Peds Exam 3

Sucking exercises

*Ice around lips - Dry with towel A. Suck liquid through a straw

Securing funding

*Team works together to secure funding* - Therapist writes letter of justification - Insurance is looking for a MEDICAL need - Family ultimately responsible - If child is in school, consider at educational need

Wheelchairs

- Available in custom or standard sizes - Available in manual or power - Must consider client's needs and goals - Special features that the client needs must be discussed by the team Power w/c 1. Goals must be defined 2. Common to use a power chair as a trial 3. Must evaluate the client's ability to control the device

Contoured system

- Body has more contact with support surface - Shape conforms to curves of spine, pelvis, thighs - Helps distribute pressure more evenly - Can layer varieties of foam - Can purchase contoured cushion

Team evaluates child:

- Child: developmental & functional levels of motor, sensory, perceptual, cognitive, communication, and psychosocial areas - Adult: Motor, vision perception, cognition - Activities client wants or needs to do - The environment/context where AT will be used - The potential goals of using AT

Assessment: Nutritional management assessment

- Demographic info - Food allergies - Medications (how are they given?) - Feeding method (medical problems that may interfere; cleft, do they need to be suctioned first) - Programming (Sensory responses that interfere) - Mandible (overbite or underbite; check about dentist) - Teeth (conditions, do they have any?) - Palate (tongue tip elevation will be difficult) - Positioning for feeding - Facial tone _ Gross motor abilities (important for carrying trays) - Reflexes that interfere ( ATNR - grab food while looking and bring to mouth while looking away) - Types of breathing - Types of swallowing - Oral patterns (some should be YES, most others should be NO)

Why is the team important to the success of the child?

- Devices are used in all settings, so all team members have a vested interest in the equipment - Includes family members & child - Includes teachers and all therapists - Different team members are involved in teaching child to use the equipment - Do not want the use of the AT to interfere with other parts of child's education - May depend on type of facility, funding sources

What to look at when assessing caregivers ability to use equipment with client

- Ease of transportation - Ease of maintenance - Costs versus benefits

Poor action of the intrinsic muscles of the tongue during sucking:

- Failure of the intrinsic muscles to flatten and thin the tongue and create a cupped or bowl-shaped configuration. - This cupped configuration of the tongue provides a normal groove or passageway for efficient movement of the liquid or food to the back of the mouth for swallowing. If the intrinsics are not working properly, the tongue may appear to be thick or bunched and may never or rarely have a bowl- shaped configuration during suckling, sucking, of liquids or semi-solids.

With both types of standers:

- Fasten strap across pelvis first - Then fasten strap across upper trunk - Be sure LEs are as extended as possible - Want feet flat in foot plates, fasten in - Fasten strap across upper trunk - Try to keep the arms as free as possible so child can play on tray - Both can come with or without wheels (can be moved by others)

Munching:

- Flattening and spreading of tongue combined with an up-and- down movement of the jaw. - The body of the tongue may elevate slightly and make contact with the hard palate. - The jaws make a definite biting or chewing rhythm. This normally develops at around age 5 months.

Assessment process requires:

- Formation of a team - Determine client/family/child goals, priorities, preferences - Identify sociocultural considerations 1. Financial resources 2. Adaptability of the technology (as child grows) 3. Degree of importance family places on independence 4. Family's knowledge of disabilities and sources of information 5. Balance of work and play

Gag reflex

- Frequent gagging may indicate abnormal hypersensitivity of the gag or swallowing difficulties. - If the child is unable to move food efficiently into the pharynx for swallowing, particles of food may remain on the posterior portion of the tongue or at the entrance to the pharynx.

Goals of postural support

- Gain or reinforce normal movement - Achieve normal postural alignment - Prevent contractures and deformities - Increase opportunities to participate - Provide mobility and encourage exploration - Increase independence in ADLs and self-help skills - Assist in improving physiologic functions - Increase comfort - Appropriate positions to enhance function

Seating considerations

- Goal: inhibit abnormal muscle tone, reduce undesirable biomechanical forces, accommodate stiff postures - Provide maximum weight distribution for stability, comfort, skin integrity - Provide support at 3 contact points in the pelvis - Determine if a flat surface or contoured seat is needed - May need side support to prevent shift - May need stability above the pelvis to prevent it sliding up and forward - Use seat belt at 45 degree angle to the seat

Sidelying Positioning

- Great alternative to prone or supine - Lessens effect of gravity - Position child on side with trunk and head against a supporting surface - Prevent trunk hyperextension - Fasten strap firmly across hips and below armpits - Make sure head is supported - prevent hyperextension, ATNR - Keep top arm forward and down - Put a toy on the floor at chest height for child to hold/play with - Keep top leg flexed at knee & hip - Keep bottom leg more extended at knee & hip - Put a wedge between the legs to stop adduction & internal rotation

Team provides trial opportunities for using AT

- Helps prevent getting wrong device - Some facilities lend out AT for trials - Some vendors lend some equipment for trials - Some are able to be rented

Possible causes of abnormal lip closure:

- Hypertonicity -Hypotonicity

Parenteral

- IV feeding - Subclavian lines (a bigger deal; are for long-term IV use) Whites = lipids/fats Yellows = amino acids/hyperalimentation Clean = glucose or saline

Jaw clenching:

- Involuntary closure of the jaw that makes opening the mouth difficult. - May be associated with overall flexor patterns or with self- stimulation through the tonic bite reflex. - Close observation should be done to determine the difference between a tone problem and food refusals.

Ancillary supports:

- Lateral trunk supports, leg adductors, or humeral "wings", should be large enough to distribute pressure over the surface of the body part. - Does not dig in and cause discomfort or, in some cases, provide active resistance. - Use blocks rather than straps

Lack of lip closure (abnormal):

- Lips do not close completely - Child will clean the spoon with teeth rather than lips

Nasal regurgitation

- Loss of liquid or food through the nose during sucking and swallowing. - It may occur when the movement of the soft palate is poorly coordinated with the swallow or when the palate is too short or contains a cleft.

