Occupational Therapy in Pediatrics PDF

OT1029: OCCUPATIONAL THERAPY IN PEDIATRICS LESSON: ADL, REST AND SLEEP, IADL Professor: Asst. Prof. Nikka Karla Santos, OTD, MAOT, OTR, OTRP Date: October 7, 2024 What is the importance of the physical environme...

OT1029: OCCUPATIONAL THERAPY IN PEDIATRICS LESSON: ADL, REST AND SLEEP, IADL Professor: Asst. Prof. Nikka Karla Santos, OTD, MAOT, OTR, OTRP Date: October 7, 2024 What is the importance of the physical environment? How can it TABLE OF CONTENTS affect self-care performance? I ADLs ○ To target the skills needed for ADL completion. II Rest and Sleep ○ Ex. Terrain, furniture, physical aspects of materials, III IADLs sensory aspects of the environment What is parental overinvolvement and how does it impact ADLS self-care performance? Why are ADLs important to be mastered first? ○ While ADLs are co-occupations, OTs should assess family ○ As the child matures, they should be able to learn to members' personal characteristics (temperament, coping perform ADLs in socially-appropriate ways so that they abilities, flexibility, and health status) to address may be able to engage in other occupations within the overinvolvement. family unit and community ○ Parents often provide excessive assistance, which can ○ You must be able to take care of yourself first before you obscure the child's capabilities. It's our role to teach can participate in other occupations strategies like shaping and cueing, helping parents understand that the child can perform tasks independently What does co-occupation mean? and doesn't always need assistance ○ We must learn how to provide interventions to the parents because for childrens, they perform occupations with What self-care tasks are expected to be mastered once the child other people. That entails the parents establishing goes to school? routines or performance patterns for the child through ○ These basic ADLs should be mastered before school, as bathing, dressing, feeding, and delegating more complex they form the foundation for developing higher-level skills ADLs to other members of the family. (ex. sustained attention, memorization, ability to interact ○ More than teaching the child to be more independent, we with teachers, play with classmates) needed in the school must understand that parents are part of the occupation. environment. When did you learn how to eat by yourself? Bathe? Clean after CASE APPLICATION toileting? 7-year-old Shiloh, African American, who needs to wash and style her hair What can you say about the difference in terms of expectations of How does the following affect the child’s performance and Filipino households in self-care independence versus the participation in this ADL task? developmental milestones norms? Where can you account for the ○ Personal: age, gender, education, SES difference? What is age-appropriate for a 7 year old? Is the ○ There are differences in culture when we expect the child child supposed to be independent or assisted? to be more independent. ○ Cultural ○ In western countries, children are expected to be more African Americans have their own methods to style independent right away (as early as 1y) and wash their naturally curly hair. What we know ○ In the PH, it is part of our culture to take care of a child as might not be applicable for this patient it entails affection and showing love for them ○ Temporal ○ Physical The role of cultural values, parental expectations, social routines, Tools; layout of bathroom and physical environment to ADL skills. ○ Social ○ Most Asian cultures expect less from kids when it comes Tied to the culture; Is it expected for the child to to independence. We tend to focus more on academics have braided/styled hair? (cognitive skills, concepts, playing musical instruments). ○ Activity demands Helpers, parents, relatives are expected to tend and look after the child’s needs. EVALUATION ○ Western culture values independence and individualism, where parents allot more time for work or chores. Interview ○ Generally, we expect the child to increase the level of Inventories independence as they grow older and mature. Structured and naturalistic observations ○ As OTs, we must learn the culture of our patient’s family, ○ Simulation in clinic wherein we understand what is important for them and ○ Observe child in their natural context advocate for independence. Standardized tests Why is routine important in self-care independence? How do you choose an assessment tool or evaluation procedure? ○ It helps satisfy or promote the completion of ADL tasks to Depends on the reason for evaluation meet the role expectations at home, school, community, or work environment How can you use the advantage of telehealth in evaluating self-care? ○ They are usually culturally based and often of what is It is not an option. It is imperative as an OT during these times, expected and practical we know how to optimize the use of telehealth in providing our ○ ADLs are supposed to be automatic (ex. we don't have to services think about how to eat / bathe) ○ Though everyone has their own way of doing ADLs, the What self-care tasks can you evaluate at home through telehealth that process remains automatic. will be difficult to perform in the clinic? ○ In intervention, it's crucial to understand the child's routine If available and the client is willing, we should take advantage of at home, as this is their natural environment. telehealth to observe tasks in their natural context, as clinic simulations can miss key nuances. ADAJAR, AMPARO, BERINA, CARLOS, CO, CUDAL, DATA, DOMDOM, FELIX, MAIGTING, MONTON, SANTOS, TORRES, VELARDE I 3OT 1  ○ For self-care tasks like bathing or toileting, it’s hard to After providing grading in terms of level of independence, we replicate real conditions in a clinic. should