quite intense (often referred to as obsessions or perseverations), such as Jason and his interest in the subway. Also, interests may seem "unusual" because people with ASD are often very detail oriented. The way one little girl I treat "plays" with toys is to line them up in various categories, such as organizing them by color, size and shape. To her, this is more interesting than using toys for their intended purpose. I suppose this may seem "unusual" but for her lining toys up into organized categories is meaningful and makes sense to her. It is the propensity for specific, intense, and often detail-oriented interests that can allow people with ASD to make important contributions to society. Temple Grandin (a woman with autism well-known for her work both in the autism community and her accomplishments in the field of animal husbandry), jokes that NASA is the largest sheltered workshop in the world! We should be thankful for these "unusual" interests!

What do occupational therapists do to treat individuals with ASD?  As discussed in previous blog entries, OTs assist when a person is experiencing barriers to successful participation in his or her daily occupations. OTs will work with clients diagnosed with ASD in many different areas of occupation. Interventions may target regulating emotion and behavior; processing sensory information that is needed for participation in occupation; developing social abilities, interpersonal skills and peer relationships; self-care skills such as dressing, feeding, hygiene, and sleep; skills for school success such as organization of task materials, independent work skills, group process abilities; using assistive technology to accomplish communication or other occupational needs; and developing motor skills that may be delayed.

I mentioned in previous blog entries that in December I attended the 2010 American Occupational Therapy Association (AOTA) Autism Specialty Conference in Baltimore, MD, which was an amazing opportunity to hear from the experts in the field, as well as convene with other occupational therapists who treat clients on the autism spectrum. At the conference, a point that was emphasized throughout the two days of presentations was that people with ASD are people first and a diagnosis second. They may have difficulty expressing and understanding feelings, but they certainly have them. Just because they lack social awareness and social skills does not mean they don’t long to be included. Research shows that children and adults on the autism spectrum want to have meaningful relationships, they just don’t know how. Additionally, people with ASD can contribute wonderful things to society. Sometimes, however, they just need to make their own way.  The norms of a society that is mainly made up of “neurotypicals” may not be how individuals with ASD find their path to success, and that is okay! As OTs, we have the ability to help individuals carve their own paths in the world and be able to make unique and important societal contributions. Occupational therapists are equipped with the skill set to look at a person’s strengths as well as challenges, analyze the tasks the person wants or needs to do, take into account the environment and extraneous factors that may support or inhibit participation, and collaborate with the individual to find a unique solution that allows for success!

At the conference, I had the privilege to attend presentations given by adults on the spectrum, and something they taught me that really made an impact on me was that many people with ASD do NOT consider themselves to have a disability!! They just accept that they are “wired differently” from neurotypicals. Most of these individuals have no desire to be neurotypical. They do not need to be “fixed.” They just want to be accepted, and assisted in order to be successful functioning in neurotypical society. Many adults on the spectrum have found the ability to celebrate their uniqueness and accept and embrace autism as a diversity. Now, if only neurotypicals would see it that way!

Sources for this blog entry include presentations from the 2010 AOTA Autism Specialty Conference, and “The American Occupational Therapy Association Frequently Asked Questions: What is Occupational Therapy’s Role in Supporting Persons With an Autism Spectrum Disorder?”

FAQs: "What is an occupational therapist anyway???"

I do sincerely apologize to my blog readers for the very long break in blog entries. First came the holidays, then when the new year began I became very busy because I began a new job. I still am working full-time at the job I’ve had, but I’ve taken on an additional part-time job. In addition to my work at a pediatric therapy center (through which I work at a clinic every weekday afternoon/evening and am contracted out to a public secondary school two mornings per week), I am now also working two mornings per week at a special needs school. There, I work primarily with children in the school's preschool program. It has been a great experience so far, but it has taken a few weeks to acclimate to my new much busier schedule. So, once again, apologies for neglecting my blog.