Lack of tongue elevation or lateralization (abnormal):

- May be caused by tongue thrust or tongue retraction. - May be hyper or hypotonic in the tongue. No dissociation is present between the tongue, jaw, or lips.

Exceptions

- Medications - Dismissal ("they were discharged last night, you were not able to see if they are at age level") - Development of medical complications 1. CNS 2. Musculoskeletal 3. Internal - Poor attending - Non-cooperative behavior 1. Parent/caregiver 2. Child - Interference of presenting problems 1. visual 2. auditory 3. spasticity 4. rigidity 5. hypotonia 6. hypertonia 7. flaccidity 8. limited AROM 9. limited PROM 10. muscle weakness 11. tremors - Limited resources - Age-appropriate skills

Passive or inactive swallowing:

- Minimal type of swallowing pattern. - The child swallows the liquid or food by passively allowing it to flow down the pharynx and into the esophagus without active muscle action. - The head is often extended and the child is frequently "bird-fed". - Passive swallowing can be observed/felt by feeling the failure of normal elevation of the hyoid bone and larynx at the point of swallow.

Order of chew movements:

- Munching - Chewing - Tongue lateralization, tip elevation

Tongue retraction (abnormal):

- Muscle's pull the tongue into severe flexion in the pharyngeal space. The tongue tip is not forward and even with the gums. It is usually pulled back toward the middle of the hard palate. This makes inserting a spoon or bottle difficult. Severe retraction can also partially block the airway, leading to increased respiratory distress. - Tongue can block the airway and cause aspiration

Weak sucking:

- Nipple can consistently be pulled out of the mouth with great ease. - This is normal in children as they become satiated. - However, other infants will use a weak sucking pattern even when they are very hungry. This frequently accompanies a long feeding time and/or the liquid intake is small.

Jaw stabilization

- Observable up-and-down movement of the jaw during drinking. Liquid intake occurs through independent action of the tongue and lips. - Stabilization occurs by biting down on the edge of the cup or by active co- activation of muscles controlling movement of the TMJ. The biting is usually seen by 15-24 months. Muscle co-activation usually occurs by 18-26 months. This pattern then persists through adulthood.

Very slow swallowing:

- Particles of food may remain on the posterior portion of the tongue or at the entrance of the pharynx - The child requires an unusual amount of time to swallow a specific amount of food. - Sucking or suckling can be quite active, but the same spoonful remains in the mouth or reappears at the lips. - Food may pool or be stored in the front of the mouth or in the back of the mouth between the dorsum of the tongue and the soft palate. - Very few active or palpable swallows can be felt.

Inefficient sucking:

- Pattern is characterized by an excessive amount of up-and-down movements, with a marked variation in sucking rhythm or a lack of a characteristic rhythm of sucking, or any pattern that more subtly appears to reduce the speed, skill or amount of liquid intake from the bottle or breast.

Team identifies and considers specific types of AT

- Planning the intervention - Selecting the components (parts) and interfaces (how person will use it)

Precautions in feeding people with severe disabilities - Observe the following:

- Position - Utensils that are used - Texture of food (blend or grind) - Rate - Amount - How liquid is given - Likes and dislikes of the child

Supine positioning

- Prevent hyperextension of trunk - Prevent "Frog" position (abduction, external rotation) in LEs and/or UEs - Prevent too much adduction/internal rotation, flexion - Not preferred position due to influence of gravity

Prone Positioning

- Prone is the hardest position - If use wedge, position both arms over the edge so child can WB on arms - Consider height of wedge - closer to being upright tends to be easier than being completely horizontal

Custom Molded system

- Provides an intimate fit by closely conforming to the shape of the client's body - Gives the most postural support and pressure relief - Fabrication is time consuming and costly

Hypoactive

- Reflex is desensitized and is not able to be a protective mechanism - Gag cannot be elicited on the main portion of the tongue.

Contraindications for oral feeding

- Respiratory distress - Depressed respiratory and heart rates during feeding - Frequently suctioning of tracheostomy - Increased suction during feeding attempts *Looking at the color being suctioned is essential) - Frequent vomiting around feeding or active reflux - Suspected and/or confirmed aspiration based on videofluoroscopy - Uncontrolled seizure activity - Acute illness with fever - Unresolved metabolic problems

Sucking

- Rhythmical method of obtaining a liquid in which tongue action is primarily a raising and lowering of the body of the tongue. - More tongue-tip elevation is observed as is firmer approximation of the lips. - Less jaw movement is present. Negative pressure increases within the oral cavity with combined closure of the lips and lowering of the tongue. This helps pull the liquid into the mouth. - Generally present between 6 and 9 months. It persists into adulthood.

Wheelchair Cushions

- Roho Cushion - Roho custom recliner system - Invacare Contour U Back - Invacare Infinity Lo Contour Flo-Gel Cushion -Stimulite(Honeycomb) Contoured Cushion - Stimulite Bariatric Cushion

Feeding behaviors are influenced by:

- Social environment - Oral stim

Lack of chewing skills:

- The child may or may not also have a tonic bite reflex present. The child does not exhibit the jaw movement needed for chewing due to one of the following: 1. Jaw thrust: The jaw extends widely, with no gradation of movement. The child has difficulty trying to close the mouth due to too much extensor tone. 2. Bite reflex: as above 3. These two problems frequently occur in combination, making chewing movements extremely difficult

General principles of positioning:

- The surface should be solid and stable so that it does not "give" or change the client's movements. - Flexible surfaces (beanbags or sling seats on wheelchairs) accommodate to the client's weight shifting and can exacerbate asymmetries or dysfunctional postures. - Ancillary supports - Consider needs of the care providers - Equipment that is more likely to be used effectively.

PICU - Therapy

- Therapy is almost always on the unit 1. medical stability is critical 2. role may be supportive, positioning, educational 3. assess and treat at bedside

Tongue thrust (abnormal):

- Tongue remains outside the mouth longer than a few seconds. - Forceful extensor tone pattern forces the tongue outside the mouth. The tongue is often thick and bunched during the thrust. It generally does not require a swallow to stimulate it.

