OP1 Final

What makes meals more enjoyable?

-socialization -good food (comfort food, cheat day, etc.) -wine pairing -preparation (cooking with others) -variety -eating out -quality of food -texture of food -type of food -atmosphere (comfortable) -positive emotions -physical comfort (warm, quiet, etc.) -mindlessness (do not have to think about eating)

What factors make meals less enjoyable?

-temperature of food -alone -taste (salty, bitter) -texture of food -physical comfort (too close to people, cold inside, noisy, etc.) -bad smells -stress (ex: job interview meal) -decreased capabilities (six with a sore throat, tube feeding, not hungry) -appearance of food -type of food -social/emotional = not comfortable with people

circles of intimacy and relationships

-visual model of teaching children/young adults what is appropriate -red = stranger (ex: would not hug a stranger, they should not be touching you) -orange = wave circle (waving to an acquaintance) -yellow = handshake (ex: know their name) -green = far away hug -blue = hug circle (mutual agreement) -purple = private circle

3) Other hygiene issues: Constipation

CAUSES -medications, diet, dehydration, low tone, decreased activity level, decreased fluid intake, decreased amount of fiber in diet

ADLs & IADLs

Ch. 15 & 16 of Case-Smith

2) adapting the teaching approach

FORWARD CHAINING - you teach the first step, then next steps consecutively REVERSE CHAINING - teaching last step first, working down to the first step (ex: starting by putting their pants near their hips and having them pull them the rest of the way up, then to their knees, etc.) -one step at a time, verbal cuing, changing environment (decreased distractions, etc.), pneumonic (bunny ears for shoe tying), etc.

Sex education

Find out what is being offered; should be prepared for physical & emotional changes; need to be provided private places for private behaviors (masturbation)

The Parent Zone website

Parent website on tips for potty-training

ADLs and IADLs game

Pepi Bath Lite A role-playing game where children learn about hygiene in an entertaining way 4 diff sitations like kitchen sink, toilet area, bath area, and laundry room Player will learn about cleaning in a predefined way or an undefined manner To make it interesting, props such as soap bubbles and color sprays have been added

EVALUATION OF ORAL-MOTOR AND FEEDING ABILITIES

Approaches to Gathering Information *Read to pp. 163-174 of Morris & Klein (2000). 1. Gather relevant information from caretaker: § Interview and parent questionnaire. See Parent Questionnaire for Eating & Drinking from Morris & Klein (2000). § Obtain caregiver information about feeding history, medications, allergies, food preferences, and most importantly, about the parents' primary concerns related to feeding. § Obtain information about the child's current feeding routine (types/amts. of food eaten at various meals, utensils used, who feeds child, length of meals, interactions during meals, etc.) 2. Direct observation of feeding: § Observation setting § Parent-child feeding interaction § Therapist's observations from feeding the child

IADLs of Older and Younger Adolescents and Middle Childhood

Example of Meal Preparation & Clean-up -Middle childhood (6-11): gets own snacks, sets & clears table -Younger adolescence: (12-15) plans and prepares simple hot and cold meals; dishes in dishwasher -Older adolescence (16-20): All of above and safely operates stove, oven, toaster, blender, microwave and dishwasher Boxes 16-1, 16-2, and 16-3

Dressing

FOR -PEO -independent living -task analysis -developmental

Expressing sexuality appropriately

dress, touching others, appropriate interaction with opposite sex -Need to learn a variety of ways to receive or express praise and affection

Toilet Training: A Parent's Guide (Autism Speaks)

http://www.autismspeaks.org/science/resources-programs/autism-treatment-network/atn-air-p-toilet-training

•Discuss sexual activities to prevent

sexual abuse and exploitation (at higher risk because they are often dependent on others for meeting basic needs) - teach about boundaries, privacy and appropriate touch

1) Adapting toilet/potty seats

-side supports for poor trunk control -foot rest to support feet (Velcro to maintain) -deflector for boys -bigger hole for seat

Issues of Sexuality & Privacy

"The manner in which a practitioner physically touches, speaks to, or approaches a person with a developmental disability has implications for contributing to the individual's sexual development."

Oral Phase

(active) - intake and preparation of food for swallowing; food moved to back of tongue Page 7 on handout1) ORAL PHASE: intake and preparation of food for swallowing; the lips, tongue, jaw, teeth, and cheeks are all active in forming a bolus and moving the food to the back of the tongue for swallowing. This is an active phase of swallowing.