I realize that a lot of my blog readers are not occupational therapists themselves. A lot you readers are people who do know me in real life, and kind of sort of know what it is I do, and have heard me try to explain it, but as readers who ARE fellow OTs know, summarizing what we do in any kind of concise way that can lead to any real understanding of our profession is almost impossible! I’ve been told many of my blog entries so far has contributed to my non-OT readers’ understanding of what OT is and what pediatric OTs do. So I decided to expand on that and write a blog entry giving my best description of my profession to help with my readers' understanding. I’ve decided to do it as a “FAQ”. These are real questions I’ve been asked when I’ve said to someone that I’m an occupational therapist. Most of these questions I’ve heard several times, as has basically every OT I know! Here are my answers.

The OT Slogan

Question: Is an occupational therapist someone who helps people find jobs?

This is one all OTs hear rather often, and always produces a collective groan from the OT community. A very common misconception is the meaning of the word “occupation.” In colloquial language an "occupation" refers to someone’s job, but an “occupation” refers to more than just a job. Occupations are what people do to occupy their time that is meaningful to them, and/or required of them. For you, your occupations likely include: activities of daily living (ADLs) (ex: dressing, eating, bathing and toileting), instrumental activities of daily living (IADLs) (ex: cooking, cleaning, pet care, and child care), your job, driving and/or navigating public transportation, and what you do for fun (such as participating in hobbies or meaningful leisure activities). Occupational therapists assist when people are unable to participate in, or have difficulty successfully participating in any of their occupations because of various barriers (including disability, disease, injury or mental health issues).

Question: What is an occupational therapist? What does an OT do?

Occupational therapists are professionals that assist their clients to overcome barriers to performing their daily occupations. This may involve assisting clients to: develop or improve necessary component skills for successful performance in their occupations; develop compensatory methods in the process of developing the component skills, or when these skills cannot improve (such as in the case of a permanent disability affecting the ability to develop the skill); adapt the task to accommodate for the client's current abilities; adapt the environment to promote the client's success; and most commonly occupational therapist use a combination of some or all of these methods for each client. An OT's overall goal with a client is to help him or her to become as independent and functional as possible, participate in meaningful occupations, and experience a high quality of life.

Question: What does an OT do with kids? Kids don’t have jobs!?

Children don’t have jobs, but children DO have occupations, For children, common occupations are: participating in ADLs (dressing, eating, bathing, toileting); being a family member and functioning within his or her family environment; playing/engaging in leisure; and being a student. Barriers to being successful in childhood occupations that pediatric occupational therapists treat include:

• Sensory integration/processing issues
• Developmental delay or disability
• Gross motor delays
• Fine motor delays
• Muscle tone abnormality
• Poor endurance
• Retained primitive reflexes
• Learning disabilities
• Cognitive impairment
• Physical disabilities
• Acquired injuries
• Behavioral issues
• Attention/focus difficulties
• Motor planning or praxis difficulties
• Visual perception and/or visual-motor integration difficulties
• Psychosocial issues

Question: Occupational therapy? Is that like physical therapy?

This is a question OTs get all of the time, likely because physical therapy has more mainstream recognition and most people understand the basics of what PTs do, but many people have no idea what OTs do. For those that can recognize a difference in the professions there is a stereotype that PTs rehabilitate from the waist down, and OTs from the waist up. Another stereotype that is out there is that PTs address gross motor skills, and OTs address fine motor skills. While these stereotypes aren’t entirely unfounded, they’re not entirely true either. Occupational therapy (OT) and physical therapy (PT) are both considered “related services” and often work in similar settings and with similar populations, but we are very different professions with different theoretical bases. Physical therapy rehabilitates a client when there is a physical problem that exists. Although OTs do that too, our treatment is always directly related to daily life functioning and ability to participate in daily occupations. OTs never have clients perform non-function based exercises merely for the sake of making a body part stronger or more flexible. We may do similar exercises as PTs if there is a physical problem limiting the client’s participation in their occupations, but the exercise will always only be a “warm-up” to working on a specific activity or developing or rehabilitating a specific skill required for the occupation. While both our professions help clients function, OTs treat all aspects of the person we are treating, not just the physical. Often we have overlapping caseloads (such as people who have had strokes or children and adults with physical disabilities). However, there are many settings where there is rarely overlap in cliental, for example OTs don’t often have a role a lot of strictly orthopedic situations where overall daily life functioning is not affected (such as a sprained ankle), and PTs don’t generally have a role in mental health or other barriers to occupation that don’t require physical rehabilitation.