Chewing:

- Using the teeth and/or tongue in a movement designed to break up or pulverize solid pieces of food in preparation for swallowing. - The tongue spreads and rolls in an attempt to move food between the teeth.

Plantar System

- Usually made of solid seat and back covered with foam and upholstery - Suited for clients with good postural stability and sitting balance and minimum of deformity - Lateral supports can be added if necessary

tube feeding complications:

- Vomiting and diarrhea - Constipation (because you are not getting enough liquids) - GERD - Large residuals - Tube feeding syndrome (dehydration; excess urea or other nitrogenous bodies in the system - low sodium count) - Fundoplication (surgery that keeps food and acid from coming up; this can be negative because the child is unable to throw up) - Hyponatremia (too much fluid) - Clogged feeding tubes - Leakage of gastric contents (usually after a new surgery) - Bleeding around the stoma

Roles of school therapists: Assessment

- check for parental permission - use multiple methods, including direct observation in the students natural setting - top-down or bottom-up approach - document approach

Increased stress

- child is separated from family & familiar environment - unfamiliar with hospital, staff frequently changes - dependency increased - painful medical procedures - stress may cause developmental regression

Keep in easy reach

- elastic straps -plastic garden chains

family centered philosophy

- family helps planning & implement services - interventionist helps identify the needs, concerns, priorities of child and family - team needs to know how much family can/wants to participate - assist family in helping their daily routine

General nutrition

- formula (20 calories per oz) - additional calories - hyperalimentation - Lipids - special formula (increase calories or nutrition)

Children's hospitals

- full range of IP & OP services - wide range of pediatric diagnoses - length of stay tends to be slightly longer than general hospital - medical intervention tends to be more labor intensive - culturally diverse group

Acute care

- hospital/medical based - specialty hospital vs home hospital 1. level of care 2. peds and adults *higher number = more trauma patients* *infection control to broken bones, all specialties are there*

Regular floor

- illness/injury requires hospitalization - routine care - may be there for diagnostic workup

Goals of equipment

- improve distal function - positioning uses external devices to promote the client's functioning 1. Provide central stability to decrease pathological movement (this relates to ROM, head, and trunk control) and prevent deformity - liberate the head and arms (hand control, mobility, feeding, and toileting responses) 1. does it require cognition, perception, attention, motor planning, and fine motor skills - postural control is a foundation for the development of many functions 1. absence of postural control impedes the development of skills in this area.

Typically with institution

- kids are medically fragile - no one to provide care at home - parents may be on vacation - child admitted to facility for temp care

Normal sensory deprivation and stress

- lack privacy, immobility, continuous sound, & light - unable to orient themselves to time of day

Remove unnecessary features

- look at your goal, remove unwanted features - introduce one concept at a time (color, size, shape, weight, volume) -simplify the background

Handling identifies postural responses on different positions:

- look for compensatory movements during handling/positioning - use objective observation (response to what IS happening, not what is expected to happen - use trial and error

Enlarging the toy

- make toy bigger ; easier to see/manipulate - cab just be a part of the to, does not have to be the whole thing - use fish tank tubing or elastic shoelaces instead of of shoelaces - use foam curlers, plumbers insulating foam, bicycle handle bar grips - enlarge using the photocopier/laminate the pieces

Things to acknowledge: Family

- may be overwhelmed - may cause grief reaction - team can help family by explaining rationale for AT

Pre-writing Development

- mouths crayon - bangs crayon - random marks

Reduce response needed

- move toy closer, change ROM requirements, complexity of response - use a tray with a lip (like a cookie sheet) so that toys stay within reach - use plate switch rather than an on/off switch

Why could gagging occur?

- oral hypersensitivity - poor handling - illness - may be full - doesn't like food

Suck swallow reflex persists

- person continues to exhibit the involuntary, reflexive movements an infant (0-5 months) uses to get food. - It is an inward and downward; upward and outward movement of the tongue. - It is accompanied by excessive jaw movements. *This prevents: normal chewing and swallowing or normal drinking and swallowing.

visual and auditory considerations

- put light colored toy on dark cloth - repaint the puzzle so background is only one color - select appropriate play environment

Interventions

- reducing secondary issues - increase self-care

Service coordination

- responding to family needs - develop, implement, revise, monitor IFSP

what can trigger vomiting

- seizures (fevers, brain injury, etc.)

Isolation

- strict isolation - reverse isolation - toys/equipment into the room

family circumstances/ issues

- transportation over time - parent does not make the time or effort

PICU

- traumatic event or surgery - immediate access to medical support, close monitoring

therapy services

- understand the needs of the family - facilitate improved outcomes

hospital-based therapists

- understanding of diagnosis, prognosis, contraindications, implications, of childs problem - child is not there for very long, therapist must be able to work quickly

Children with low tone should still try to stand by age

1-2

Levels of tone:

1-7 1 = no tone 7 = very high tone

Advantages of caster carts:

1. Ability to get on/off independently

Beckman's Corner Lip Stretch - Do both sides 3 times***

1. Align first knuckles of both forefingers at corner of mouth. 2. Press in and move in opposite directions

Oral stimulation

1. All children require oral stimulation for development of feeding skills. 2. Many children who are tube fed can consume food by mouth and should be encouraged to do so if they are physically able. 3. If unable to take food by mouth, some type of oral stimulation is needed such as a pacifier, teething ring or sucking on his fingers. This will help the child to develop skills necessary to begin eating by mouth.

Controlling flow and placement of food (procedure):

1. Always use appropriate equipment and food consistency. 2. Watch the coordination of breathing and swallowing. Make sure that the food or liquid in the mouth is swallowed before giving the next bite/drink. 3. Begin feeding slowly and improve speed as person improves & gains control of food in the mouth. 4. Avoid putting too much food on the spoon and in the mouth. It should be the right amount to help the person swallow.

