Peds II Midterm - Content Questions

What is play?

Any spontaneous or organized activity that provides enjoyment, entertainment, amusement, or diversion. It is fun, intrinsically motivation, flexible, and totally absorbing. It can be explained through form, function, meaning, and context

Takata’s Taxonomy of Play

Birth - 2 yrs: Sensorimotor

2 - 4 yrs: Symbolic and simple constructive

4 - 7 yrs: Dramatic, complex constructive, and pregame

7 - 12 yrs: Games

12 - 16 yrs: Recreational

Importance of utilizing play in OT

Play is an area for development of sensory integration, physical abilities, cognition, language skills, and interpersonal relationships

• Children can practice adult and cultural roles and learn to become productive members of society

• It can also be a therapeutic agent and a critical outcome of intervention

What are the different Play assessments

1) Revised Knox preschool play scale

• 0 - 6 yrs

2) Test of playfulness (ToP)

• 6 mo - 18 yrs

3) Takata Play History

• Children and adolescents

4) Kuhaneck

• Questions to consider when assessing a child’s play preferences

5) Test of environmental supportiveness

• Caregiver questions

6) The Parent/Caregiver’s Support of Young Children’s Playfulness

• Criterior referenced: 6 yrs

• Play observation in natural setting which is based on qualities observed and time

7) The pediatric interest profiles

• 6 - 21 yrs

8) Child Occupational Self-Assessment (COSA)

• What the child finds interesting and meaningful

What are some factors that make assessing play more difficult?

• Hard to create a reliable and valid assessment because play is complex

• Assessment are designed to be use din the child’s familiar/natural environment which may not always be possible

• Lack of time and resources to use assessments in a child’s familiar environment

• Unavailability of reliable and valid assessments of play that are designed for use in the clinic

What are factors that should be included in an assessment of play?

• Definition of play or attributes unique to play behavior

• Measurements of spontaneous play versus adult directed play

• Materials used in Play assessments, there is a limited and predetermined set of play materials

• Standardization and norm-referenced to enable comparison between children and across time, making is replicable, reliable, and valid

What are constraints to play?

• Effects of environment and neglect

• Long hospitalizations

• Play in children with varying disabilities

• Intervention begins with the child’s play strengths

To develop playfulness the child must..?

• Develop intrinsic motivation

• Internal Control

• Ability to suspend reality

• Ability to give (take turns)

• Read verbal and nonverbal cues when interacting

Things to consider for the space, play atmosphere, or toys and equipment

• Use of color and texture

• Novelty of equipment and supplies

• Attention to the sense

• Consideration of age and developmental levels

• Convertibility of play spaces to allow for varied level sof ability and interest

• Comfort, size, safety

• Ability to suggest themes or allow for varied thematic play

• Therapeutic use of self and others

When should behavior be a concern?

• When it interferes with a child’s ability to engage and participate in daily life activities

• When behaviors are disruptive to the engagement and participation of others

• When the behaviors place the child or others at risk for injury

What is behavior?

An expressive act by an individual that can have many different forms and meanings

What are examples of passive inappropriate behaviors?

• Noncompliance

• Withdrawal

• Avoidance

• Inattention

• Lack of response

• Challenging questions

What are active inappropriate behaviors?

• Direct refusal to engage

• Opposition

• Aggression to people or property

• Self-injurious behavior

What is the Polyvagal Theory?

Belief that behavioral responses represent how a person’s nervous system is constantly regulating the body’s response to stress

Describe the Green, Red, and Blue pathways of the Polyvagal Theory

Green: Ventral vagal system, which supports social engagement and connection under the conditions of relational environmental safety

Red: Sympathetic nervous system, which supports survival through mobilization, AKA fight-or-flight response

Blue: The dorsal vagal system, which helps us protect ourselves against lift threat by immobilizing or shutting down

What are the 4 primary purposes of behavior and a possible 5th?

1) Obtaining a desired object or event

2) Avoiding a situation

3) Escaping from an undesired object, event, or demand

4) Attention

5) Sensory functions for an automatic reinforcement

What are strategies for therapists to use to address behavior?