The Occupational Therapy Domain

There, in summary are my answers to “OT FAQs”. Hopefully this contributed to my non-OT readers’ understanding a bit!

"Seven senses? Like that movie with Bruce Willis where the kid can see dead people?" Sensory Processing and our Seven Senses

I’ve mentioned sensory processing (also known as sensory integration) a few times in my past blog entries. Non-OT readers of this blog have probably been wondering exactly what I’m talking about. It’s a part of my everyday language as a pediatric OT, and it’s actually part of every single person’s everyday neurological process, but outside my field it’s not something commonly known about or talked about. So here’s my “sensory processing in a nutshell” explanation.

Those not familiar with the term “sensory processing” may be able to deduce that it has something to do with how the brain processes information from one’s senses. However, what you may not know is that people actually have SEVEN senses that we receive input from. (And no, the sixth sense is not being able to see dead people!) There are the 5 “basic” senses that most people are familiar with: touch (tactile sense), sound (auditory sense), sight (visual sense), smell (olfactory sense) and taste (gustatory sense). However, there are also two other systems from which receive input and contribute to sensory processing: the vestibular system (movement sense) and the proprioceptive system (position sense).

The first "secret sense" that is very much a part of your sensory system but few people are aware of is your movement sense. The vestibular system. Vestibular receptors are structures within the inner ear. When the head changes position, these structures register this information and send it to the brain to process it to help determine the body’s position in relation to earth’s gravity. This system is how people know when they are in motion.

The OT in this picture is providing vestibular input to a child on a therapy swing

Proprioception, "the position sense" is the brain’s unconscious ability to determine where all one’s body parts are without having to look at them, and where the body is in relation to other objects or people without having to touch them. Receptors in our muscles, joints, and connective tissue (ligaments and tendons) receive propioceptive input and send it to the brain to process. It is how the brain interprets sensory messages about the position, force, and direction of one's body and its parts. Gravity acts on these receptions even when we are not moving.

Sensory integration/processing is a normal neurological process that every person’s neurological system does, all the time. Every person’s nervous system/brain is designed to receive information from the world around us through sights, sounds, touch, tastes, smells, movement and gravity. The body receives this input, and the brain perceives and interprets the information. The brain then “tells” the body what to do based on how it is interpreting the sensory information. When people experience a challenging level of sensory simulation and successfully respond to it, they develop an “adaptive response.”

Sensory processing problems occur when some aspect of sensory processing does not function effectively, and the person may experience stress throughout the course of everyday occupations. This is because the neurological processes should be automatic and accurate (the processes of taking in sensory input, interpreting it, and generating an appropriate adaptive response) are not.

Even with properly functioning sensory processing, everyone has sensory preferences and dislikes. For example, loving or hating rollercoasters, spicy foods, certain musical dynamics, scents or colors. That is normal. However, for children who have sensory processing disorder/sensory integration dysfunction, or “sensory issues,” the way they experience the world is so much more than sensory preferences or dislikes.

When there is a breakdown in these neurological processes, it can manifest in several different ways (and every child is different!) It can present as a trouble with sensory modulation, which causes the child’s responses to sensory input to be out of proportion to the actual experience. This can present as over-, or under-responding to sensory stimuli, seeking sensory stimulation, or a mix depending on the type of input and the situation. Another effect of sensory processing difficulties can be motor output that is disorganized as a result of incorrect processing of sensory information. The child may be dyspraxic (unable to plan and execute motor movements necessary for everyday tasks), and appear accident-prone, clumsy, physically awkward and struggle with both gross and fine motor skills.  Another manifestation can be difficulty perceiving the salient qualities of sensory input, and/or struggling to differentiate between sources of sensory stimuli, such as judging how much force to use on different objects. However, the most common manifestation is disordered modulation and the seeking or avoiding of types of sensory input due to the inability to effectively process that input.