During an OT Assessment:

1. Analyze movement as it relates to posture and gravity. 2. Determine if dysfunction is delayed, slow to develop, or pathological 3. A/PROM, contractures 4. Positioning log

Referrals form

1. Attending physician at hospital/medical center 2. Community-based physician 3. Physician at a specialty clinic 4. Referral determines services

Beckman's Mini "C" Stretch (middle cheek) ***

1. Begin at the lower corner of the lip 2. With gentle pulling motion, move back toward ear (slide around the gum ridge), up toward the eye, & across the upper lip. 3. Hold for count of 3 4. Do 3 times on each side of face 5. You are going higher up on the cheeks than you did in lower check stretch

Beckman's Lower Cheek Stretch***

1. Begin at the upper corner of the mouth 2. With gentle pulling motion, move your finger up toward the eye,back toward the ear & forward across chin 3. End at the midline of the lower lip 4. Hold for count of 3 5. Do3times 6. Do on each side of the face 7. The intent is to stretch the lower cheek muscles. Therefore, do not go up very high on the cheeks.

How to treat hypoactive gag reflex

1. Brush, tap, touch the uvula, soft palate, posterior sides of the mouth near the tonsils until a gag is elicited. 2. Vary pressure - light touch helps 3. Repeat 3-5 times

Considerations for sitting

1. Can provide head support or not 2. Can provide lateral trunk supports, abductor wedge, adductor support 3. Ideal to have adjustable back, adjustable tray height 4. As child gets older, want foot support available

Getting the Mouth Open**

1. Check the person's position - make sure s/he is aligned 2. Tap lightly on the lips with the spoon 3. Use firm pressure on the lower lip with a utensil 4. Stroke downward at an angle along the smile lines. Begin at either side of the nose and push down slowly toward the corner of the mouth. 5. Place food between the cheek and gum - this may stimulate opening of the mouth 6. Using your thumb, press up and in firmly and quickly on the bony part of the person's chin. When you release, the jaw should drop down (uses "quick stretch") 7. Gently massage the gums from front to back with your finger. Start at the center and move slowly in one direction, until the person opens his/her mouth.

Emphasis in treatment

1. Chewing for jaw control and dissociation of tongue 2. Lip closure for spoon feeding, swallowing and speech 3. Phonation and articulation improve respiration

Sequence in Use of Scissors

1. Child shows an interest in scissors. 2. Child holds and manipulates scissors appropriately 3. Child opens and closes scissors in a controlled fashion. 4. Child cuts short random snips (2 - 3 years). 5. Child manipulates scissors in a forward motion. 6. Child coordinates the lateral direction of scissors. 7. Child cuts a straight forward line. 8. Child cuts simple geometric shapes. 9. Child cuts simple figure shapes. 10. Child cuts complex figure shapes. (5 - 6 years) 11. Child cuts non-paper materials.

Receiving a thorough evaluation for potential aspiration

1. Choke easily on the second or third bite and continue this pattern throughout the meal 2. Congestion increases during feeding. 3. Congestion increases when dairy products are given - allergies 4. Chokes or coughs long after the feeding. 5. Frequently sick because of pneumonia.

Developing scissor skills: prerequisites

1. Construction level in play (attend, cooperate and interact with toys) 2. Open and close the hand and have ROM in fingers 3. Use of both hands to hold and manipulate 4. Eye-hand coordination a. Proximal stability of shoulder, elbow and wrist for smooth, coordinated movement 5. Praxis

Consider the needs of the care provider by looking at:

1. Cosmesis 2. Space needs 3. Ease in putting client in/out 4. Interference with client's social interactions

Tool use: Sequential development

1. Development of grasp and release of objects 2. Calibration of UE in space 3. Re-calibration of UE with introduction of tools 4. Skill in manipulating the tool's working edge

Tongue Thrust:

1. During feeding, place the spoon on the middle or toward the front of the tongue with gentle, but firm pressure for a few seconds until the lips begin to close to remove the food. 2. The jaw should be allowed to open only one-half way, making it difficult for the tongue to thrust itself out. Use jaw control to assist with this. 3. Placing a finger under the child's mandible may assist in decreasing tongue thrust. 4. Use the "law of opposites" better known as quick stretch - using the spoon or toothbrush, stroke the tongue along either side or in the midline from the back part of the tongue to the front of the tongue. Do this 2 - 3 times - most children will respond by flexing the tongue back in the mouth.

Child with athetosis: Treatment

1. Facilitation of graded jaw movement, which will provide stability for the lips and tongue during feeding 2. Facilitation of more rhythmical respiration for sustained phonation and speech and to reduce choking during feeding

disadvantages of prone scooters:

1. Fatigue maintaining head/back extension 2. Head can hit objects (issues with spacial awareness) 3. Hands can get caught in casters or rough surfaces 4. Hard to see above ground level

Gender Differences

1. Girls and boys usually do not cut well until 6 years of age 2. Girls develop earlier than boys due to maturational differences and home practice

Consider

1. Handles 2. Puzzles 3. Enlarging the toy 4. Reduce response needed 5. Remove unnecessary features 6. Visual & auditory considerations 7. Improve safety/durability 8. Keep toys in easy reach 9. Hang up 10. For books:

Child with floppy tone: Treatment

1. Improve trunk control for respiration/phonation 2. Chewing for jaw control and dissociation of tongue 3. Improve oral-motor facial tone for feeding and speech

Occupational therapy includes:

1. Improving, developing, or restoring functions impaired or lost through illness, injury, or deprivation 2. Improving ability to perform tasks for independent functioning when functions are impaired or lost; and 3. Preventing loss of function

Purpose of adaptive toys

1. Increase discovery - promote sensorimotor stage of development 2. Promotes child's success 3. Child can be active participant 4. Increases child's self-esteem, control, enjoyment

Progression:

1. Index finger one loop with other fingers extended 2. Index finger one loop with other fingers flexed 3. Index & middle fingers both in one loop with other fingers extended 4. Index & middle fingers both in one loop with other fingers extended 5. Middle in one loop, other fingers flexed, index not stabilizing 6. Middle in one loop, others flexed, index stabilizing 7. Mature grip - Child size scissors a. Thumb on preferred hand is put into one loop of scissors handle b. Index, middle and/or ring fingers are placed into other loop c. Index finger placed below the bottom loop indicates mature grasp 8. If loops are same-sized a. Thumb in one loop with the middle finger in the other loop b. The index finger remains on out to add stability to the cutting hand

Initiate a "tasting" program in conjunction with oral-motor treatment appears to be better carryover toward oral feeding. How is a tasting program implemented?