also state if it is age-appropriate or age-inappropriate ○ By setting up a camera at home (with permission), we can since we follow the developmental milestones. observe details like the placement of soap, shampoo, and ○ Compare it to the child’s chronological age to know if there other items, how the client organizes their space, and their is delay or none. actual routines. ○ Ex. we graded that the child needs maximal assistance, ○ This helps us understand the specific environment—such but the child is only 1 year old and it is expected that the as how far the sink is from the table or how they use tools child should be given maximal assistance like flip-cap versus pump bottles. While clinic simulations are still valuable, knowing what questions What comprises ADL independence aside from completion of all to ask about tools, setup, and steps is essential to tailor steps? interventions more effectively to the client’s home environment.i The child should also be able to do the set up, perform all the steps, be safe, and do it in a time efficient manner. LEVEL OF DESCRIPTION INDEPENDENCE EVALUATION: OBSERVATION Break down the steps (activity analysis) Independent Child does 100% of the task and all Level of independence of the steps, including the setup ○ Who helps the child? ○ Amount of assistance needed including set-up Ex. in feeding, it includes getting the Ex. Step 1&2 (w/ assistance), Step 3&4 (w/o plate, slicing food, etc. If parent assistance), 5 (w/ assistance) pre-slices the food, it is not Score: 3/5 (Moderate assistance) independent since they set up the ○ Safety task ○ Efficiency Take note of the tools, materials, and equipment used Performance patterns Independent with set up Child does 100% of the task and all ○ When does the child do this? (In the morning? After the steps, except for the initial setup, eating? Before going to school?) which is handled by the parent or Contexts influencing the performance caregiver ○ Sociocultural expectations, parental expectations, parental over involvement, codependency, socioeconomic status Supervision Child performs a task by with choice of tools and equipment themselves, but they cannot perform it safely enough to be left alone CASE APPLICATION: EVALUATION Interview questions to ask during the evaluation of feeding: Someone is needed to supervise the Eating Routine: child (ex. child can bathe but unsafe ○ What time does the child eat? s/a risks of slipping) ○ How often does the child eat? ○ Does the child often eat with the parents? Who feeds the May need verbal or physical child? prompts 1%-24% of the task (ex. ○ Is there snack time in between meals? “may sabon ka pa sa tenga, Food Preferences: banlawan mo na”) ○ What is the child's food repertoire / what does he eat? ○ Is the child a picky eater? Minimal assistance or Child is able to perform 51%-75% of If yes, what does the child eat when being picky? skillful the task independently, but needs Do you need to make a separate meal for the physical assistance or other type of child? cueing for at least 25% of the task Eating Environment: ○ What does the child do while eating? Moderate assistance Child is able to perform 26%-50% of ○ Is a TV or cell phone used during meals? (26% - 50% partial the task independently, however Self-Feeding Skills / Steps: participation) they still need physical assistance in ○ Can the child take a food scoop from the bowl by himself? other steps for at least 50% ○ Does the child eat by himself? If so, what tools are used (e.g., spoon, fork, knife)? Maximal assistance Child only performs 1%-25% of the Does the child spill when scooping food? How (1% - 25% partial task independently. The caregiver much percent of food is spilled when eating? participation) assists/cues/prompts 75% of the Quantify how much spillage in documentation task through min, mod, max ○ Can the child pour water into a glass? Dependent Child is unable to do any part of the ○ Can the child drink from a cup? Do they still use a sippy task cup? ○ Is the child still breastfeeding How many times in a day? Three components of level of independence How many ounces in a bottle? ○ Is the child safe? ○ Is the child efficient? *observe after interviewing parent / cg ○ Is the child independent? Adam – Dressing Documentation: we must justify how we graded the performance. Donning upper body garment - Mod A ○ Ex. We graded the ADL with minimal assistance, meaning ○ Hold to scrunch shirt - OT the child should have assistance for 25% of the task. ○ Put on head - with assist from OT, pt was able to pull ○ We should be able to break down the steps (ex. into 4) down specifically and pinpoint the steps that the caregiver ○ Shoot R arm - Pt helped in doing and what steps the child did ○ Shoot L arm - with assist from OT independently. ○ Pull shirt down - Pt ○ TOTAL: 2/5 ADAJAR, AMPARO, BERINA, CARLOS, CO, CUDAL, DATA, DOMDOM, FELIX, MAIGTING, MONTON, SANTOS, TORRES, VELARDE I 3OT 2 Adam - Brushing teeth PEDIATRIC EVALUATION OF DISABILITY INVENTORY - Brushing - Max A COMPUTER ADAPTIVE TEST (PEDI-CAT) ○ Open toothpaste - Pt Used for children from birth to 21 years of age ○ Squeeze - with assist from OT to put toothpaste on Measures the child’s abilities in three functional domains: Daily toothbrush accurately Activities (ADLs), Mobility, and Social/Cognitive domains ○ Brush front teeth - with assist from OT It is intended for use with children and youth (from birth through ○ Brush R side of teeth - with assist from OT 20 years of age) with a variety of physical and/or behavioral ○ Brush L side of teeth - with assist from OT conditions ○ Brush upper teeth - with assist from OT Mostly physical; assistive / locomotion device questions are ○ Brush lower teeth - with assist from OT included s/a if child uses cane or wheelchair ○ Rinse - with assist from