Sensory Processing Disorder (SPD) will be recognized for the first time in the upcoming DSM-V (the Diagnostic and Statistical Manual of Mental Disorders). SPD is becoming more widely recognized in the pediatric community, with many books shedding light on this issue hitting the shelves for both professionals and as self-help for parents of children experiencing these problems. These books include “The Out of Sync Child” and “The Out of Sync Child Has Fun” both by Carol Stock Kranowitz, “Raising a Sensory Smart Child” by Lindsey Biel and Nancy Peske, and “Sensational Kids” by Lucy Jane Miller and Doris A. Fuller. These are all books I’ve read, loved, and recommended to parents, and parents have reported back to me about finding hope and understanding in these books.

In addition to children with SPD, most  children diagnosed on the autism spectrum also have significant sensory processing problems. In a study of children with autism spectrum disorders, 94% of the 200 children studied having significant sensory issues*. In the mental health realm, sensory processing issues are inherent to schizophrenia. A number of other disabilities include problems with sensory processing and/or are co-morbid with sensory processing disorder.

So what do occupational therapists have to do with sensory processing? OTs deal with sensory processing because when a child has issues with sensory processing, it affects his or her ability to play, work, learn, have appropriate social interactions, dress, eat, and function within their family or school environment. Anything affecting a child’s ability to engage in his or her childhood occupations (self-help, eating, functioning in his or her family unit, and functioning in school) OTs can be involved. Now you may be wondering what is it that OTs do for these “sensory kids”? OTs use the Sensory Integration Frame of Reference (affectionately known as SI) developed by A. Jean Ayres to guide treatment. First, when beginning treatment, OTs meet the child where he or she is at. Therapists provide the child with opportunities to get a lot of the input he or she is seeking while monitoring it to help the child stay regulated, and do not force input that he or she is defensive of. Therapists help the child feel safe, calm, and comfortable in his or her own body and in the environment. We as pediatric OTs create an environment that facilitates exploration of different sensory experiences that is both fun for the child and therapeutic. OTs use a variety of swings and suspended equipment, textures, fabrics, toys, games, places to crash, things to climb, music, and other equipment to create a sensory environment that is both comfortable and challenging for each child. We use knowledge of sensory processing and how the brain perceives the different types of sensory input to create experiences that will affect his or her brain’s ability to process and regulate sensory information and generate adaptive responses.

Not the gym I work in but a very good example of the equipment used in an OT "sensory clinic" much like where I work

Hope that clarifies a bit. Not wanting to make this entry too long, I will save specific examples of sensory processing disorder with the kids I treat for a later blog :)

*(Greenspan & Wieder, 2000)

Rough life doesn't mean damaged for life

Yesterday morning before work, I completed a mandatory child abuse training online (as I am a mandated reporter of suspected child abuse, and am required to keep up to date on laws, policy, reporting procedures, ect). Spending several hours reading statistics about child abuse and case studies based on true stories, my mind couldn’t help but drift back to the summer of 2008, when I was completing one of my occupational therapy internships at a residential treatment center for adolescents diagnosed with Emotional Disturbance. Almost every single one of the teenagers I had worked with there had led very rough lives and had been either neglected, physically abused, emotionally abused, or sexually abused, and unfortunately most of them a combination of more than one (or even all) of the above. Even worse, many of them had been abused by multiple caretakers—taken from their biological parents by social services because of abuse and then moving in and out of foster homes where sadly, many of them were abused by foster parents and/or foster siblings.

I did a very different method of occupational therapy during that internship what I do now in my job. I did not work with the residents at the center individually, but instead in groups and on a consultative basis with the residential staff. One of the main areas addressed in the series of groups I ran that summer was instrumental activities of daily living (IADLs), which are activities that are not essential, but are necessary to live independently—including homecare, work, shopping and meal preparation. This was a focus of my groups because many of the kids ended up in the residential treatment facility after living very difficult lives with very little adult mentorship, and (although the goal is always short term stay) many of the residents end up calling the facility home until they age out on their 18^th birthdays. At that point they are legally adults, and many end up in adult group homes, where they're expected to be at least somewhat independent in most IADLs.  However, the system can sometimes set them up for failure after the transition because the residential treatment center is a bubble—the kids go to school there, live there, and only leave on seldom, supervised, and highly controlled special occasions. [Note: since my internship ended, I found out that the facility added a "transition unit" for the older residents getting ready to transition into the community to continue to combat this issue and give the transitioning residents more tools for community integration, but this did not exist at the time.] The groups I ran targeted self-esteem and team building in addition to hygiene, cooking, money management, and community skills such as grocery shopping. The summer culminated in assisting the residents in planning a dinner with their living unit which included looking up a recipe, making a grocery list of ingredients, going on a trip with me and other staff to the grocery store to purchase these items, and then cooking their meal and having dinner with their unit. Additionally, as my internship project, I created job descriptions for several jobs around the facility in order to help begin a job program for the kids. This program would allow the residents to hold jobs in the facility under the supervision of job coaches in order to gain real-life practical job skills. I learned so much about that summer. Although I work in a very different setting now with a very different population, the internship was invaluable to me as a therapist and a person. 

