Monday, July 28, 2014

Is Water Play Therapy?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Share your questions and ideas at

Monday, July 21, 2014

Too young to diagnosis Autism?

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

Let me start by admitting that this blog is a bit more serious than the last few. Although this topic takes on a very serious tone, I must make a confession:  
I LOVE children with Autism. Period.  
It is my passion. It is what I do.  
Children with Autism see the world in a delightfully unusual way, and I love it. However, the world of Autism is largely unknown, and many people are scared. With the CDC reporting that 1:68 children in America now have a diagnosis of Autism Spectrum Disorder (ASD), most of us know at least one child (or adult) with this diagnosis. This also has many parents in a panic. 

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

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

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

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

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

Early intervention and treatment of Autism is vital to creating the most functional outcomes.  Next week, I will discuss the importance of receiving early interventions and the treatment options available to parents.  

Early Warning Signs, UC SanDiego 
Autism Symptoms, Mayo Clinic 
Diagnosing Autism, American Academy of Pediatrics 

Monday, July 14, 2014

Barefoot in the Backyard?

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

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

There are benefits to going barefoot which include:
1.  Allowing your feet to feel a variety of sensations: soft grass, prickly grass, smooth pebbly rocks, sand, etc... Your skin is your largest sense organ. Take advantage of it!
2. Going barefoot provides less support than a tennis shoe. This can cause the muscles of the foot to work harder and therefore become even stronger. 
3.  And, going barefoot just makes you feel good! 

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

What do you do if your child doesn't like to go barefoot?  
Many children with sensory sensitivities HATE going barefoot. These children are often irritated in other areas, such as the feel of clothing, food tastes and textures, and grooming tasks such as combing hair, brushing teeth, bathing, and clipping fingernails. Helping your child to enjoy the grass between his toes is a way to help him decrease his overall touch sensitivities. Here are a few ways to help your child “baby step” her way towards becoming comfortable on bare feet:
1. Take shoes off in the house. 
2. Expose her to different shoe styles.
3.  Gradually progress through outside surfaces - first smooth porch, then smooth driveway, then soft grass, then different textures of grass, etc.
4. If you don’t have access to a safe barefoot outdoor space, create one inside! Spread out different textures of rugs/mats, various blankets/quilts, or even bubble wrap!  This also makes  a great rainy day activity! 

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

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


Monday, July 7, 2014

iPad Time: How much is too much?

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

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

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

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

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

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

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

For more information, please follow the links below: 

Monday, June 30, 2014

Tummy Time for Babies

Dear Melissa,
I just had a baby and I want to make sure that I am doing everything I can to give her a good start!  What is “tummy time” and how do I make sure I am doing it right?

Ahh, "Tummy Time"…It seems like this is such a common buzzword among new parents these days! And this is for good reason - tummy time is SO important for babies! The American Academy of Pediatrics (AAP) recommends that babies are placed “back to sleep”, but they also recommend “tummy time.” What’s a new parent to do?  To put things simply, the current recommendation of the AAP is to place babies on their backs when they sleep in order to reduce the risk of Sudden Infant Death Syndrome (SIDS). However, the AAP and therapists alike recognize that babies NEED to have playtime on their tummies for proper muscle development. 

Tummy time helps a baby develop the head, shoulder and back muscles required to progress with their gross motor and fine motor skills. Research shows that babies who get more tummy time gain the strength and coordination to roll over, reach and crawl sooner than babies who do not receive time on their stomachs. Tummy time also helps prevent flat spots on a baby’s head known as positional plagiocephaly. In addition, as an Occupational Therapist, I love how tummy time helps a baby develop the visual, fine motor and gross motor skills needed for handwriting. These handwriting building blocks start in infancy! 

Tummy time can begin when your baby is only days old. How does tummy time actually work? Here are a few steps for successful tummy time with your baby when he/she is awake and alert:

1. Start with gentler positions. For example, consider placing your baby on her tummy in your lap, or lay down on your back with your baby on your chest facing you. If she still has her umbilical cord stump, make sure that it is not making her uncomfortable. 

2. Progress towards allowing the baby to lay on her tummy on a blanket on the floor. 

3. Make sure to use toys, mirrors, and your face to make tummy time FUN! Try to incorporate tummy time into daily activities such as applying lotion, burping your baby, and towel drying after bath. 

4. Always supervise tummy time! “Rescue” your baby if she seems frustrated or is having difficulty raising her head off the surface. 

When introducing tummy time, begin with only a few minutes at a time, several times per day.  Recommended tummy time for a 3-4 month old ranges from 20-90 minutes per day.  I like to focus on frequent, fun, short bursts of tummy time; I then work to increase that time until your little one is rolling and crawling all over the place! 

For further information on this topic, please consult:
Establishing Tummy Time Routines to Enhance your Babies Development, American Occupational Therapy Association

Monday, June 23, 2014

What is SPD?

Dear Melissa,
My 4-year-old son is very smart.  He knows all of his colors, numbers, and ABCs. Therefore, I was shocked when his preschool teacher said that he can’t sit in his chair, throws frequent tantrums and even occasionally hits the other kids. At home he has always been very active, but I thought that was typical for a four-year-old boy. His teacher suggested that we seek help from an occupational therapist to see if he has Sensory Processing Disorder. What is sensory processing disorder, and how could therapy help?

Sensory Processing Disorder (SPD), formerly known as Sensory Integration Dysfunction (SID), occurs when a person has difficulty regulating the sensory input from his environment.  This challenge relates to the 5 basic senses of sound, touch, taste, sight and/or smell. It can also relate to the 2 movement senses of vestibular input (which gives input for balance and where your body is in relation to the ground) or proprioceptive input (which gives input as to where your joints/limbs are in space). 