Pharyngeal Phase

(reflexive) - swallow reflex is triggered when food reaches the base of the tongue •Tongue elevation and retraction •Velopharyngeal closure •Airway protection - epiglottis covers larynx •Cricopharyngeal muscle relaxes PHARYNGEAL PHASE (Swallow reflex): the swallow reflex is triggered when the food reaches the base of the tongue; this is the automatic, reflexive phase of swallowing. Five things occur during swallowing: a. Back of the TONGUE ELEVATES AND PRESSES against the posterior wall; b. VELOPHARYNGEAL CLOSURE TAKES PLACE - the soft palate moves backward and upward to the pharyngeal wall (closing off the nasopharynx); c. AIRWAY PROTECTION OCCURS (epiglottis covers the larynx, etc.) d. the BOLUS OF FOOD IS MOVED DOWN THE PHARYNX by the pharyngeal constrictors which squeeze the food down the pharynx; e. the CRICOPHARYNGEAL MUSCLE RELAXES to allow food to move down the esophagus (food moves down the esophagus into the stomach).

VOCAL FOLDS:

- FALSE (or falx)- top - TRUE

ORAL CAVITY

- LIPS - TONGUE - HARD AND SOFT PALATE - TEETH - LINGUAL TONSILS: assist with immune system (produces antibodies) - UVULA

Spaces Where Food May Get Caught

- SULCI: space between lips and gums, and gums and cheeks - VALECULAE: spaces on each side between tongue and epiglottis - PIRIFORMS SINUSES: spaces formed by cricopharyngeus muscles on top of esophagus

Environmental factors

-ADA accessibility -grab bars -sink height/toilet height

videos in class of OT feeding sessions

-aversive to ketchup on fingers -scared to lick finger -aversive to placing finger in mouth (only touches tip of tongue to finger) -noisier environment -pocketing food -little bites -slow to swallow -verbal, visual, and tactile cues -water to help swallow -therapist going too fast, too forceful -gagging/coughing -looking in mirror while eating to see movements required (oral motor) (where to place the food) (use of teeth) -verbal addition ("chew, make it tiny") -reward for finishing food -tongue sticking out at end -smelling the food à kiss the food à lick -preferred food as reinforcement -mirror use -allowing the kid to spit the food out/remove it Group feeding -different food textures (pasta and veggie sticks) -play and encouraging imitation -placing preferred foods with new -holding softer food in hands harder = harder to eat -playing with the food (not as scary) -influence of peers -picking up food is the first step -out of mom's lap is a success -adjusting sensory environment (quiet setting) -eating with the child is important (see it is okay) (hope for imitation)

Decisions regarding oral feeding when aspiration is observed

-consider the amount of aspiration -consider the infant's response to treatment strategies [observe these during videoflouroscopic swallowing study (VFSS)] -consider the infant's baseline pulmonary status (healthy lungs or damaged by BPD)

Management and Intervention for Infants Who Aspirate

-eliminate oral feedings: in infants with significant aspiration or severe lung disease -therapeutic swallowing trials: continue to work on facilitation of swallowing while waiting improvement. Use sterile water and saline; sterile water is preferred -small therapeutic feedings: these may be offered with less severe aspiration and reasonable pulmonary status. Controlled amounts of food are offered with the remaining nutrients offered non-orally (usually by tube). The focus of feeding is to maintain or improve oral and swallowing control so that full oral feedings may occur in the future. Use food types and strategies that reduce occurrence of aspiration as confirmed by VFSS. Close medical supervision is essential -full oral feedings using therapeutic techniques: when VFSS results indicate aspiration or high risk for aspiration that can be eliminated with the use of food types or positioning, full oral feedings may be attempted especially with infants who are medically stable. Close medical attention is important with routine follow-up VFSS

Everyday Life (EDL) project - teaching functional skills

-money -health and safety -work skills -telling time -etc.