Yesterday, reading all about child abuse got me thinking about the internship. And then, as if that stirred something in the universe, I went to work and there was a new kid on my schedule at the clinic, diagnosed with Emotional Disturbance. As child abuse is unfortunately a prevalent problem in this country it’s almost impossible to work with kids and not come into direct or indirect contact with kids who have had it rough. However, this new kid I started with yesterday was the first kid that I’ve seen working in the setting I do now who’s IEP (Individualized Education Plan) gave a primary diagnosis of Emotional Disturbance. This boy, Alexander (once again all names of clients have been changed) is 10 years old. He is in the custody of the state, currently living in foster care. Upon reading over his IEP, I came to learn that he has a lot of attention and behavioral difficulties affecting his performance in school. According to his IEP, Alexander tends to be very angry, withdrawn, and distracted when he is in school. His home life has been unstable for a long time. [Yet, when I reached the section that included his occupational therapy goals, they related to his poor handwriting (hmm looks like someone seemed to make the common mistake and forget that OTs are so much more than just the Handwriting Ladies!) ]

Although the setting and method of service delivery is very different from my internship at the residential treatment center and Alexander is a few years younger than the residents, a lot of what I learned there will hopefully be advantageous to me as I begin to work with Alexander (and we will certainly be working on more of what is affecting his success in school than just his poor handwriting). One of the most important thing I learned at my internship that I will apply with Alexander is the importance of therapeutic use of self with this population. Of course, therapeutic use of self is important with every single child I treat. For example, I act very differently depending on the child I am working with at the time, constantly judging how to best use myself to benefit each child during each therapy session. Therapeutic use of self can be as simple as me being goofy and energetic with an eight year old boy who thinks he’s too cool for therapy, and then a few minutes later very quiet and soothing with a very shy and easily overwhelmed three year old girl. With children with Emotional Disturbance and other related psychosocial issues, however, therapeutic use of self is so very important in helping these children to be successful.  A child who has been in abusive situations may have had a very limited number of adults he or she could trust, who want to help instead of hurt. Because of the past, it is often hard for these children to get out of their own way and be wary of allowing another adult "in," even an adult with truly good intentions. Building a trusting, nurturing relationship is paramount if I have any hope of making progress with a child who has been through a lot of hurt in his or her life. This starts internally. This starts with me truly believing that these types of kids aren’t just “damaged goods.” That they are children who--although they may have been through unimaginable evil things in their young lives, although they may “fit the profile” of a future abuser or criminal themselves, although they may be little more than a statistic to many--still have a possibility of having a good quality of life, and still have a shot to become a functional adult, and that as an OT I have the ability and responsibility to give these children the tools to help make this possibility a reality.  It may take a lot of patience, kindness, and understanding, but getting through to kids with Emotional Disturbance isn’t impossible. I will always have a special place in my heart for children who have had difficult lives. Kids can be very resilient. Kids can overcome things that man people may have never thought possible. They can become functional members of society despite the odds. I am looking forward to working with Alexander, and hoping that I can use what I learned during the summer of 2008 to help benefit him.