• Utilize therapeutic use of self

• Notice your own self-regulation

• Build Rapport

• Antecedents & consequences

• Avoid Rushing

• Allow time for processing

• Provide environmental modifications

• Utilize routines

• Provide creature comforts

• Use representational objects

What is the Positive Behavioral Intervention & Support (PBIS)

Based on behavioral science, this emphasizes the relationship between behavior and environmental factors and the belief that human behavior can be changed

• Utilizes practical interventions, has outcomes that are socially significant, and Adheres to a systems perspective

• Team approach (school setting)

What are the 5 steps of the Functional Behavior Analysis (FBA)

1) Team building and goal setting

2) Functional Assessment of the behavior

3) Hypothesis development

4) development of the comprehensive support plan

5) Implementation and outcome monitoring of the plan

What are the theories behind going Beyond Behavior?

Co-regulation: supporting another person through our presence

• Importance of adult’s awareness related to how their own nervous system impacts a child’s nervous system

• Importance of providing a stable platform, presence, tone of voice, facial expression, pacing, timing, & posture

Describe the purpose of providing Crisis Prevention Institutes (CPI)

Behavior influences behavior

• Provide examples of behavior levels and staff/caregiver approach

• Use of nonverbal communication

• Use of verbal communication

How to implement CPI

Be: be empathetic and nonjudgemental

Respect: Respect personal space

Use: Use nonthreatening non-verbals

Avoid: Avoid overreacting

Focus on: Focus on feelings

Ignore: Ignore challenging questions

Set: set limits

Choose: Choose wisely what you insist upon

Allow: Allow processing time and allow time to make decisions

What is the Functional Behavioral Assessment?

A process of gathering and analyzing data in an effort to determine what function an exhibited behavior may be serving for a child

• Typically this behavior interferes with the student’s learning

What are some common FBA’s?

• SSIS

• Vineland Adaptive Behavior Scales

• SFA

• BRIEF-2

• BRIEF-P

Name some common strategies for behavior management

1) Rule or Pain or illness

2) Provide predictability and consistency

3) Create a calm atmosphere

4) Praise for appropriate behaviors

5) Be aware that challenging behaviors will still occur at times no matter your efforts

6) Share control with the child

7) Provide an environment that promotes successful engagement

8) Increase communication effectiveness and clarify your expectations

What is ASI?

An individualized occupational therapy approach that Jean Ayers developed specifically to remediate sensory integrative problems in children

All learning and development is based on a foundation of multi-sensory integration within the brain that often develops in children through play

• Presents sensory and activity challenges that are individually tailored and are embedded in the context of play

What are important elements of ASI?

• Ensure physical safety

• Present sensory opportunities that support sensory modulation for attaining and maintaining a regulated state

• Challenge praxis, organization of behavior, postural, ocular, oral, and/or bilateral motor control

• Allow collaboration in activity choice

• Tailor activity to present the just right challenge and ensure that activities are successful

• Support child’s intrinsic motivation to play

• Establish therapeutic alliance with the child

What are specific sensory techniques compared to ASI?

Interventions that involve application of specific types of sensory stimuli that are controlled and delivered in a predetermined manner, usually a schedule, protocol, or sequence

What is a sensory diet?

Intervention program that involves individualized sensory experiences and activities completed throughout the day to support optimal functioning

• Includes: Sensory-based activities, completion of activities throughout the day, is tailored to the specific needs of the child, consideration for the intensities and frequencies for the specific child’s needs

What are typical Somatosensory techniques?

Involve controlled application of tactile, proprioceptive, or combined input

• Includes: Brushing, massage, compression clothing, hug machine, or weighted items

What are typical vestibular techniques for sensory interventions?

• Stimulate the vestibular receptors of the inner ear

• Rotary, linear, angular, or combination movements

• Swing, trampoline, dynamic seating

• Astronaut Training Program

• Slow, consistent linear movement will typically be calming de to its inhibitory effect on arousal

• Fast swinging will increase arousal level and attention, especially when the swinging involves unpredictable changes in velocity or direction of movement

What are typical Auditory techniques used in sensory interventions?

• Auditory programs, listening programs, sound-based interventions, or sound therapy

• Complex applications of music delivered through headphones or other listening systems

• Therapeutic Listening Program

What are typical cognitive interventions?