1. Introducing flavors on the child's fingers if he can reach his mouth 2. Encouraging hand-to-mouth and toy-to-mouth exploration 3. Introducing thick "pasty" textures on adult finger or spoon to place laterally in mouth to encourage chewing. 4. Using oral control to facilitate vertical chewing helps to organize oral rhythm while facilitating for jaw stability, tongue lateralization, lip closure and controlled movements. (Graham cracker crumbs with adult finger in place laterally on the gums can be effective)

Feedback

1. Kinesthetic, tactile, vestibular, visual 2. Calibration of sensorimotor feedback 3. Recalibration

Disadvantages of Aeroplane mobility devices:

1. Lack of adjustment for growth 2. Difficulty turning corners, moving backwards 3. Heavy

Nondiscriminatory evaluation: Determines eligibility for SPED

1. Look at existing data (classroom-based assessment and observations from teachers/therapist) 2. Initial SPED determination typically completed by teachers/psychologists 3. Evaluation is completed by knowledgeable and trained personnel

Resistive Chewing

1. Make a"chew-bag" using a 4x4 gauze pad. 2. Place chew-bag between the last upper and lower molars. Hold the chew bag at right angles to the jaw. DO NOT allow the chew bag to extend into the mouth due to gag. 3. Press up into the upper molar at a rate of one per second 4. Try for 5 to 10 chews on each side 5. Use jaw support as needed

what are some ways to make child feel more secure with a new feeder

1. Make transitions slowly and smoothly 2. Stick to one new feeder rather than a different one for each day 3. If highly congested, child should receive postural drainage or be suctioned prior to feeding 4. Make sure child's mouth is empty of food following each feeding. Run your finger inside the gums, under the tongue and in the high palatal vault. 5. Clean teeth and gums with a gauze pad dipped in warm water or diluted mouth wash, or brush the teeth if child tolerates.

What to consider when performing an assessment:

1. May need a therapist with special expertise 2. Consider client's age, therapeutic history, physical status, prognosis, and environment 3. End goal: Not just to look good posturally, but that s/he can DO something that is important to HIM/HER.

Beckman's Palatal and Tongue Sweep ***

1. Move brush across the middle of the hard palate with firm pressure from left to right molars. Bristles must point toward the hard palate 2. Continue making a circle by moving the brush across the middle of the tongue. The bristles are still pointing toward the hard palate 3. Repeat 3 times 4. Reverse direction and repeat 3 times

Tongue - Beckman's Lateral Pressure to the Tongue ***

1. Place NUK brush at the side of the middle of the tongue at the level of the first molar 2. Press the tongue quickly & firmly into the middle of the mouth (tongue moves toward other side 3. Immediately move brush back to the gum 4. Do this 3 times 5. On the last one, move the brush all the way into the cheek, stretching it out. 6. Hold for a count of 3

Beckman's Pressure to the Gum Ridge Behind Lower Teeth ***

1. Place NUK brush with bristles pointing down to behind the lower teeth 2. Press firmly & move brush slowly side to side 3. Do 3 times 4. If person does not tolerate moving touch, hold the brush in one area for a count of 3 and gradually increase time

Beckman's Pressure to the Gum Ridge Behind Upper Teeth ***

1. Place NUK brush with bristles pointing to hard palate behind the front teeth 2. Press firmly & move brush slowly side to side from eye-tooth to eye-tooth 3. Do 3 times 4. If person does not tolerate moving touch, hold the brush in one area for a count of 3 and gradually increase time

Beckman's Resistive Lip Stretch***

1. Place NUK toothbrush #2 under the corner of the upper lip in front of the gum with bristles pointing toward lip 2. Move brush out & down, stretching lips lightly 3. Hold downward for 1 second as lip resists movement 4. If no lip resistance occurs, place finger over the lip to assist in movement of the lip out & down 5. Move brush out & over 1/4 inch and repeat continuing across the upper & lower lips at 1/4" intervals

Beckman's Gum Massage (Helps relax tonic bite) ***

1. Place finger firmly on upper gum in center of the mouth 2. Slowly move finger across gums toward molars 3. When finger is behind the last molar, move it down to the gum behind the last lower molar 4. Continue moving finger across the center of the lower jaw 5. At center of lower jaw, move across gum to the opposite side of the mouth to the last molar 6. Then move to upper molar and back to the starting point 7. Do this 3 times

Beckman's Lip Curl and Stretch***

1. Place finger on lip and thumb under lip 2. Pull lip out and curl it up over finger 3. Hold lip in this position for 1 second and stretch upper lip down. 4. Repeat at 1/4 inch intervals around upper and lower lips, including corners. 5. For lower lip, hold the lip in the position for 1 second and stretch lower lip up.

Beckman's Horizontal Lip Roll***

1. Place finger on lip, thumb of same hand under the lip 2. With firm pressure, roll thumb back and finger forward in horizontal direction (small movement) 3. Reverse the movement using firm pressure so the thumb moves forward and finger moves back 4. Slide both fingers forward 1/4 inch and repeat steps 2 and 3 5. Continue around upper and lower lips, including the corners, placing the finger on the outside and the thumb on the inside as you move across the lower lip.

Beckman's Side to Side Lower Lip Stretch - Do 3 times***

1. Place forefinger against lower lip, pressing in and up 2. Move lip slowly & firmly side to side

Beckman's Side to Side Upper Lip Stretch - Do 3 times***

1. Place forefinger against upper lip, pressing down and in 2. Move lip slowly and firmly from side to side

Swallowing - Beckman's Pressure to the Tongue Base (assists with swallowing) ***

1. Place open hand with forefinger against the bottom of the chin and press up in light, rapid strokes so the chin "jiggles" 2. OR rock the hand from side to side, maintaining upward pressure 3. Do it for 5 seconds

Beckman's Upper Lip Stretch - Do 3 times***

1. Place thumb and forefinger at top of smile lines 2. Press firmly, move fingers down to just above upper lip 3. Move fingers apart so lip stretches out (fingers do not slide) 4. Bring fingers back together, holding middle of upper lip between them 5. Pull the center of the lip down over the bottom lip

Beckman's Lower Lip Stretch - Do 3 times***

1. Place thumb and forefinger beneath center of the bottom lip 2. Move fingers apart so lip stretches out 3. Bring fingers together, holding middle of lip between them 4. Pull lip out away from gums. Pull center of bottom lip up.