The Handwriting Lady

At the AOTA Autism Specialty Conference I attended last week (there will definitely be more about the conference in a later blog), Winnie Dunn, an amazing OT and researcher, said in her keynote address, "Don't let yourselves be pigeonholed. We are more than just the Handwriting Ladies!" (Followed by a comic nod  to the 3 male OTs in attendance). This is very true. In the world of pediatric OT, we are so often linked with handwriting to the point where other related service professionals, teachers, parents (and if we're not careful even us as OTs!!) can forget or never realize in the first place that OTs do so much more than just helping the kids we treat improve their handwriting!

Why is it that pediatric OTs so frequently address handwriting that it has become possible to pigeonhole us as “the Handwriting Ladies”? Why is it that poor handwriting is the most common reason for OT referral in school aged children (and poor pre-writing skills in pre-school children)? I believe it is because of a paradox that is a very real part of school for kids. And that is that handwriting is an essential part of a child’s occupation of being a student (for those non-OTs who may be reading, an "occupation" refers to the things people do in their daily life that are of necessity and/or of meaning to them, for children being a student is one of the primary occupations they engage in).  Children are required to produce written work in basically every school subject, because writing is how they communicate what they know and have learned.  Unfortunately for children with special needs, handwriting is also one of the most complex tasks children are expected to perform. It seems automatic for those without a disability, but handwriting actually encompasses an extraordinary amount of body systems and underlying component skills, and if a child has issues with any one or combination of these skills it will very often manifest as poor handwriting.

[Here’s something that will probably blow the minds of the non-OT readers. Take a deep breath in....ok, readysetgo: In order to write successfully, first one needs to be able to sit in a chair. Just that involves a lot, such as having the core strength and postural control to stay upright in the chair against gravity. Then there are also a lot of visual elements to handwriting. There's visual acuity (being able to see and see clearly), occulomotor skills (such as being able to move one's eyes to visually scan from left to right and top to bottom), visual perception (which includes being able to interpret series of lines and curves as different and distinct letters), and visual-motor integration (which includes being able to write in between the lines). Another key component to handwriting is fine motor skills. One needs to be able to grasp a pencil appropriately, and manipulate it using very small movements. This involves having good control over the very small muscles of the wrist, hand and fingers in addition to strength and endurance of these muscles. Also, there's praxis (motor planning), which is the ability to plan and execute the specific movements required to form each letter consistently and correctly. Then there's other neurological components, such as the ability to sustain attention to task. There’s cognitive components such as memory--one needs to remember which set of lines and curves represent which letter. There's sensory processing components involved, such as being able to feel the pencil in one's hands and judging how much force to use on it, and having the ability to filter out excess sensory stimuli from the environment. And a partridge in a pear tree, lions and tigers and bears oh my!!! This is just to name SOME of the many components and skills involved in handwriting!!!] 

I am an occupational therapist, not a handwriting specialist. However, as OTs, we have the knowledge base to break down the task and determine exactly which components are posing a barrier to the student's success in handwriting, and then determine an appropriate intervention to help that student. The reason why OTs so often address handwriting is not so much the WHAT (the student writes poorly), but the WHY (ie poor fine motor coordination and endurance, poor visual perceptual skills, ect), and most importantly, HOW it is affecting the student’s ability to be successful in school.

Our jobs are to help our clients with any and all things that prevent success in their occupations. Although handwriting is a big part of the childhood occupation of being a student, it is not by any means the only part. As Winnie Dunn said, it is very important to make sure that we are recognized as more than just "the Handwriting Ladies," and I do make sure to do my best to advocate for the many other things we do as pediatric occupational therapists to other professionals and those outside the related service field. However, that being said, I am also excited to be, for 45 minutes every Friday, just that: The Handwriting Lady! On Fridays at the clinic I run a handwriting group for 5, 6 and 7 year olds. I was so happy to see them today, because we did not have group the last two Fridays due to being closed the day after Thanksgiving, and then me being away attending the aforementioned Autism Conference.