• Focus on teaching strategies or procedures to he child to support successful performance or participation

• Alert program

• COOP

What are Occupation-based interventions with strong sensory input?

• Household chores, such as carrying heavy laundry or vacuuming

• Meal prep: kneading dough

• Leisure: swimming, dance, yoga, horseback riding

What is STAR?

Parent-centered approach that addresses the child’s challenges through focusing on the parent-child relationship and coaching parents in sensory-based strategies or developing a sensory lifestyle

• Individualized to each child’s needs and the parent’s priorities

• Treatment should be integrated into the child’s natural environments when possible

• Separate parent-only education sessions with parents participating actively in all treatment sessions

What is the Etiology of ASD?

There is no specific cause found yet

• Suspected to be from a genetic cause

  • Pre-natal Environmental Factors: Diet, Exercise, Stress, Exposure to substances, viruses, infections

What are common co-occurring conditions with ASD?

• Motor abnormalities

• Gastrointestinal Problems

• Epilepsy

• Intellectual disability

• Sleep Disorders

• Language disorders

• Sensory Processing differences

What are common social participation concerns for individuals with ASD?

• Children and early teens: Imitation, communication, pretend play & Ideation, safety issues, friendships, shared interests

• Teens & Young Adults: Dating, Employment, Resources

What are common Play concerns for individuals with ASD? And what are some interventions?

Preoccupation with objects, unusual use of objects, functional play/pretense, lack of flexibility, Sensorimotor exploration past regular age

Interventions:

• Use of choice, use of preferred sensory toys or interests, variation of task demands, incorporation of ritualistic behaviors

• Smiling, sound effects, and imitation

• Floor time, sensory interventions, peer mediated play groups, reciprocal imitation training, adult imitation

What are common ADL concerns for individuals with ASD? And what are some interventions?

Feeding, toileting, oral care, dressing, bathing

• Motor and cognitive issues could interfere highlighting the importance of a comprehensive assessment

• Use visuals or videos to help in the development of skills

• Develop consistent routines and promote motor learning strategies

• Provide task modification strategies for sensory issues

What are common education concerns for individuals with ASD? And what are some interventions?

Concerns:

• Varied needs and abilities, accommodations, special education

• Typical and atypical cognitive abilities

• Social and behavioral concerns

• Sensory differences

Interventions:

• Differentiated curriculum, tiered instruction, removal of social aspects of instruction

• Visual Supports: Pictures, visual schedules, choice boards, signs, maps, timers

• Social supports: Social skills groups, peer mentoring, play groups, emotional regulation strategies

• Behavior plans and sensory supposrts

• Motivational supports: Child’s preferences in tasks to increase engagements and providing choices

What are performance pattern, skills, and client factor concerns for individuals with ASD?

Performance Patterns:

• Need for Routine and predictability

• Impact on the family

Performance Skills and Client Factors

• Communication, social, emotional regulation, motor, praxis, sensory perceptual skills

• Sensory processing deficits lead to issues with other performance skills

• Hypersensitivity vs. Hyposensitivity; Hyper responsiveness vs. Hypo responsiveness

• Motor skills including gait, posture, balance, coordination, imitation, praxis

• Executive functioning skills

What type of impact can ASD have on the family?

• Coordinating care services

• Family stress

• Financial impact on the family

• Burden of care including community involvement, religious participation

• Maternal stress vs paternal stress

  • Sibling relationships including the sibling as a future caregiver, jealousy, loveliness, varied family rules

Describe the 2 categories of interventions for ASD

1) Adult directed and compliance based

• Approach the child from a position of gaining compliance with the ”work” that needs to be done

2) Naturalistic and more child directed and playful

• Try to achieve learning through more playful means using the child’s inherent preferences

What are specific interventions for sleep for ASD?

• Evaluation of sleep routines and habits

• Focus of assessment is on bedtime routine, environmental conditions, challenging behaviors, and parental responses

• Consider the impact on parent sleep

• Consider how the lack of sleep can impact the child’s health and ability to learn, including behaviors

What is the Early Start Denver Model (ESDM)

A comprehensive early behavioral intervention for infants to preschool-aged children with ASD that integrates ABA with developmental and relationship-based approaches

• Intervention is provided in a toddler’s natural environment and is delivered by trained therapists and parents

What is the theory behind ABA? What is OT’s Role?