Basic Principals

1)Dressing and undressing should be practiced at a time when they most likely occur as a part of the daily routine (eg.going to bathroom, to bed, etc.) 2)Specifically and objectively define the task being taught. 3)Feedback - fade feedback, encourage intrinsic feedback 4) Setting should be free from distractions. 5) With cognitive impairment population, use simple language and short sentences. 6) Parents need to be involved in the program. Have them observe; explain program; have parents follow program at home. 7) Remember to work on undressing first. 8) POSITIONING: Whatever works! Sitting on low bench against wall, on floor against wall or in corner; * Want to reduce abnormal positioning as much as possible 9) MAKE IT FUN: (for younger children) Have a dress-up box with simple outfits (sleeveless, vests, elastic waists), have mirror, child size tables & chairs. 10) Toys can help teach skills -teaching = importance, etc. -intrinsic = self-evaluation -ask parents for priorities -suggest routines for parents -undressing easier than dressing -costumes/playing dress-up, etc. -Dress up is a fun way -button boards, zipper boards, etc. -dolls

steps to toilet training

1. feel the urge 2. hold it in 3. communicate the need 4. get to the toilet 5. pull down pants and underwear 6. sit on the toilet 7. relax 8. urinate/defecate 9. wipe 10. get off the toilet 11. pull up pants 12. flush 13. wash

Factors that influence mealtimes

1. psychosocial environment - influences desire to eat; pleasure in eating; and appetite a. stress level b. feelings about food 2. culture - food preferences based on culture 3. physical environment - a. comfortable position b. pleasant surroundings c. attractive and tasteful food 4. biologic factors - hunger, physical well-being, etc. B. Significance of early pleasurable feeding experiences: Early, pleasurable feeding experiences are important for the infant's later psychosocial and communicative development - 1. positive experiences: 2. negative experiences: lead to a sense of mistrust and a lack of joy in eating (perhaps even failure to thrive (FTT). C. Purpose of eating: 1) to take in food for nutrition and survival; 2) a social activity.

Strategies of instruction

1.Standard teaching technique 2.Adapt the teaching approach 3.Adapt the teaching technique 4.Adapt the teaching device (different article of clothing) 5.Adapt the teaching equipment (adaptive equipment)

DEVELOPMENTAL MILESTONES OF TOILET TRAINING

12 - 15 months: remains dry for 1-2 hour periods indicates discomfort over soiled diapers verbally or by gesture (or crying) 16 - 23 months: has regular bowel movements may be toilet regulated by an adult (adult knows child's pattern and puts child on potty during "prime times" may anticipate need to eliminate; uses same word for both functions 2 - 3 1/2 years: potty training begins; uses toilet with assistance (daytime control) remains dry in between regular toileting uses gestures or words to indicate need to use toilet has infrequent bowel accidents 3- 4 years: able to go to the bathroom by self (needs assistance with fasteners and cleansing) able to wash and dry hands toilet trained; may need reminders to go to the bathroom 4- 5 years: remains dry at night; manages clothes by self 5 - 6 years: independent including wiping and handling clothes

IADLs (ch. 16)

Complex aspects of daily living -Care of pets -Use of communication device -Community mobility and participation -Shopping and financial management -Health maintenance and management (ex: medicationmanagement, exercise, etc.) -Meal preparation and clean up -Household maintenance and management -Safety and emergency procedures (driver's ed) -Pre-vocational training

ORAL STRUCTURE

Describe the mouth at rest, i.e. resting position) § jaw (deviated?) § lips (retracted?) § teeth (condition?) § gums (inflamed? hypertrophied?) § palate (shape?) § tongue & cheeks (tone)

Eating & mealtimes as occupation

Eating is something we do several times a day. We need to recognize the importance of eating in our own life as we address eating with children who have difficulties in this area.

Work on pre-dressing skills or components:

GROSS MOTOR: improve sitting balance, improve wt. Shifting in sitting, work on appropriate positioning for dressing. UPPER EXTREMITY USE: improve functional AROM, improve use of necessary grasp and release patterns, improve necessary strength of grasp. SENSORY PROCESSING/INTEGRATION: improve motor planning, improve proprioceptive feedback and body part awareness (improve body percept). Activities: powder play, lotion, etc. COGNITIVE: improve concepts related to dressing - "on, off, up, down, front, back, behind". Also, parts of clothing. VISUAL PERCEPTION: Figure ground - being able to pick out a sleeve from rest of shirt or identify an article of clothing from a whole drawer of clothes. form constancy - knowing that a shirt is a shirt even when it's crumpled up or when it's a different size and shape. PSYCHOSOCIAL: Is child and parent motivated in this area? An interest in dressing will help child want to practice the skill. Make sure the way you are working on dressing is meaningful for the child. *** These goals can be worked on using activities other than dressing

hyoid bone

HYOID BONE: supports the tongue; is the intermediate between the tongue and larynx