Tool use: Position of hands and scissors

1. Position of thumb, position & number of fingers 2. All have thumbs in one loop 3. Progression

Advantages of Aeroplane mobility devices:

1. Reduces muscle tone because child is positioned in hip abduction & knee flexion 2. Relative ease of viewing environment 3. Looks handmade (not commercially available) 4. Looks more like a toy, so parents may like it better

Tongue elevation treatment:

1. Sticky food (peanut butter) on roof of mouth 2. Place peanut butter on the roof of the individuals mouth using the tongue depressor or spoon. 3. Verbally give directions to remove the substance if necessary. 4. Physical assistance may be necessary. If so, use the tongue depressor to give needed assistance.

Program Evaluation

1. Students with disabilities are included in district and state assessments or alternate methods identified 2. Performance goals and outcomes given (report cards on IEP goals) 3. Results reported to the public

Tonic Bite Reflex Treatment**

1. Use small plastic covered metal baby spoon or Mothercare spoon. 2. ***Do not pull on the utensil - this will only worsen the bite reflex 3. Check alignment - Person's head and trunk should be upright with chin tucked - move head gently into flexion if it is extended. 4. Press in on the utensil, quickly and firmly 5. Stroke down on the smile lines (see #4 with opening the mouth) 6. Massage the gums from front to back 7. If child clamps down on spoon, wait until jaw is relaxed before removing or push up on the jaw to facilitate its opening. 8. Use a small spoon as large spoons tend to stimulate the bite reflex.

How to treat hyperactive gag reflex

1. Use tongue depressor constructed of non-splintering material or toothbrush handle. 2. Walk down tongue, beginning at tip and applying firm but gentle pressure with tongue depressor. 3. At point of gag, close mouth, a swallow should follow. 4. Repeat 5-7 times.

Beckman's Stimulation to Middle of Tongue ***

1. With NUK brush, bristles pointed toward the palate, press up into the hard palate 2. Press down on to the middle of. the tongue 3. Repeat up/down movement 3 times

Beckman's Lip Fold and Stretch***

1. With forefinger, lift the inner edges of the upper lip out and up 2. Firmly press the folded lip in and down, hold 1 second 3. Repeat at 1/4 inch intervals around upper and lower lips, including corners.

Tongue retraction treatment:

1. With spoon or toothbrush, 2. Use the "law of opposites" better known as "quick stretch" 3. Using the spoon or toothbrush, gently push the tongue tip/blade further back into the mouth 4. Provide support to the tongue base (Beckman's exercises #13). This helps bring the tongue forward passively. 5. Place food between the cheek and gums - as the child tastes the food, the tongue usually comes forward

Beckman's Upper-Cheek Stretch ***

1. With thumb & forefinger, press firmly at both sides of the base of the nose (Point X) 2. Move finger in small circular direction, first moving out away from the nose & then moving in toward the nose. 3. Continue for 5 to 10 seconds 4. Reverse directions 5. Do on each side of the face

After ordering the AT:

1. build 2. delivery 3. provide training (for anyone and everyone involved) 4. schedule follow-up

When coloring, note:

1. color 2. lines 3. grasp

Factors that influence use of mobility devices

1. fit 2. the device 3. physical and social environments 4. efficient access to the device 5. future changes must be considered 6. use of augmentative communication equipment 7. family makes final decision

shape progression

1. horizontal line 2. vertical line 3. circular 4. circle 5. cross 6. Right to left diagonal 7. Left to right diagonal 8. Square 9. X 10. Triangle 11. Diamond

Advantages of prone scooters:

1. increase play on floor 2. ability to get on/off independently 3. ability to change direction easier

Typical settings

1. medical centers 2. regional AT centers 3. IP rehab facilities 4. public schools

Normal chewing pattens:

1. munch 2. vertical 3. diagonal 4. rotary chewing movements *Full dissociation of jaw from head movement.

Classification of mobility skills

1. people who will never ambulate - independent mobility is not possible except by power w/c 2. People who have lost independent mobility include trauma or progressive neuromuscular diagnoses. the issue is the acceptance of assisted mobility as an adaptation to the diagnosis 3. people that require assisted mobility temporarily and most often progress to independent mobility - Includes osteogenesis imperfecta or arthrogryposis - Functional considerations are developmental and practical

When positioning for device:

1. start at BOS 2. May be tempting to place a client in piece of equipment to see how it "fits" 3. once in equipment, client initially may look well-supported

Order of operations for development of mouth:

1. tongue 2. jaw 3. lips

To stimulate huger, calories given by tube should be reduced by ____

25% (be sure this is approved by medical professional prior)

re-eval further tube feeding when child takes more than

50% orally

at about _______ months child will get weaned off of tube

6 months (this is a team decision)

Maintaining toys

A. Check moving parts B. Check for weak parts, splits in seams C. Sand edges if splintered D. Check for peeling paint E. Look at wires F. If the toy has a heating element, generally use for over age 6 only G. Watch battery operated toys

Chewing and swallowing

A. Chew gum for 5 minutes B. Bend head back as high as possible, try repeating the letter sound "K, K, K," 5 times, then bend head back to mid position and swallow. Say AH-H-H - Abruptly several times.