OT Caregiver questionnaire - OT, cg, or teacher can answer the form ○ *Counting 1-10 all throughout to know when to stop Norm referenced ○ TOTAL: 1/8 Grading: CASE APPLICATION: DOCUMENTATION EXAMPLE Please choose which response best describes your child’s ability Gab, 6 years 4 months, ASD in the following activities Dressing: ○ (1) Unable = Can’t do, doesn’t know or is too young ○ UB Dressing: Gab is able to orient his UB garments ○ (2) Hard = Does with a lot of help, extra time or effort correctly and independently. On rare occasions (~1/10 ○ (3) A little hard = Does with a little help, extra time or effort opportunities) that he is dressing hurriedly, it is reported (ex. provided supervision, prompts, instructions) that he would make mistakes in orienting his clothes. He ○ (4) Easy = Does with no help, extra time or effort, or is able to don pullover tops independently. In terms of child’s skills are past this level managing fasteners, he is able to button and unbutton ○ (5) I don’t know shirt with minimal assistance, and zip up separating zipper of jacket with moderate assistance, specifically in clasping ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS) the bottom before pulling the zipper up. He is able to doff ADL and IADL performance skills in various environments, pullover upper body garments independently. familiar (home or school), and unfamiliar (OT clinic) ○ LB Dressing: Gab is able to orient his LB garments Rates the 16 ADL motor and 20 ADL process skills correctly and independently. He is able to doff all lower body garments independently, except with fasteners. He is SCHOOL FUNCTION ASSESSMENT (SFA) able to don elastic lower body garments independently. He is able to don socks with minimal assistance in orientation. Child’s participation in six different environments: Transportation, He is able to don slip-on and Velcro-type shoes Transitions, Classroom, Cafeteria, Bathroom, Playground independently in correct orientation. He is able to tie Measuring child’s self-care performance in school shoelaces with moderate assistance in sustaining hold of the bunny ears and tying the last loop. *Usually, we use FIM and PEDI-CAT to assess ADLs ○ Assessment: Overall, Gab shows age-inappropriate dressing skills. INTERVENTION When planning treatment for children with performance problems *Discuss both UB and LB dressing in ADLs, the occupational therapist must ask himself or herself *Discuss both donning and doffing; can be graded together or as the following questions: separate entries ○ Which ADLs are useful and meaningful in current and *Specify ability to understand orientation as this determines future contexts? independence in set up or not ○ What are the preferences of the child and/or the family? *Specify type of clothing (sando, pullover) Different tools, materials, and expectations in cultural and social norms/values STANDARDIZED TOOLS ○ Are the activities age-appropriate (used by peers without disabilities)? Functional Independence Measure ○ Is it realistic to expect the child to perform or master this Functional Independence Measure-II for Children (WeeFIM-II) task? ○ Self-care ○ Which alternative methods can the child use to perform ○ Sphincter control tasks (e.g., including the use of activity modifications or ○ Transfers assistive technology)? ○ Locomotion Especially for kids with physical disabilities ○ Communication May increase independence and safety instead of ○ Social cognition solely improving skills and client factors Pediatric Evaluation of Disability Inventory Computer Adaptive ○ Does learning this task improve the child’s health, safety, Test (PEDI-CAT) and social participation? Assessment of Motor and Process Skills (AMPS) Consider child’s identity - does it increase School Function Assessment (SFA) self-confidence and participation ○ Do cultural issues influence how tasks are taught? WEEFIM You cannot impose your own beliefs and values ○ Can the task be assessed, taught, and practiced in a variety of environments? Must be multi-contextual or child must generalize the skills in all contexts INTERVENTION APPROACHES Promoting or creating Establishing, restoring, and maintaining performance Modifying or adapting the task, method, and/or environment Preventing problems and educating others ADAJAR, AMPARO, BERINA, CARLOS, CO, CUDAL, DATA, DOMDOM, FELIX, MAIGTING, MONTON, SANTOS, TORRES, VELARDE I 3OT 3 INTERVENTION DESCRIPTION Assistive Devices APPROACHES ○ Completion at a higher level of efficiency using the device than Promote, Goal: health promotion without it Create Create supports within the environment for ○ Should assist in the performance of all children the opportunity to engage in task ADL occupations that are age-appropriate ○ Acceptable to child and family (child and not related to a disability status has skills and culturally appropriate); Does not assume a disability is present or meet the cost constraints of the family that any aspect would interfere with ○ Practical and flexible for the performance environments ○ All children should benefit from this ○ Durable and easy to clean; strategy or intervention; universal expandable; safe for the child Examples: ○ Have a system of maintenance or ○ Design a school program where all replacement with continued use children (with or without disability) may participate in Prevent, Anticipating ○ Provide a teacher with box of fine Educate Provide solutions ahead of time motor or self-care activities which students may use everyday *Can reduce anxiety of family when trying a ○ Provide in-service presentations to new task or entering a new environment teachers/school about importance of self-care care or specific strategies ○ teaching healthy sleeping habits CONSIDERATIONS among the teacher or community Age-appropriateness of the activity ○ Provide recommendations on ○ Chronological vs developmental stage universal design, in the bathroom, ○ Ex. Cx is 7 y/o but developmentally functions as 2 y/o. gym, or play area so all kids would Activities provided should be for 2 y/o have access to those specific areas Consider performance pattern ○ Should be embedded to cx and family's routine Establish, According to a typical development Grading of activities Restore, sequence ○ Personal assistance vs partial participation Maintain ○ Build the skills ○ Grade/Fade/Shape skills til independence is achieved ○ Consider the child's developmental Incorporation of technique based on the approach and FOR used and chronological age to plan the ○ Occupations is the end goal treatment according to the typical ○ If using Remediation/Restoring/Establishing Approach, developmental sequence determine the lacking skill (ex. can't brush teeth d/t tactile ○ Developmental FOR defensiveness; can't dress d/t motor planning issues) Identify gaps in skills ○ Build skills up, apply them, then generalize if they can do ○ Identify deficits, barriers, or gaps that the same with the affected occupation hinder their performance in ADLs Provide specific interventions to teach, INTERVENTION remediate, or establish underlying problems Coaching ○ Parameters: activities should be ○ Requires having the children, parents, and teachers age-appropriate when targeting a reflect on their progress in doing ADL tasks specific skill ○ Therapists listens respectfully and objectively to all parties Provide expectations for the parents ○ Planning strategies to try, modifying routines that doesn't ○ Ex. If parents want child to write or work, providing feedback (to both family and child) eat by themselves, OT should explain ○ Use of demonstration and modeling on how to do a task to the parent that before tool-use, Coach parent/cg about the strategies they want to there are underlying skills that are learn (“Dito niyo po siya hawakan; Maikli lang po needed to be targeted (ex. grasp dapat instructions; Hintayin nyo po muna siya at pattern, RGCR, bilateral coordination) prinoprocess nya pa po sinasabi nyo”) ○ Establishing: target all skills to reach goal of tool use *Involve parent and provide tools for easier facilitation in their home ○ Maintaining: maintaining the performance level while also understanding and maintaining the CASE APPLICATION: INTERVENTION child's patterns and routines. Create Case: 9 y/o Eliana, Dx: ASD a healthy and structured routine ○ Problem: difficulty manipulating clothing fasteners—zipper, aligning with their expectations buttons, laces which are present in her school uniform ○ Goal: independence in dressing Modify Task / task method modification, use of AT, environmental modification If you are the OT, what specific strategies will you use for the following ○ Do not focus on skill that is lacking approaches? What is your approach and FOR? ○ Change time or no. of steps Promote, create Compensatory strategies ○ Give recommendations to teacher to integrate dressing Personal assistance vs Partial Participation goal where all kids can participate ○ Personal assistance - another person ○ Suggest FMS activities involve using fasteners does the task d/t child’s inability to ○ Recommend different calendars/visual support complete task independently and Ex. Button the number on the calendar or provide safely or the task requires too much a snap activity where they can snap the current energy date to the calendar ○ Partial Participation - child is able to Establish, restore, maintain perform some steps, then caregiver ○ Identify skill deficit completes the task ○ Ex. problem in fine prehension = provide clay activities that require pinching ADAJAR, AMPARO, BERINA, CARLOS, CO, CUDAL, DATA, DOMDOM, FELIX, MAIGTING, MONTON, SANTOS, TORRES, VELARDE I 3OT 4  Modify, adapt INTERVENTION ○ Provide velcro / snaps instead (modifying task) or provide Think of the steps on how to do toileting: tool to make buttoning easier (environmental modification) Preparation/Readiness Prevent ○ No big changes coming up (e.g. start schooling) ○ Teach/educate parent/teacher to use different approaches ○ Words to associate (e.g. “wiwi”, “poopoo”, “go”) to enable practice and decrease cx frustration / difficulty ○ Modeling / vicarious learning ○ Can consult teacher or daycare provider to carry over Watch and observe trusted family member and activities done by OT talk about it Start putting training pants to help child SPECIFIC INTERVENTION STRATEGIES FOR ADLS understand the feeling of wetness; Let child TOILETING experience specific situation Self-maintenance milestone ○ Habit forming Carries considerable sociologic and cultural significance ○ Accidents: do not show frustration ○ If the child is able to manage bowel and bladder, it is a Educate parents/other family members; mentally self-sufficient milestone which is often a prerequisite for and physically prepare them about accidents participation in centers, school programs, recreational ○ Eating habits communities and other vocational schools Look into the diet to to avoid constipation; eat lots ○ US: cannot put your child into a school or daycare if they of fiber, drink water are unable to manage their bowel and bladder movements If bowel movements is not regular, or child is a Child must be physically and psychologically ready to begin toilet picky eater or have poor eating habits, they are not training and show patterns (time, frequency) of urine and feces yet ready for toilet training; hard to anticipate when elimination they will poo ○ In typically developing children: from 18 months - 2 y.o. Embedded in the routine ○ Look at signs → encourage but do not force! SIGNS OF READINESS When the child wriggles, moves to the corner, or Walking and can sit for short periods of time