OBSERVE THE FOLLOWING:

ORAL STRUCTURE POSTURAL TONE AND MOVEMENT PATTERNS RESPONSE TO SENSORY STIMULI COMMUNICATION and SOCIAL INTERACTION DURING FEEDING ORAL MOTOR SKILLS & SELF-FEEDING ABILITIES IDENTIFY EQUIPMENT NEEDS DURING FEEDING:

Intervention

NATURAL APPROACH -natural approach—can puree things (smoothie) -natural fiber (prunes, mango juice, fruits and veggies, etc.), fiber gummies, Metamucil, miralax, water, etc.

do2Learn

Nice step by step coloring pages http://www.do2learn.com/picturecards/printcards/selfhelp_toileting.htm

3) adapting the teaching technique

One handed shoe tying, one handed tie tying, -teaching a different way -modify process -ex: dressing with hemiplegia = dressing affected side first, undressing affected side last adapted putting on/taking off a shirt •Hemiplegia -Put affected side in first -Take affected side out last

Hidden Curriculum

PBIS Behavioral Expectations Classroom Rules SLIDE 33 = websites

Swallowing Problems and Intervention

Swallowing disorders can result from •Delayed initiation of swallow reflex •Poor organization of bolus formation in oral phase •Insufficient laryngeal elevation and closure resulting in aspiration •Decreased pharyngeal peristalsis •Dysfunction of the cricopharyngeas muscle

Most Essential Skill Needed --> Activity Analysis

TASK: Observe person putting on & taking off a T-shirt. Analyze needed function in: •Gross motor •UE & fine motor •Perceptual & Sensory processing •Cognitive •Psychosocial -gross motor: shoulder abduction/flexion/adduction, walking to get the shirt, postural control/balance, elbow flexion and extension, active weight shifting, ROM, bilateral integration, crossing midline, -UE and fine motor: reach, grasp, pinch -perceptual and sensory processing: tactile (positioning of the shirt, holding it, tolerating textures of clothing), vestibular (maintaining balance), proprioception (body position in space), visual perceptual skills, motor planning, R/L coordination/sequencing, figure ground discrimination -cognitive: attention, motor planning, right/left discrimination, concept formation (purpose of the item), memory, sequencing, problem-solving, appropriateness of clothing (ex: sweatshirt for winter), matching clothing -psychosocial: selection for appropriate weather, matching, motivation, expression

CRICOPHARYNGEUS MUSCLE

The top of the esophagus is marked by this muscle. It runs from the base of the cricoid cartilage to the pharygeal wall. This muscle is always closed except after the triggering of the swallow reflex. When there is no swallow reflex, this muscle does not relax and open to allow food to pass down the esophagus to the stomach. (It is sometimes called the "P-E junction" or pharyngeal-esophagel junction).

swallowing problems: delayed swallow reflex

Thermal stimulation with oral feeding - chilled formula to stimulate swallow Improve bolus formation during oral phase •Provide single boluses •Provide small bolus •Thicken liquid -change position, food (texture, amount, temperature, etc.), and/or feeding strategy

Oral Motor and Feeding

VVV

Toileting and Hygiene

VVV

Anatomy

VVVV

The ORAL AND NASAL CAVITIES form a single tube that divides into two areas:

a. TRACHEA: air b. ESOPHAGUS: food COMMON WALL: soft tissue wall between the esophagus and trachea

The PHARYNX has a number of VALVES that constrict it at various points. They are:

a. VELO-PHARYNGEAL CLOSURE - The SOFT PALATE is brought up to meet the back of the PHARYNGEAL WALL to separate the nasal cavity from the oral cavity. Purpose (of velo-pharyngeal closure): To direct food down the esophagus and keep it from going up into the nose. It also directs sound out the mouth to forms vowels and consonants. b. EPIGLOTTIS - This valve closes off the pathway to the lungs during eating and helps direct the food down the ESOPHAGUS instead of the trachea (critical for airway protection). c. The oral cavity may be valved at the front by the LIPS and TONGUE. The POSTERIOR TONGUE may valve the oral cavity in the back.