Purchasing toys

A. Consider child's developmental level, interests B. Look at the labels, directions C. Consider the cost

Child with floppy tone

A. Facial expression reduced B. Mouth is open (mouth breathing) C. Lips are floppy and tongue is clumsy in moving vertically and laterally D. Swallowing occurs without mouth closure E. Chewing movements are weak F. Soft food is suckled with tongue in forward position G. Drinking with little upper lip movement H. Movements of speech apparatus reduced in quantity I. Drooling is present

Child with athetosis

A. Facial grimacing B. Poor dissociation of tongue/jaw (during walking, turns head to talk) C. Poor timing of oral movement D. Often asymmetrical facial movement (jaw)

Preliminary activities to help in the transition from tube to oral feedings:

A. Identify factors interfering with oral feeding B. Establish adequate caloric intake via tube C. Facilitate more normal postural tone and alignment (positioning) and oral-facial tone. D. Improve respiratory control. E. Normalize response of the oral cavity to sensory stimulation. F. Develop oral sound play where indicated. G. Encourage non-nutritive sucking during tube feeding, and at other times if appropriate.

Therapeutic toys

A. Needs to stimulate interest, but not be too difficult B. Be aware of the child's personality - mood, tone, affect C. Be aware of YOUR clothes, fragrances, etc. -

Jaw and neck exercises

A. Open and close jaw slowly B. Bend head forward trying to touch chin to chest, roll head slowly in circles to right & left C. Stretch neck up with chin as high as possible. Open and close jaw several times.

Toy safety

A. Pieces should be nontoxic, sturdy, well-constructed B. Watch for sharp edges, choking hazards C. Watch for breakable toys, toys with many moving parts D. Watch for removable parts - small enough to go in the mouth? E. Protect objects from sticky fingers or drool

Tongue exercises

A. Protrude tongue. "Wipe the ice cream" off mouth by licking upper lip, lower lip, the corners of the mouth. B. Push tongue into cheeks - and stick tongue far out. C. Push tongue up against spoon handle.

ADAPTIVE EQUIPMENT POSITIONING & BIOMECHANICAL FORCES

ADAPTIVE EQUIPMENT POSITIONING & BIOMECHANICAL FORCES

ADVANCED FINE MOTOR SKILLS

ADVANCED FINE MOTOR SKILLS

Sucking Treatment:

Activity: resistive sucking Purpose to improve weak sucking (use thicker liquids intermittently)

conditions requiring hospitalization

Acute burns Come infectious diseases -encephalitis, meningitis Bone marrow transplants - leukemia

FAPE definition

All children with disabilities receive a free appropriate public education that emphasizes special education and related services designed to meet their unique needs and prepare them for employment and independent living.

Continuous tube feeding

Allow formula to be admin at lower rates, usually 1.5 ml/min over a longer time usually 12-24 hours. delivered by gravity flow system or an electronic feeding pump

Mobile stander

Allows LE WB while moving

Gravity dependent tube

Amount of nutrients depends on gravity

Autism:

Autism: developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child's educational performance.

Softer mats are...

Bad for positioning; use a firmer mat when possible

Independent Feeding Development: 12-14 months

Brings full spoon to mouth but turns spoon over losing food

Independent Feeding Development: 2 months

Brings hand to mouth in prone or supine

Independent Feeding Development: 3 months

Brings hands to mouth when holding object

Independent Feeding Development: 24months

Brings spoon or fork to mouth while supinating

CHARACTERISTICS OF NORMAL AND ABNORMAL ORALMOTOR PATTERNS

CHARACTERISTICS OF NORMAL AND ABNORMAL ORALMOTOR PATTERNS

4 years

Can fix cereal or snacks

9 years

Can make simple meals

30 months

Can pour from small containers

Independent Feeding Development: 9 months

Capable of finger feeding some of meal Eats mashed or soft table food Hold or bangs spoon Objects food fed to them by others Imitates stirring with spoon

Social environment:

Caretaker can hold, talk and play with child during feeding.

Who should be tube fed?

Children: 1. unable to meet 80% of caloric needs by mouth 2. No weight gain or weight loss for 3 months. 3. Weight/height ratio less than 5th percentile. 4. Triceps skin fold less than 5th percentile for age. 5. Total feeding time greater than 4-6 hours per day.

DISCHARGE CRITERIA

DISCHARGE CRITERIA

Learnability

Ease of assembly, initial learning requirements, time & effort to master?

1975: PL 94-142

Education of the Handicapped Act (EHA)

Considerations for specific types of AT

Effectiveness Affordability Reliability Portability Durability Securability Safety Learnability Comfort & acceptance Maintenance & repairability Operability

FEEDING ASSESSMENTS

FEEDING ASSESSMENTS

FEEDING INDIVIDUALS WITH DISABILITIES

FEEDING INDIVIDUALS WITH DISABILITIES

Disadvantages of caster carts:

Fatigue from pushing self (small wheels) Children with LE tightness may not be able to sit on cart

Positioning devices should be:

Fitted to the client; the client should not be fitted to the device

Diced

Food cut into small pieces

Criteria; what should you get prior to feeding interventions?

Get clearance from doctor prior Get together with nutritionist

What may enhance feeding?

Good hygiene

Independent Feeding Development: 6 months

Gums hard food (crackers)

Effects on functional performance

Hand function - eating Levels of independence in mobility Self-care: personal hygiene Transfers Social interaction with others

Edentulous

Having no teeth

Independent Feeding Development: 12 months

Holds and drinks from cup and spills Holds cup to drink

Independent Feeding Development: 5 1/2 months

Holds onto bottle immediately

Independent Feeding Development: 4 1/2 months

Holds onto bottle with hands with assist

Active face & mouth exercises

I. Yawning II. Blowing A. Blow a Kleenex across the table B. Blow out a match C. Blow a small whistle III. Lip exercises - Ice around lips - Dry with towel A. Pucker the lips B. Smile broadly and then pucker lips C. Bite lips between teeth then grin broadly D. Pucker lips - twist to left and then to right

state institutions

ID (was MR)- DD; ICF-ID (was MR) group homes state institutions

2004:

IDEA aligned with NCLB

IFSP is similar to ...

IEP - includes family-related info - their resources, priorities,

INTRO TO ORAL FEEDING

INTRO TO ORAL FEEDING

IFSP

Individualized Family Service Plan

1990: 101-476

Individuals with Disabilities Education Act (IDEA)

Nutritive sucking:

Infant/child is receiving nutrition

Nonnutritive sucking:

Infant/child is sucking on a pacifier or something similar. The rate tends to be higher in nonnutritive sucking.