distances from you; Encourage the child to go to Becoming generally more independent, including saying ‘no’ more the toilet but don’t force often (1-2 y/o: time when child develops their identity) It is easier to ask the child to go to the toilet when Becoming interested in watching others go to the toilet there is a change in ax (e.g. We’re done eating, Has dry nappies for up to two hours (shows consistency in peeing but before we play, we have to go to the toilet first) and pooping) Going to the toilet and transitions are done Can tell with words or gestures when they do a poo or wee in their simultaneously nappy (indication to change) ○ Make a routine Begins to dislike wearing a nappy, perhaps trying to pull it off If after 3-5 minutes, the child does not go potty, let when it’s wet or soiled the child get off the toilet and proceed to next ax Has regular, soft, formed bowel movements Regardless whether the child pees or poops, let Can pull their pants up and down the child practice doffing and sitting/standing Can follow simple instructions like ‘Give the ball to daddy’ tolerance on potty, then don, wash hands, flush ○ Time MILESTONES Going to the toilet Table No. Typical Developmental Sequence for Toileting ○ Check physical environment ○ Check bathroom floor space, location of and height of sink Approximate Toileting Skill (is a step stool needed?), faucets, towels, soap, toilet Age (Year) paper, bidet or dipper (for Filipino context) ○ W/C accessibility 1 Indicates discomfort when wet or soiled ○ Sensory aspects: auditory – flush, exhaust fan; olfactory – Has regular bowel movements odor Sits on toilet when placed there and supervised Consider if sensory inputs present within the toilet ( standing Motor Provide EMT ○ Strong extensor and adduction patterns in the legs → ○ Dynamic postural control tone management techniques Risk of falling d/t change in BOS Impedes seating Try different positions or modify positions that is Teach mom how to decrease tone though NDT most optimal for the kid ○ Postural control difficulties → grab bars, reducer ring ○ Bilateral coordination & In-hand manipulation ○ FMS difficulties → LBG modifications (elastic, snap, Recommend clothing with easy to manipulate Velcro) materials ○ LOM in the shoulder (ex. No IR/ER )→ teach anterior Ex. pullovers, slip-ons, adaptive aids (button approach hooks, rings on zippers, one-handed shoe Provide precautions since it might increase the risk fasteners/hooks, loop closure) of infections vs posterior approach Sensory Sensory issues ○ Tactile overresponsiveness ○ Auditory sensitivity → ear plug, closing lid Provide different tactile ax to improve modulation Cognitive of the child ○ Uses too much tissue paper → remove toilet paper roll Modify the clothing material and use Kleenex, or pull off correct amount to be Perceptual used; or (2) place a tape mark on the wall of how ○ May target visual perceptual skills first much paper to roll out ○ Orientation ○ Does not stay seated → use of timer ○ Body awareness Grade it until they can tolerate it Cognitive Ex. 10 secs first then increase to 15 secs ○ Sequencing / Temporal organization Provide reinforcements Provide visual support (ex. pictures, charts, checklists) to help them remember Make it a routine to make it a habit (automatic) MENSTRUAL MANAGEMENT Same steps, position, location. Repeat. Part of toileting hygiene for girls who reached puberty stage Should be prepared before menarche for expected changes in the body BATHING Choose methods and hygiene habits necessary for managing menstruation INTERVENTION ○ Ask the consent of family if it’s okay for them to target it Checking water temperature ○ Research on how to teach it to the child ○ Teach how to safely perceive temperature and adjust it ○ Are the family okay with other options like tampon, cups ○ Warm / cold water For kids with sensory issues, consider the DRESSING appropriate temperature to use. Developmentally, which is learned first, donning or doffing? Warm = calming; warmth also decreases tonicity ○ Doffing comes first because it is easier and increases ROM for independent movement What are included in dressing? ○ Hypersensitive / overresponsive ○ UBG & LBG Use deep pressure or rubbing instead of light ot ○ Orientation ticklish touch during bathing to reduce sensitivity ○ Different types of clothing (ex. Pullovers, zippers, buttons, Ex. hand-held showers, eye-guard hat (to avoid fasteners, snaps, velcros) soap getting in the eyes), adjust water flow by ○ Socks & shoes, slippers using dippers (to control amount of splashing) ○ Orientation of L-R Sensitive body parts: face and tummy ○ Accessories (ex. hats, jewelry) Tools to use ○ Ex. shower (detachable shower head or not) or dipper, INTERVENTION soap (liquid or bar) Think of the steps on how to do dressing: ○ What are the skills needed for these activity components Choosing clothing (set-up) and tools? ○ Appropriateness (occasion, weather, etc.) Ex. FMS, strength ○ Locating (in the dresser) ADAJAR, AMPARO, BERINA, CARLOS, CO, CUDAL, DATA, DOMDOM, FELIX, MAIGTING, MONTON, SANTOS, TORRES, VELARDE I 3OT 6  Skill deficits PUBERTY - NEW SELF MAINTENANCE TASKS ○ Motor Skin care, hair styling, putting on deodorant, hair removal, Tone problems/postural control application of cosmetics Adaptive positioning or bath hammock if the child There may be skills (FMS, perceptual, sequencing, cognitive) that cannot sit to make it easier for cg and safer need to be targeted; you can incorporate interventions to address Non-slip bath mats, grab bars, trunk support rings, these into the activity itself shower bench ○ Sensory FEEDING, EATING, AND SWALLOWING Temperature of water, scrub used, drying Feeding ○ Perceptual & Cognitive ○ Process of setting up, arranging, and bringing food from Sequencing, forgetting body parts, not