Caregiver strategies

ask permission before touching, describe what is done and why to establish boundaries

1) Standard Teaching Technique

basic dressing method; different ways to put on and off clothing -culture specific (everyone taught a certain/different way based off their caregiver's techniques) -ID skills needed and why there are difficulties (cognition, emotional, etc.)

"taking care of myself" book

book for youth with autism -how to take care of menstruation, dressing, undressing, deodorant, etc.

Mealtime

critical social activity

dysphagia

difficulty swallowing

Delayed swallow reflex

may see a delay in swallowing from a fraction of a second to more than 10 seconds -results in food/liquid pooling in the pyriform sinuses or valleculae prior to swallowing -food may spill over into open airway and be aspirated Intervention -thermal stimulation with oral feeding: refrigerator-chilled formula or semi-solids helps to trigger the swallow reflex more quickly. Can also apply thermal stimulation during non-nutritive sucking with a frozen pacifier (fill hollow nipple with water) -improve bolus formation in oral phase: if the tongue is unable to form the bolus and hold it prior to the initiation of the swallow, there may be spill over of the food over the posterior portion of the tongue in a piecemeal fashion that does not adequately trigger the swallow reflex -treatment: a. provide single boluses ("pacifier trainer" may be used; a 5 fr. Gavage feeding tube attached to a 20 ccfeeding syringe) Thicken the liquid to form a more cohesive mass and moves more slowly (use tblsp of baby rice cereal to 2 oz of liquid)

Eating

meaningful occupation; important for survival and health (OTPF)

LARYNX; LARYNGOPHARYNX; LARYNGEAL CAVITY (or vestibule):

open area at base of tongue - top structure: epiglottis - bottom structure: false vocal cords Functions as a valve to keep food from entering the airway during eating through laryngeal excursion.

PHARYNGEAL CAVITY

open area; opens into the larynx - OROPHARYNX (ORAL CAVITY) -NASOPHARYNX (NASAL CAVITY)

Swallowing Phases

oral phase Pharyngeal phase

Feeding

term used in pediatrics; referring to adults feeding infant or child; may include self-feeding

Oral-motor

the use of the oral mechanism to take in food and swallow (anatomy and physiology)

Aspiration after swallow

this is usually due to residual liquids or solids remaining in the pharynx following the completion of the swallow resulting in the material being inhaled or aspirated into the airway -This particular problem may be due to: decreased pharyngeal peristalsis, dysfunction of the cricopharyngeas muscle, and inadequate generation and maintenance of pressure gradients to propel the bolus through the pharynx -symptoms: usually present with extremely noisy, wet-sounding breathing that becomes worse following feeding INTERVENTION -modify food consistency: pharyngeal peristalsis may be better with one texture or type of food than another resulting in less residue after the swallow (ex: there may be less residue with thin liquid vs thickened liquids). With other infants, the opposite may occur -encourage "dry" swallows: give 1-2 boluses of thicker substances followed by several bouses of tinner liquids to help clear the pharynx. Another strategy is to have the infant suck on a pacifier in between a bolus -improve pharyngeal pressure: pharyngeal pressure may be inadequate if velo-pharyngeal closure is inadequate causing poor sealing of the oral and pharyngeal cavities. This can lead to poor clearance of the bolus during the pharyngeal phase. Food can also escape into the nasopharynx with poor velo-pharyngeal closure (palatal training appliance (PTA) may be used to assist in velar function. Pressure and tactile input are provided to facilitate palatal elevation)

Definition of sexuality

touching and being touched; loving and being loved; sensual pleasure in the world around us; and a sense of being feminine or masculine •Birth - 5: learn modesty and privacy; social distance by 5 •6-11 years: curiosity about bodies; explore bodies •Adolescence: puberty; secondary sexual characteristics; need for privacy; interest in relationships •Adulthood: strong drive toward intimacy emotionally and physically; marriage; having children

Examples of Adapted IADLs

•Physical challenges: modify task - use reachers; use scooter or cart with decreased endurance •Cognitive challenges: use a 'buddy system', provide simple instructions, repeat, present in small steps •Psychosocial challenges: structure routine, role play, prepare ahead of time, sensory diet Table 16-2, p. 475