Behavior can be modified through reinforcers, Desirable behaviors are rewarded and undesirable behaviors are ignored

Role of OT:

• Token economy systems or sticker charts

• Prompting, chaining, fading out

• Concepts integrated into session but not using techniques specifically

What is the definition of feeding?

The process of setting up, arranging, and bringing food from the table, plate, or cup to the mouth

What is the definition of eating?

The ability to keep and manipulate food or fluid in the mouth and prepare to swallowW

What is the definition of swallowing?

A complex act in which food, fluid, medication, or saliva is moved from the mouth through the pharynx and the esophagus into the stomach

What is the role of the OT in feeding?

• Basic anatomy and physiology

• Growth and developmental milestones

• Nutrition

• Medical conditions and their impact on feeding

• Social and emotional factors that can affect feeding

What is the progression of mealtime participation?

Infant Feeding

• Bonding, warmth, comfort

Independence Develops (7 - 24 mo)

• Finger feed, variety of foods, sensory qualities of food, communication

Toddlers to independent (2yrs +)

• Full participant’ in mealtime, feeding behaviors

What are the phases of swallowing?

Oral preparatory phase, oral phase, pharyngeal phase, esophageal phase

Describe the Oral preparatory phase of Swallowing

• Mastication involves breaking down food particles and mixing them with saliva, through mastication the food particles fall within the oral cavity and into the lateral sulcii

• Teeth crush the food during chewing as a variety of movements occur at the temporomandibular joint

• Lower facial muscles (buccinators) act to squeeze the food particles that fall laterally back to the tops of the teeth

• Muscles like Orbicularis Oris, prevent food from falling outside of the mouth

Describe the Oral Phase of Swallowing

• Tongue forms food particles into a bolus by cupping, the cupping also forms a central groove which contains the bolus

• Tongue’s middle portion depresses while the anterior, posterior, and lateral portions elevate against the hard palate

• Elevation of tongue’s anterior portion causes bolus to flow posteriorly, but the bolus does not enter the pharynx yet because the posterior part of the tongue elevates against the velum (soft palate)

Describe the pharyngeal phase of swallowing

• Pressure of the bolus against the anterior faucial arches triggers the swallow

• Velum retracts and elevates to protect the nasal cavity

• Pharyngeal peristalsis caries the bolus through the pharynx to the top of the esophagus at the cricopharyngeal sphincter

• Closure of the aryepiglottic folds, false vocal folds, and true vocal cords protect the airway, which then closes due to activity in the suprahyoid muscles that elevate the hyoid bone

• Hyoid acts as a fulcrum for muscles involved in swallowing

• Finally, cricopharyngeal sphincter relaxes, allowing the bolus to pass into the esophagus

Describe the Esophageal phase of swallowing

• A peristaltic wave of muscle action pushes food through the esophagus into the stomach

• This action is considered reflexive

What are Swallow considerations?

• If a swallow is not actively triggered during the pharyngeal phase, the risk of aspiration increases

• Aspiration can lead to pneumonia

• A strong cough can expel food by quickly decreasing intrathoracic volume and increasing pressure in the airway

• Intact sensation, muscle coordination, and muscle strength are necessary during the oral preparatory, oral, and pharyngeal phases of eating

What are the Oral Motor Development skills associated with Eating?

• Coordination of sucking, swallowing, and breathing

• Biting and chewing

• Self-feeding

• Drinking

What are the developmental eating skills of a Full-term Infant (37-42 wks)

• Strong oral reflexes

  • Rooting

  • Gagging and coughing

• Coordination of SSB at 34 - 36 wks

• Amount of liquid is determined by:

  • Rate or speed of sucking

  • Force of suction or compression

  • Length of feeding time

Describe Biting and Chewing Developmental Skills

General progression: tongue anterior to posterior movement (suckling) - then up and down (sucking) - then lateralization

6 mo: Munching (vertical jaw movement: up/down)

8 mo: Tongue transfers food to sides

12 mo: Rotary chewing

Important to consider the qualities of the food will lead to increased motor demands

What is the Progression of Self-feeding?