The group I run is based on the handwriting program Handwriting Without Tears. I took the course to become trained in the program this summer and I absolutely adore it! It was developed by an occupational therapist, Jan Olsen, and encompasses underlying skills that support handwriting success as well as using techniques that target the way children learn best--through multi-sensory, experiential learning, as backed up by years of research. It's also fun, motivating, and easily adaptable for kids with many different special needs. OTs understand that there is so much more to writing than pencil meets paper, which is why when children have handwriting issues we tend to be the ones called in. The kids in my group came to me with a variety of different challenges and were at varying developmental levels, but they all have shown remarkable success in group so far. This, in my humble and professional opinion, is because I'm using a program that's fun, motivational, developmentally appropriate and multi-sensory, and I can tailor each group's activity to meet the needs of each of the five children in the group. We sing songs, color with crayons, use play doh, write on chalkboards, do activities using our whole bodies, and exercise our fingers all before sitting down and practicing letters with a pencil and paper.

I know the importance of not being pigeonholed as "the Handwriting Lady," but for 45 minutes on Fridays that is exactly what I love to be......just with a very "OT" spin!

A lesson learned about assumptions

In my job, I work primarily in a private pediatric therapy practice with pre-school and school aged children in New York City in a clinic setting. Through the practice, I also contract to a secondary school and work with middle and high school aged children in the public school system two mornings per week. At this school, I treat a high school student who has “high functioning” autism. I will refer to this student Jason (not his real name). Jason is fascinated by the New York City public transportation system, particularly the subway system. In fact, the very first thing Jason said to me during our first occupational therapy session, after “hello” was, “Did you read the Subway Report Card that was published?” Then he proceeded to give me abundant detail about the best and worst lines and why each line ranked the way it did. He is forever giving me random subway statistics, such as which line is longest and which is shortest, or how many lines cross more than two boroughs. It is not uncommon for individuals with autism to fixate on a certain interest and develop an extensive knowledge base on this interest. It is also common for these individuals, who frequently have trouble understanding social cues and social protocol, to have difficulty understanding that others do not always share these the same interests, and may not be as excited to hear all about [subways, space, animals, ect].

With many of my teenagers at this school, I work on community mobility goals, especially with the students that are in the “basic” program (a program in which they do not receive a high school diploma from but an IEP diploma instead, the program focuses on life skills and functional skills as opposed to just academic skills). With many of my students who have these goals, we look at subway maps and talk about how to read them, and plan routes from point A to point B. This is not one of Jason's goals, but Jason always requests to look at subway maps in OT sessions. However, he has more knowledge about the subway system than most MTA workers probably do! He loves inventing “challenge problems” and will walk into sessions and ask things such as, “So today can we look at the subway map and can we try to figure out how to get from point A in Brooklyn to point B in the Bronx and pretend it’s a weekend, so line X runs a modified route and line Y doesn’t run, and there’s a snow storm and all elevated lines are not running?” Since looking at the subway map brings him so much joy, but is not therapeutic to address since it is a skill he already excels at, I came up with an idea. In therapy, I have been having Jason write down subway problems and answer keys for other students with whom I am working on community mobility with to figure out. This helps him work on his organizational skills, and the legibility of his handwriting, which are goals of his. This also helps him with social skills, because it is very hard for him to understand that not everyone understands the subway system as well as he does. I do let him write some “super duper challenge questions” that he really enjoys to figure out, but then I try to help him understand how to simplify things and create “beginner” questions that his peers may actually be able to do. Bingo! He gets to look at subway maps in OT, but I have made the exercise more functional for the skills he needs to work on. He feels so honored to have taken on this responsibility of creating subway problems for the kids I work on community mobility goals with. He loves to hear how the other kids are doing with the problems and continuing to create new ones. Jason has become my resident community mobility expert at the school.

After working with Jason twice per week for the last 2 months, one thing he told me served as a huge eye opener for me as a young therapist. For a young man who loves the subway system so much, and is so adept at theoretically navigating the subways, I incorrectly assumed that Jason was independent in community mobility, therefore it did not need to be an OT goal of his. Then, one day, I do not even remember exactly what we were talking about (as many of the conversations we try to have somehow end up relating back to the subway system), but he ended up mentioning something that shocked me. He told me that he cannot ride the subways by himself, and does not actually go anywhere in New York City on the subway without his mother! He revealed that the crowds on the subway and all the loud noises bother him too much and make him anxious, and he is afraid to go anywhere alone without his mother for this reason. A high functioning, bright teenager who is an expert on the subways, cannot ride the subway independently! Out of all my students at the school, I expected Jason to be the one who is most independent in community mobility because of his extensive subway knowledge and uncanny ability to quickly figure out how to travel between two points in New York City during any time of day or any unplanned circumstance. I felt so silly for assuming this, because I am aware that as OTs, we are taught to be masters of holistic thinking and task analysis. We learned in grad school how to think of all factors that are involved with everything our clients need to do on a daily basis. However, it just didn’t occur to me to ask him if he has any difficulty with community mobility because Jason spends so much time talking about it and demonstrating theoretical competence with it.