oriented or the plate or cup to the mouth. aware Eating Use visual supports, BMTs ○ Ability to keep and manipulate food/fluid in the mouth and Drying swallow it. ○ After scrubbing and rinsing ○ Process of chewing ○ Use towel wraps and different methods to ensure all body ○ Oral phase parts are dry. Swallowing *Make it into a routine, same steps so that the child is able to ○ Complex act in which food, fluid, medication, or saliva is remember the steps and do the bathing routine automatically. moved from the mouth through the pharynx, to the esophagus, and into the stomach. Things to take note of: Constant monitoring until the child demonstrates safety in the Contextual and Personal Influences on Mealtime: tub/shower is necessary Cultural – food choices, practices BMTs on expected and unexpected behaviors in the bathroom ○ Speaks a lot where you came from, values/culture at ○ Establish rules if you will permit play in the bathroom; home what toys, how many, how long Family composition ○ Ensure that it won’t become a play activity ○ Who are you with when you are eating? Faucets need to be marked for temperature Family’s socio-economic status ○ Visual cues for which faucet is cold and hot ○ Food choices heavily reflect on how much you earn ○ Teach the child how to manipulate and adjust temperature ○ What food can you afford to eat? Caregiver’s personality traits GROOMING ○ Are the parents controlling? Brushing teeth ○ Are they the one who will dictate what you will eat? Washing hands and face ○ How much will they eat? Combing Child’s health Puberty: skin care, hair styling, hair removal, application of Eating skills cosmetics Communication skills *Overall, feeding is also a social activity since you can eat with your INTERVENTION family at home or eat with friends at school. Understand the steps / tools and break it down through activity Think of the steps on how to do feed: analysis to provide interventions Tool use ○ Can the child do finger feed? BRUSHING TEETH ○ Can the child use utensils like a spoon, forks, knives, or Think of the steps on how to do brushing teeth: chopsticks? Getting the toothpaste and toothbrush ○ Can they cut food using the knife? Can they use the knife Opening toothpaste to spread the butter? Squeezing toothpaste Scooping ○ Bilateral coordination: one holding the toothbrush while ○ Type of grasp; is it mature? the other squeezes ○ How do they hold the spoon? ○ Finger and hand strength ○ Preferred hand Brushing ○ Is the forearm and hand coordination good? ○ All quadrants—thoroughness ○ Is bilateral coordination good? Perceptual awareness; knowing what parts of the Bringing food to mouth mouth to brush, how long they should brush ○ Are they aware where their mouth is? ○ Sensitivity ○ Good control (adjustment of hand to avoid spillage) Particularly for SI issues; you may want to do ○ Overshooting/Undershooting? desensitization first through facial or oral Drinking massages using soft bristles ○ Can they drink from a bottle, sippy cup, or open cup? ○ Tongue thrust ○ What do they use? ○ Hypersensitive gag reflex ○ Can they use a straw? ○ Coordination issues, FMS Provide large-handled toothbrush, hand-over-hand techniques, mirrors for visual feedback Rinsing mouth, spitting Clean up WASHING HANDS AND FACE What is the context of the family? ○ Do they use bar soap or liquid soap? ○ How does mommy wash her hands? Adapt from there Think of the steps on how to do wash hands/face: ○ Opening faucet ○ Wet your hands/face ○ Get the soap ○ Rub it on your palm How long? Should they count or sing a song to know when to stop? ADAJAR, AMPARO, BERINA, CARLOS, CO, CUDAL, DATA, DOMDOM, FELIX, MAIGTING, MONTON, SANTOS, TORRES, VELARDE I 3OT 7  Consider the child’s nutritional status. ORAL MOTOR DEVELOPMENT ASSOCIATED WITH EATING ○ Collaborate with pediatrician and nutritionist (picky eater SKILLS or LBW) ○ Provide enough food intake to meet the nutritional needs. 4 months Hallmark movement for true sucking can be Understand that certain foods have high choking risk and require observed modifications specifically for younger children. Sucking reflex – predominant method for the first 8-10 months ○ Nutritive - breastfeeding / bottle-feeding INTERVENTION ○ Non-nutritive - pacifying themselves Identify the problem: motor? Sensory? Both? Regularly schedule meals at consistent times or locations 4-5 months Munching: characterized by vertical jaw ○ Routine building movement and a back-and-forth tongue Therapeutic snack* movement ○ Don’t provide intervention during regular mealtimes. ○ Do it in the therapeutic snack time / outside regular 6 months Jaw stability increases mealtimes to foster the goals to achieve without Start to transition: food compromising the nutritional needs of the child. Adaptive equipment 9 months Infant can transfer food from the center of the BMTs mouth to the side using lateral tongue movements SENSORY MOTOR 12 months Rotatory chewing develops 🡪 solids ○ d/t diagonal jaw movements and lateral Order of presenting foods and Order of presenting foods and tongue movements liquids based on the texture liquids based on the Transition from bottle to cup drinking and taste – what can the child consistency – what can the tolerate? child manage? 