Children (and adults) who have SPD can have a wide range of difficulties. Some children with SPD are very timid and seem to be overly sensitive to the world around them. Other children tend to be “crashers”. They run, jump, climb (and often fall), and it seems like nothing phases them! When a child has difficulty interpreting the world around them, he can often react in inappropriate and unpredictable ways.  It is for these reasons that SPD can often mimic other illnesses such as Oppositional Defiant Disorder, behavior problems, anxiety, depression or ADHD. 

SPD is NOT a medical diagnosis but rather a symptom, often stemming from an immature neurological system. This does not mean, however, that one should neglect treating SPD. For example, fever is also simply a symptom. The fever could be from a virus, strep throat, ear infection, etc. However, you would still give your child plenty of fluids and possibly medication to bring the fever down. 

The treatment of SPD generally involves working with an occupational therapist (OT) with special training for children with sensory difficulties. Ideally, much of this treatment would take place in a sensory-rich gym area with swings, ball pits, trampolines, etc. True sensory therapy often looks like play, but it involves working with the child to carefully regulate their sensory system. This may mean encouraging the timid child to try new things or teaching the “crashing” child to choose activities which can help him obtain the sensory input he needs while learning safety awareness. Once the OT and child learn which activities work to help regulate his sensory system, then they can work together to educate parents, teachers, etc. about activities that can take place in the home and school settings. These activities can help with regulation in all areas of life. Once the child's senses are regulated, then other areas of deficit such as strength/coordination, handwriting, and dressing skills can be addressed far more effectively.

For more information on Sensory Processing Disorder, please refer to:
The Out-of-Sync Child by Carol Kranowitz

Monday, June 16, 2014

Water Safety Worries

Dear Melissa,
"It gets SO hot here in Arkansas during the Summer. I have 3 boys (one on the Autism Spectrum) and I love to take my children to the neighborhood pool or to the pool at Grandma’s house.  What can I do to keep my kiddos safe around the water?" 

Ahhh!  Nothing is better than a relaxing day at the pool!  But with kiddos in tow, don’t be fooled and let your guard down!  While swimming is excellent exercise and a great way to cool off, it can be a highly dangerous past time. This is especially true for children with Autism. Accidental drowning accounted for 91% of deaths of children under 14 years of age with Autism from 2009-2011. This is largely due to the tendency of children with Autism to elope (either from randomly wandering off or from actively running away due to sensory overload). 

Children with Autism tend to have very poor safety awareness and may lack an ability to effectively respond to verbal cues. For example, while many children respond when their name is called, this may not be the case for a child with Autism. If an adult does see a child wandering/running toward water, the child may completely ignore the adult calling the child’s name and shouting “Stop!”  Most water accidents and drownings are not due to a complete lack of supervision, but rather they are due to a brief lapse in supervision. 

Drownings generally do not involve thrashing and shouting as is often depicted on TV.  Rather, it is generally a silent event. Therefore, if a child is missing, for even a second, adults should first search the pool before exploring other options.    

Now, with these scary scenarios out of the way, what can YOU do to help keep your children safe?

1. Teach your child to swim!!! 
I can’t stress this point enough.  Teach him to swim however you can and as early as possible. Being able to swim can save your child’s life. Short of keeping your child locked in a bubble, there is only so much you can do to keep a child with Autism from getting in the water when you turn your head.  As I mentioned the topic of this blog to several of the parents I work with, they shared many stories of “close calls.”  In fact, 32% of parents of children with Autism report a “close call” with their child and drowning.   Some children with Autism take like a fish to water and learn to swim immediately. Others are very hesitant around water. If your child is of the more hesitant type, ask around for a reputable swim instructor with experience teaching children with Autism and other Sensory Processing Disorders.  Your child’s Occupational Therapist should be a valuable resource for this information. 

2. Teach pool safety “rules.” 
Most children with Autism are very concrete thinkers.  They respond well to rules and consistency.  Therefore, you should discuss water safety rules with them.  I even like to use “The rule is…” so that it is completely clear that this is a black and white, non-negotiable issue.  For example:  “The rule is, you must always have an adult present when you are near water.” Depending on the concrete nature of the child's thinking, you may need to define “near” as an arm’s length away;  “water” as a pool, creek, lake or ocean; and you may need to define “adult” as mom, dad, grandpa, etc.  Then, role play and write social stories to make these rules even more integrated. Adapt the rules to your particular situation. In addition, a younger child may not understand the term “the rules” but you can practice to ensure that he/she always holds an adult’s hand when walking on the concrete around a pool. 

3.  Practice wearing a life jacket.  
Many children with Autism have tactile defensiveness and this may make wearing a life jacket difficult.  If necessary, practice baby steps of wearing the life jacket unbuckled in the house while watching TV, then buckled, then outside, buckled, while blowing bubbles. You get the idea.  If you need further help, ask your child’s Occupational Therapist for advice.  Wearing a life jacket is non-negotiable!

4. Safety proof the pool. 
There are many things a pool owner can do to keep their pool safe for everyone:
a) Install a 4 foot tall fence with locking gates around the perimeter of the pool.
b) Make sure that a child could not move furniture, use a retaining wall, climb a tree, etc. in order to scale the pool fence.   
c) Keep toys out of the pool when the pool is not in use. 
d) If the children will be in the house, install additional security to the exit doors including hook and eye locks on the door above the child’s reach and wireless door alarms (found at Wal-mart and hardware stores). 
e) Deter access to the pool/hot tub by removing ladders and using pool covers. 

And as always, use sunblock and have fun!!!  

For more information (as well as the sources for the statistics listed above), please visit the websites below:  

 If you have more ideas on how to keep kids safe around water, I would love to hear them!