**Lightbulb moment!** There are a lot of generalizations here, but individuals with autism tend to have very strong visual/visual perceptual skills. Which is why PECS (a picture exchange communication system for kids with autism who have limited or no verbal abilities), picture schedules, pictures of each step of tasks, and pictorial social stories are so successful with individuals with autism. Also, individuals with autism tend to think very concretely and logically. So, it is not surprising that reading a subway map and quickly being able to determine even difficult routes is a breeze for Jason. Riding a subway is completely different! The sensory challenges of riding on a subway are monumental. (Why didn’t I originally consider this?? I spend most of my professional life addressing sensory challenges with the little kids at the clinic!) People with autism are frequently very auditorily defensive, meaning their brains process sound differently from people with typical neurology. Their brains have difficulty processing and interpreting auditory input, and as a result often everyday sounds that are noxious to most people can be overwhelming and even painful for those with autism. Additionally, people with autism often have difficulty processing input from other senses, such as the sense of movement (vestibular) and the sense of touch (tactile), and have a lot of sensory sensitivities. This is the case for Jason. Being on a subway is a very intense sensory experience for even people with typical neurology. The subway car starts and stops frequently, and dives underground and rises above ground quickly, in addition to sometimes making quick turns. The track can be bumpy. The car can sometimes vibrate and shake. There is gratuitous noise. The wheels screech. The doors ding. The conductor makes announcements. A booming computerized voice is constantly updating the passengers about the next stop, the current stop, to be mindful of the closing doors, to keep an eye on belongings. People talk to each other at loud volumes. On a crowded subway car you will be brushed against by many different people and their different textured coats and bags. For someone with autism who may have sensory processing difficulties and sensitivity to some sensory input such as auditory, vestibular and tactile input, it can be overwhelming and even traumatizing! No wonder Jason, despite his subway knowledge and navigational skills, cannot bring himself to ride the subway alone without the comfort of his mother!

This to me was a reminder about to never assume things, and to always consider all aspects of a task. Considering the environment, all skills required both cognitive and physical, and body systems required including sensory processing, is just as important as the actual steps of the task being performed. This goes down to the very core of what occupational therapy is, and we as OTs learned that in OT school ad nauseum. I learned that I should not have assumed independence in community mobility for Jason just because he is an expert in theoretically navigating the public transit system. There are so many more demands intrinsic to the task of riding the subway and factors that are part of Jason's neurological processes that are limiting Jason’s ability to be successful in this task. All these aspects need to be addressed that I originally did not fully consider. As OTs, we need to constantly remember, that more than any other person our clients work with, we are equipped with the skills to analyze all areas of every single task and occupation. Even though the goals on paper may say “will be able to determine the route between two points in New York City using the subway map to improve independence in community mobility skills,” there is so much more to riding a subway than that, and we are responsible for helping out clients find the tools to be successful and not just addressing the goals at face value.

First Blog Ever

Hello blogging community! This is my first blog ever. I never saw myself as much of a blogger, but I do love to write and journal and share thoughts and articles with friends and on Facebook, so I decided why not!

I am a pediatric occupational therapist. I graduated from grad school in October of 2009, took my certification exam at the end of December, and began work as a therapist in early 2010. This blog will mostly be about my experiences as a pediatric OT. I will of course never reveal identify details about my clients, but I will mostly use this blog to share stories, my moments of growth as a therapist, things that make me really love my job and profession, information I find helpful, news articles, comments on books or continuing education courses I take, ect.

No promise about how often I'll update this, but if I have something to write, I will write it. I'm as interested if not more interested to see how this goes than probably any person who may want to read it is, haha!