24 months Can drink from cup efficiently Mature chewing is present *Similar texture; present food *Depending on the oral motor Drinking from straw emerges that are similar 75% or 25% skills. different then gradually increase until foods are totally different EVALUATION More complex compared to other ADL tasks. Guiding Questions to Evaluate the Context for Feeding PHYSICAL ○ Is seating and positioning adequate? Supportive? Does it provide stability? High chair, on lap, independent ○ Are head, neck, shoulders, and pelvis well aligned? Adequate postural control At 6 mos is the transition to solid food as child is Tolerate - make the child tolerate first visually also able to sit w/ support at 6 mos Interact with - before touching ○ Is space adequate for eating activities? it, play with the utensil (scooping ○ Are noise and activity levels conducive to eating? w/ fork) TV, gadgets Smells - food smell within the SOCIAL room; put it near their nose to ○ Who feeds the child? smell ○ Who is present during the meal? Touching - can they touch using 1 finger, 2 fingers, whole hand, ○ What is the nature of the social interaction among family forearm, shoulder, neck, cheeks, members during the meal? lips, and eventually the mouth ○ What communication or interaction occurs between the (teeth and tongue), caregiver and child during feeding? Taste - can they make it touch TEMPORAL the tip of tongue, full tongue lick, ○ Is sufficient time allotted and available for a relaxing meal? chew and spit ○ How often is the child fed? Eating - chew and swallow with water, or chew and swallow then ○ How long does it take? no water. CULTURAL ○ How do cultural beliefs and values influence mealtime? Cultural expectation; no singing, no left over Increase food range/repertoire Target oral motor structures: ○ What foods does the family eat? tongue, lips, jaw, teeth/dentition EVALUATION Tactile → messy play Oral motor exercises - ROM, strength, endurance *Not usually for entry-level therapists; needs further certification *Oral sensitivity roots from *Assess both motor and sensory tactile sensitivity *tongue movements - up and *Provide modulation techniques down, curling, left and right Feeding history and caregiver concerns through messy play *lip control, pursing, closure Assess mealtime participation *jaw strengthening, opening ○ Through questions and closing of mouth Neuromotor evaluation ○ Postural and head control, FMS Oral sensorimotor examination Calming activities before feeding Observation of actual feeding/eating Contextual factors *Proprioceptive system: Obstacle course, heavy work Considerations: before the actual feeding to Check for clinical signs of aspiration. enhance regulation ADAJAR, AMPARO, BERINA, CARLOS, CO, CUDAL, DATA, DOMDOM, FELIX, MAIGTING, MONTON, SANTOS, TORRES, VELARDE I 3OT 8  CONTEXTUAL MODIFICATIONS ENTRY-LEVEL OT ADVANCED-LEVEL OT Bedtime routine and habits ADLs to be performed prior (timing) ○ Help the child prepare the body and mind to going to sleep Basic knowledge and skills to Providing feeding, eating, and ○ Ex. brush teeth, dress, wear pajamas provide occupational therapy swallowing interventions to ○ Ex. provide quiet time before sleep, reading, singing lullabies, services to clients with eating enable performance rocking with parent (for smaller kids) and feeding dysfunction Visual supports ○ Checklists or schedules for child to see the activities they Providing feeding, eating, and Includes administering more need to prepare for bed swallowing interventions to complex assessments and ○ Child with higher language skills: social stories, video enable performance providing interventions for modeling, object ques clients Depending on the day's activity levels ○ Bedtime can be moved later if with low energy activity levels Process of bringing food or Clients who are medically ○ Consider appropriate activities before bedtime; eating, liquids from the plate or cup to fragile or who have complicated playing, and exercising may increase arousal the mouth, the ability to keep diagnoses or conditions Positioning and manipulate food or liquids in resulting in feeding, eating, and ○ Reflux / difficulty breathing / snoring problems - raise bed the mouth, and swallowing swallowing problems; head lightly assessment and management postsurgical cancer patients, ○ Sleepwalking - securing windows and doors patients in intensive care units, or infants SENSORY ASPECTS Auditory stimulation Specialized skills in activity Videofluoroscopy, cervical ○ Decrease amount: quiet, white noise, calming music analysis and synthesis auscultation, ultrasonography, Temperature fiber-optic endoscopy, ○ Not too hot or cold; consistent scintigraphy, manometry, Smells electromyography, and other ○ Alerting or calming smells; child may find a specific scent instrumental evaluations Visual ○ Turn off light, use night lights Tactile REST AND SLEEP ○ Consider weight, texture and visual attractiveness of clothing Sleep affects your physical growth, health, and our ability to and bed sheets behave. Lack of sleep impairs memory, muscle repair, and ○ Kids may prefer weighted blankets; make sure to provide just hormone release. enough (5-10% of the child’s weight) Sleep deprivation also affects cognitive, attention, and social skill Security development. ○ Add stuffed animals to make the child feel safer Sleep is important for us to be able to attend better and to have ○ Not for babies; pillow/stuffed toys may lead to suffocation good memory. If we are able to attend and perform/memorize, we are able to learn better. We would be able to develop necessary IADLS skills for occupational performance that meet our role Adolescence expectations. Autonomy and self-determination Sleep affects skill development and performance in ADLs Important for community participation ○ Children with disabilities should be prepared for transition which is done through IADLs Successful and independent community living relates to outcomes in employment and community participation Needs life skills: managing personal care and health needs, taking care of own belongings and space, managing home, cleaning, preparing meals, arranging transportation, living interdependently with others OCCUPATIONAL DEVELOPMENT SLEEP PRESCHOOL (3-5) Optimal: regular sleep routines and patterns, with similar amounts of sleep each night; consistent time to sleep, consistent With