Aspiration during the swallow:

usually caused by reduced or insufficient laryngeal elevation and closure so that part of the bolus seeps under the epiglottis and into the airway prior to sufficient laryngeal closure INTERVENTION -improve laryngeal closure: strong forward head flexion or chin tucking changes the position of the larynx so that less elevation is needed for complete closure; flexing the head forward causes the hyoid and larynx to move slightly upward -thickening feedings: thickening the feedings may create a more cohesive bolus that does not seep under the epiglottis and enter the larynx during swallowing. It also may move through the pharynx more slowly allowing more time for adequate laryngeal elevation. [try minimal thickening with 1 tblsp rice cereal to 2 oz formula or more marked thickening] Also, the infant may be able to swallow pureed foods better than liquids

COMMUNICATION and SOCIAL INTERACTION DURING FEEDING

§ How does the child communicate mealtime needs? hunger/fullness? food preferences? § Emotions observed? Type of interaction between feeder and child? § What is the overall mealtime atmosphere?

POSTURAL TONE AND MOVEMENT PATTERNS

§ gross motor (m. tone, proximal patterns in the body) § fine motor/upper extremity function - what is the child's ability to use arms for reach, grasp, and release? These abilities are necessary for self-feeding. § How do these patterns in the body influence the oral mechanism? (eg. head hyperextension --> has this abnormal pattern caused tongue retraction? tongue thrusting? what?) § Identify limiting oral m. patterns.

RESPONSE TO SENSORY STIMULI

§ tactile (response to touch on body/face) § gustatory (response to various tastes) § visual (response to food coming toward face, visual stim. in environment) § auditory (response to noise in environment) § olfactory

positioning on the toilet

•90-90-90 at hips, knees, ankles •Trunk support (if needed) •Safety •Proximity to toilet paper and bars

SEXUALITY

•All people with disabilities are sexual beings and have a right to express their sexuality. Issues: •May be treated as 'a-sexual' •Individuals with DD may lack experience and skills necessary for healthy relationships and sexuality •Vulnerable to sexual abuse •What individuals would like from sex education (Swango-Wilson, 2011): 1) Dev of friendships; 2) Dev of relationships; & 3) safe sex behaviors -sex ed: development of friendships (making and maintaining), developing relationships (expression of feelings), safe sex behaviors *Table 15-10, p. 447*

tongue control issues

•BUNCHED TONGUE TONGUE RETRACTION •Tongue pulled back TONGUE THRUST •Forceful protrusion of tongue -want: tongue control, malleable tongue (cup the spoon), full ROM of tongue -bunched = tongue is bunched instead of groove, means high toned -retraction = closer to the throat, makes breathing and sucking difficult -thrust = tongue sticking out, arhythmical

ADLs

•Bowel and bladder management; toileting •Bathing/showering •Grooming/hygiene •Feeding/eating •Dressing •Functional mobility

Tune into and keep your emotions in check

•Breaking down the act of eating •Bolus •Drooling •Emesis, spitting up •What will your reactions be? •Discomfort? •How to keep the client's needs in the forefront? -if client vomits: comfort, things to clean up -food preferences based on culture -dietary restrictions -hunger

Intervention

•Create or promote (PEO) •Establish, restore, maintain (remedial) •Modify/adapt (compensatory)- task analysis (forward or reverse chaining), grading activity; •Prevention/education (consultation) -create supports -anticipatory problem-solving -verbal sequencing or visuals prior to engaging

Toileting and hygiene

•Physiological factors •Physical readiness •Psychological/cognitive readiness •Parental readiness •See Table 15-7 on pp. 436-437 Case Smith -physiological readiness - able to have voluntary control of bowel and bladder? -physical readiness - able to get to the bathroom/toilet, get on and off toilet, manage clothes, and cleanse self? -psychological =

self-feeding and oral phase

•Pick up cracker with pincer prehension •Hand to mouth pattern •Place cracker on lips/teeth •Bite cracker •Tongue does what? •Cheeks? -pincer prehension -self feeding -tongue: push to side to chew and back to swallow -cheeks: holds food in place