1) Takes cereal from spoon

2) Sucks on cracker

3) Finger feeds

4) Dips spoon in food

5) Scoops food

6) May stab with fork

What types of evals can be used for eating and swallowing?

• Feeding problems - An overview and family routine around meals

• Neuromotor eval

• Examination of oral structures and oral motor patterns

• Assessments - Pedi-EAT, ChOMPS, Pro-ed Mealtime assessment guide

• Videofluoroscopic Swallow Study (VFSS) - Radiologist

• Medical conditions affecting eating

• Contextual factors

What is the Neuromotor Eval?

• Observation of movement

• Transition patterns

• Muscle tone

• Head/neck alignment

• Postural

Describe Videofluoroscopic Swallow (VFSS)

• Radiological procedure

• Assesses oral, pharyngeal, and upper esophageal anatomy and stages of swallowing

• Detect problems related to head and neck positioning

• Helps ID compensatory techniques to minimize risk of aspiration

What types of Medical Conditions might affect Eating

• Cerebral Palsy

• Hypotonia

• Oral-facial anomalies

• Gastroesophageal reflux

What are physical contextual factors to consider when evaluating feeding?

• Is seating and positioning adequate? Does is provide stability?

• Are head, neck, shoulders, and pelvis well aligned

• Is space adequate for eating activities

• Are noise and activity levels conducive to eating

What social contextual factors should be considered for feeding evaluation?

• Who feeds the child?

• Who is present during the meal?

• What is the nature of the social interaction among family members during the meal?

• What communication/interaction occurs between the caregiver and child during feeding?

What type of temporal and cultural contextual factors should be considered in eating and swallowing?

Temporal

• Is sufficient time allotted and available for a relaxing meal?

• How often is the child fed?

• How long does feeding take?

Cultural

• How do cultural beliefs and values influence mealtime?

• What foods does the family eat?

What are the types of feeding interventions?

• Holistic approach

• Environmental adaptations

• Positioning recommendations

• Sensory developmentally activities

• Behavioral strategies

• Neuromuscular handling techniques

• Food texture modifications

• Adaptive equipment

• Suggestions to improve independence

What are some environmental adaptations to provide during feeding intervention?

• Provide regularly scheduled meals - this may promote hunger and more interest in eating

• Shorter meal lengths

• Sensory stimulation and distractions

• Order of food presentation

What are some positioning adaptations to provide during feeding interventions?

• Proximal support

• Positioning whole body

• Alignment

• Comfort

• Stability at the trunk

• Midline orientation

• Head and neck aligned or slightly flexed

What are some interventions to provide for sensory problems?

• Sensory exploration and graded adaptation

• Child’s control

• Deep pressure

• Calming strategies

• Firm pressure

• Introduce new flavors and textures gradually

• Gradually thicken food

• Nuk brush, teething rings

• Oral activities

What are some neuromuscular interventions for oral motor impairments?

• Foods or flavors

• Non-nutritive activities before nutritive

• Positioning

• Facilitate tongue movements

• slow perioral and intraoral cheek stretches

What is the appropriate food and liquid progression based on texture and consistency?

• Pureed

• Junior, coarse pureed

• Wet-ground, mashed

• Soft, dissolvable

• Chopped, soft solid

• Full diet

What types of behavioral interventions can be provided for a child during feeding?

• Food refusal

  • Evaluate reasons why

  • Listen to child

  • Do not force child to eat

  • Make experience pleasant

  • May start with play

• Negative behaviors

• Determine rewards

• Outline clear expectations

What are some interventions to utilize to improve self-feeding?

• Develop interest

• Gradually decrease amount of physical assistance

• Create balance between effort and swallowing safety

• Adaptive equipment

• Backward chaining

• Consistency in placement of food

• Prepare child for self-feeding

What is Dysphagia? And what are some interventions for it?

• Food or liquid consistency adaptations

• Positioning

• Reducing meal length

• Oral Motor activities with heat or cold stimulation

• Neuromuscular electrical stimulation (NMES)

How to approach food refusal or selectivity

• “picky eaters” vs “problem feeders”

• Food jags

• Consider gastroesophageal reflux, allergies, digestive problems, structural abnormalities

• Environmental adaptations

• Reduce oral hypersensitivity

• Behavioral treatment plan