supervision activities before sleep Family involvement is essential to identify needs Sleep problems in children: Opportunities for problem solving and other EF ○ bedtime resistance or falling asleep ○ Ex. going shopping, going to playground, attending library ○ awakening during the night hours, going to mall, walking in the neighborhood, going to ○ irregularity of amount of time in sleep church ○ snoring, and Putting away toys and clothes, making the bed, setting the table, ○ sleepiness during the day preparing cold snacks EVALUATION MIDDLE CHILDHOOD (6-11) Assessment of a child’s activity level, bedtime routines, sleep Household chores and neighborhood activities habits, and sleep environments Opportunities to make choices, solve problems, and identifying Cultural considerations influence the sleep habits of family or child interests and skills ○ To develop self-determination, social skills, and competencies with IADLs INTERVENTIONS Clean up after meals, meal prep, putting away groceries, looking Medical after younger siblings ○ To help child develop good sleep patterns (ex. sleep Community activities – lessons, going out earlier, regular sleeping patterns) ○ Formal structured axs - sports, formal lessons ○ Ex. Melatonin ○ Informal structured axs - with peers; going to mall, riding Contextual modifications bikes with friends, or eating outside Sensory aspects of routine or environment to be conducive ADAJAR, AMPARO, BERINA, CARLOS, CO, CUDAL, DATA, DOMDOM, FELIX, MAIGTING, MONTON, SANTOS, TORRES, VELARDE I 3OT 9  Barriers Contextual influences ○ Lack of opportunities ○ Natural and built environment (physical) Depends on family; not exposed early on leads to Sensory, physical qualities; accessible materials inability to learn how do these things ○ Supports and relationships (social) ○ Difficulty generalizing skills Are there good models? Is the mother cooking? Is Packing away toys is also done in school the yaya going to buy food? If the child has no models thus, the child may not Strategies learn to do the IADLs ○ Visual supports Influence of peers Difficulty with transitions or sequencing ○ Attitudes, values, and beliefs (cultural) Form of reminder to child Needs and perspectives of how children should ○ Practice and repetition spend their time Increases participation in routines Interdependency vs. Dependency ○ Coaching o Some parents do everything for their child Opportunities parents can give to child at home o Some families expect older siblings take ○ Accommodations care of younger siblings ○ Social stories ○ Computers and assistive technology (virtual) Online resources (AAC), information about EARLY ADOLESCENCE (12-15) communication, available transportation, etc. Home and health management ○ Stages of life, time of year, and duration (temporal) Shopping and meal prep ○ Service systems and policies Community participation Does it promote inclusion of children and youth Increased responsibility for caring for others with disabilities in available out of care program? Ex. Managing the laundry, preparing simple hot meals and snacks Enable optimal participation of PWDs Additional practice and opportunities to promote autonomy with IADL and community participation because they will not be able to EVALUATION learn how to cook, shop on their own, or manage their budget if Most commonly used: we don’t provide opportunities AMPS Role playing and coaching directs the youth to seek assistance as ○ Criterion-referenced test for activities of daily living (ADL) needed with IADL and community tasks and instrumental activities of daily living (IADL) tasks that Improve their assertiveness and social skills in order to assert assess underlying motor and process performance skills their needs and ask for help when needed used to perform the task Increase engagement in leisure and recreation activities – they ○ Examiner training are taught how to use technology and different appliances to PEDI-CAT participate in different IADLs ○ Responsibility, social/cognitive domains ○ Older kids, teenagers, young adults LATE ADOLESCENCE (16-18) ○ Asks specifically % or level of responsibility the parent does or the child, the distribution who decides or Expected to spend more time outside the house responsibility for that specific task or occupation. Driving, community mobility, public transportation Volunteering, working part-time Shopping, money management TRANSITION PLANNING Health management To adulthood ○ Responsibility in taking needed medications Preparing the youth and family for role and routine change ○ Exhibiting awareness of healthful behaviors Evaluate and implement supports for employment and/or ○ Knows how to meal prep (hot and cold), clean the house, continuing education; determine interests and skills child needs manage repairs, and do the laundry. Build skills necessary for the new roles Facilitate social and community integration Barriers Foster self-advocacy skills ○ Lack of confidence Provide evaluation and intervention for occupation-based mobility, D/t lack of opportunities to understand how to do it transportation, driving, etc. IADLs require not only motor and process skills but also executive functions and social skills ○ Dependency to parents or family members ○ Weak social skills Strategies ○ Visual supports ○ Coaching ○ Peer mentors (group activities for modeling and teaching) ○ Assertiveness training, role playing (for social skills) ○ Use of technology INFLUENCES ON IADLS AND COMMUNITY PARTICIPATION Personal influences ○ Interests ○ Preferences ○ Motivation ○ Children and youth must internalize the reason to engages in IADLs Providing BMTs, such as reinforcements to highlight importance in doing the IADLs ADAJAR, AMPARO, BERINA, CARLOS, CO, CUDAL, DATA, DOMDOM, FELIX, MAIGTING, MONTON, SANTOS, TORRES, VELARDE I 3OT 10