evaluation of swallowing

•Definition •When? •Treatment The evaluation of swallowing is one aspect of an oral-motor and feeding evaluation that may be required if the OT suspects any swallowing difficulties. WHEN IS A SWALLOWING EVALUATION RECOMMENDED? any suspicion of aspiration (excessive coughing or choking during eating; recurrent pneumonia or respiratory infections); refusal to eat; irritability during eating; failure to thrive; other symptoms - ASPIRATION (definition): Food or liquid moving down the airway (trachea) below the true vocal folds. TX./INTERVENTION: If there is significant aspiration, then non-oral feeding is recommended (tube feeding) until (or if) the problem is alleviated; tx. may be effective in preventing mild aspiration. HOW DO WE EVALUATE SWALLOWING? ORAL PHASE - can be assessed by observing the person eat a variety of foods and drink liquids PHARYNGEAL PHASE (SWALLOW REFLEX) - RADIOGRAPHIC TECHNIQUES: allows one to evaluate the oral and pharyngeal phases of swallowing (Dept. of Radiology)

evaluation strategies

•Developmental Assessments: Hawaii Early Learning Profile (2004) •Functional Assessments: SFA - School Function Assessment •AMPS (Assessment of Motor and Process Skills) - an observation-based evaluation of a person's quality of performance of relevant, chosen, and prioritized personal or domestic activities of daily living tasks (3+) •WeeFIM: minimal data set of 18 items that measure functional performance in three domains: self-care, mobility, and cognition. Ages 6 months- 7 years. •*STRUCTURED OBSERVATIONS in context INTERVIEW -Melborn = children with hemiplegia, assessing daily tasks unilaterally -independent living skills assessment (17+), memory and orientation (health and safety, transportation, etc.)

Evaluation

•Developmental Checklists •Functional evaluations •Activity Analysis •Psychosocial

options for aspiration

•Eliminate oral feedings •Therapeutic swallow trials •Small therapeutic feedings •Full oral feedings using therapeutic techniques -consider: amount being aspirated, response to treatment methods attempted, baseline pulmonary status, etc. -tube feed (G tube) -small feedings only attempted when aspiration decreasing (slow integration)

Activity Analysis: Component Skills for Toileting

•Gross motor •Upper extremity/fine motor •Cognitive •Perceptual/ sensory processing •Psychosocial/cognitive -gross motor: sitting balance, sit to stand, walking to the toilet, trunk rotation, crossing midline, shoulder flexion, internal rotation, standing balance for boys, muscle strength, weight shifting, postural control, -UE and fine motor: reaching, pinching, grasping, pinch strength to rip tp, finger dexterity, -cognitive: sequencing, motor planning, attention, internal cues (knowing when to go, when wet or dry), safety awareness, knowing to wipe until clean -perceptual/sensory: seeing the toilet, depth perception, proprioceptive (body awareness, proper grip on tp), vestibular (balance), tactile (feeling tp), interoception (knowing when to go, when you're done, etc.), auditory (loud hand dryers, toilet flushing, etc.), -psychological: desire to be clean when done, parent readiness, social appropriateness of where you can go or when, privacy

sensory factors

•HYPERSENSITIVITY (sensory defensiveness) •HYPOSENSITIVITY (limited awareness) ... TO touch, sound, smell, taste ... -hyper = temperamental, aversive, etc. -can be smell, texture, temperature, sounds, look of food, etc.

swallowing problems: Aspiration during swallow

•Improve laryngeal closure - chin tuck or forward flexion •Thickened feedings --> more cohesive bolus

jaw control issues

•JAW THRUST - strong downward movement of jaw; overuse of extension •TONIC BITE REFLEX - forceful biting pattern -jaw stability = slight movement of the jaw, graded movement of the jaw (opening and closing) -thrust = uncontrolled -bite = strong

Lips

•LOW-TONE --> POOR LIP CLOSURE •LIP RETRACTION - lips drawn upward •LIP PURSING - pursed -drooling -pursing = pucker

Airway Protection

•Laryngeal excursion (larynx and hyoid elevate during swallowing) •Epiglottis covers larynx •Adduction of the false vocal folds •Adduction of the true vocal folds

Considerations for the DD/CP Population

•May need to adapt potty seat •May need to adapt clothing (especially fasteners) •Other hygiene issues

swallowing problems: Aspiration after the swallow

•Modify food consistency •Encourage 'dry' swallow in between bites •Improve pharyngeal pressure - palatal training device

possible causes of feeding problems

•NEUROLOGICAL DEFICITS •PREMATURITY •RESPIRATORY PROBLEMS •CONGENITAL HEART DISEASE •DIGESTIVE DISORDERS •AUTISM & PDD •SPD 1) NEUROLOGICAL DEFICITS (eg. cerebral palsy) Children with spastic quadraparesis may demonstrate: o oral hypersensitivity o limited tongue control o limited lip closure o poor jaw control (jaw thrust or bite reflex) o delayed chewing Children with low tone may demonstrate: o decreased m. tone (and control) in tongue, cheeks, lips o poor lip closure o difficulty moving food in mouth o poor jaw control; weakness in biting through food o delayed chewing o poor tongue lateralization o poor cheek activity o may be orally hyper- or hyposensitive 2) PREMATURITY: weak suckling; poor coordination of suck, swallow, and breathing; fatigues easily during feeding; poor intake/poor wt. gain; inefficient sucking 3) RESPIRATORY PROBLEMS: (Bronchopulmonary dysplasia, BPD) altered breathing which interferes with the coordination of suck, swallow, and breathing; tires easily during feeding; decreased consumption 4) CONGENITAL HEART DISEASE (CHD): Characteristics - rapid respiration, restlessness, cyanosis, excessive fatigability while sucking, feeding difficulties, frequent vomiting; poor coord. of suck, swallow, and breathing; poor endurance (needs frequent rest periods); weak and slow suck (poor seal around nipple); at-risk for failure-to-thrive (FTT) 5) DIGESTIVE DISORDERS: A common problems is gastroesophageal reflux (GER) which causes a constant irritation of the esophagus; this may result in discomfort as well as poor appetite and food refusal 6) AUTISM AND PDD: May see unusual food cravings or excessive pickiness based on taste or texture of food. 7) Sensory processing disorders: May see selective eating (i.e. pickiness, significant food preferences); environment may contribute to this as well.

PEO

•Person (performance skills, body structures & functions, developmental status) •Environment (family, school, community context) •Occupation (specific demands of the self-care activity * These 3 interact!

Modified barium swallow (MBS)

•Position: •Focus: Materials Barium swallow exams (two types) *TRUE Barium Swallow: position: supine focus: after the swallow reflex, problems in esophagus material: liquid barium *MODIFIED Barium Swallow: (MBS) position: sitting focus: oral and pharyngeal phases of swallowing (mouth and back of throat) (time and process of swallow) materials: licker liquid or solid with barium sulfate (colored, covers lining in intestines to see process and track) (1/3 tsp liquid, 1/3 tsp paste/thick food, and 1 bite of cookie) *Radiation exposure is limited as much as possible with MBS. The occupational therapist is often present and may assist in the evaluation and analysis. - look for any food residuals in the valleculae and piriform sinuses; - examine timing of the swallow; - can evaluate the oral phase (tongue movements, etc.) Benefits of the MODIFIED BARIUM SWALLOW EXAM: identify specific problem areas in the process of swallowing

Toilet training programs

•Pot-by-clock -Put on potty at 'prime' times -Every 2 hours or so -Avoid POWER STRUGGLES •Other factors: -Training pants -Simple clothing (elastic waist vs. zippers/snaps) -TEACH process (see Taking Care of Myself) -hone in on child readiness -giving a lot of liquid to understand process

4) Adapt the teaching device

•See Table 15-9 on p. 442 •Loose fitting clothes •Velcro -materials using to make it easier -using an adult sized shirt to start -handout on BB!!!

Eating Analysis

•Take a bite of cracker - SLOW MOTION Analyze components involved in •Self-feeding •Oral-motor phase Picking up cracker/cookie -grasp (pincer) -arm: elbow flexion, supination -motivation: hunger, like what you're eating, etc. -lips: opened, move to the side -teeth knew how hard to bite (proprioception) -tougher food = place on molars -tongue: pushing it to the side of the mouth to chew -swallowing: tongue pushes to the back of the mouth (retraction) -cheeks: helps form bolus -saliva: more produced, helps push food back

2) Adapting clothing

•Velcro instead of snaps/zippers •SIMPLE clothing!! -elastic waste band (just pull down)

5) adapted teaching equipment

•Zipper pulls •Button hooks -add something to help with the task -ex: zipper pull, button hook, elastic shoelaces, Velcro, etc.

limiting oral motor patterns

•pp. 136-137 (Morris & Klein) CLASS HANDOUT -jaw, lip, tongue patterns