Suckling:

Infantile method of sucking that involves extension-retraction movement of the tongue (sucking and licking) Seen at 5-6 months Lips are not closed at this point (poor lip closure)

Lip closure:

Lips open and close smoothly and easily to both take food off the spoon and to hold the food in the mouth while chewing and swallowing.

5 years

Makes sandwich

Effects of physiologic factors

Motor performance Postural control ROM Muscle tone Endurance Comfort Respiration Digestion

2001: NCLB

No Child Left Behind. Close the achievement gap Implement yearly testing; grading schools came in. *all children have the right to good education*

Hearing Impaired:

No legal determination; not enough hearing to understand speech

Olfaction in feeding:

Normalize the olfactory response so child will understand the "smell of food"

ORAL MOTOR INTERVENTION

ORAL MOTOR INTERVENTION

OG tube

Oral gastric tube - a plastic tube inserted through the mouth, past the throat, and down into the stomach similar to NG tube

OD tube

Oralduodenum tube

PEDIATRIC SETTINGS

PEDIATRIC SETTINGS

PUBLIC LAWS

PUBLIC LAWS

Independent Feeding Development: 4 months

Pats bottle or breast with hands

PEG

Percutaneous endoscopic gastrostomy tube (tube in stomach) *not permanent*

Pace

Progress = slow may be there for months or years may be there for vocational training family may or may not be involved

Children's hospitals also have these specialty units

Psychiatric unit Rehab unit

Selection depends on:

Purpose & reason for the device Indoor/outdoor environment Effort needed to use the device Positioning needs

Rumination:

Regurgitation food from the stomach back into the mouth (as cows, chewing the cud)

Caster carts:

Requires use of arms, ability to sit with support Use indoors or on flat outdoor surfaces

Aeroplane mobility device

Requires use of legs, arms rest on "aeroplane"

Independent Feeding Development: 15-18 months

Scoops food and brings to mouth with some spilling

Outpatient care

Services are provided for 3 reasons 1. As part of the diagnostic assessment 2. Provide intervention after hospitalization 3. Provide intervention for long-term disabilities/chronic conditions

TUBE FEEDING

TUBE FEEDING

Sensory Aspects

Taste, Texture, Temperature

Jaw retraction:

The jaw is pulled back toward the throat such that the molars do not make contact. It is usually caused by hypertonicity. This tension makes chewing very difficult and makes it impossible to develop advanced chewing skills. *might be associated with micrognathia.*

Phasic bite

The jaw opens and closes in response to oral stimulation. No abnormal tone is present.

Jaw Thrust:

The jaw suddenly, moves into strong extension. The tone is such that the child cannot close the mouth. This is what is different from a normal infant.

Therapy in the public schools

Therapy must support the students ability to benefit from an education - services must be educationally relevant - services are not rehabilitative - disease and dysfunction are not as important - a student may qualify for therapy in the outpatient clinic, but does not qualify in the public schools

Tongue extension:

Tongue is able to extend past both lips, includes being able to lick food off of the lips and between the front teeth/gums and the cheek.

Tongue elevation:

Tongue is able to move up to the roof of the mouth and can come back down independent of movement of the jaw or lips.

Tongue tip elevation:

Tongue tip is able to move to the hard palate and back down independent of the rest of the tongue, jaw or lips. This pattern typically begins to develop at 9-12 months and continues to develop to 24 months.

Tongue lateralization

Tongue tips moves to either side of the mouth to get food positioned in cheeks or between gums and cheeks.

restoration:

Treating deficits to get child back to PLOF Adaptations? AT?

Alternative powered mobility

Tricycles (provide mobility outdoors, in hallways. can get trunk support, hand propelled models) - not usually funded by insurance.

Independent Feeding Development: 7 months

Tries to feed self cracker, but sucks on it more than bites

T or F: If tube feeding child should be given medication through a tune.

True

T/F: children with sensory issues associated with food, may not like multiple textures on one food.

True (burger w/ cheese)

Gastrostomy button

Used because it is less bulky and more comfortable than an external tube. Flat on the child's abdominal wall and connects to tube that leads into child's stomach *more permanent option*

30-36 months

Uses fork to stab food

Formation of the bolus:

Using primarily the tongue (and teeth) to bring chewed food together prior to swallow. The bolus assists in swallowing all of the food at the same time.

Therapy

Usually in therapy room on floor May go to OT/PT department if need spacial equipment restricted visitation

A person needs to have a minimum of a ____________ __________ ________ to eat diced food

Vertical bite pattern

Lip Closure**

Vibration of lips to encourage closure 1. Place vibrator on lips so that the vibration causes lips to purse. 2. Repeat 3 or 4 times. 3. If individual opens mouth and attempts to suck or bite vibrator, allow this to happen. 4. Vibrate surface of the tongue if individual allows this to happen. 5. Use lip support only

Independent Feeding Development: 3 1/2 months

Visually recognizes bottle or food

Troubleshooting

Vomiting (poor alignment, swallowing air, eating too fast)

Bite Reflex or Tonic Bite Reflex:

When a person involuntarily clamps his jaws shut on a spoon, finger or other object placed in his mouth. It is usually seen in conjunction with a suck-swallow reflex.

Jaw Instability:

When a person's lower jaw either moves or remains open as they swallow. Their tongue may not move. Their mouth remains open at rest. This may be evidenced either alone or in conjunction with the suck-swallow reflex or tongue thrust.

Kinesthetic, tactile, vestibular, visual

a. Child plans the position of the paper with one hand b. Child plans the position of the scissors with other hand

Swallowing Treatment **

a. Child should be in slightly flexed posture as tilting head will passively assist swallowing, but has no training value. In passive swallowing tongue does not learn control of patterns. b. Place food between the cheek and gums c. Place food between the upper and lower back teeth. This gives the person the idea that food is in the mouth Do not use this technique if a person tends to bite down on utensils. d. If child allows food to accumulate and sit in mouth, use thumb pad to press firmly up under the chin at the base of the tongue. e. Use firm smooth pressure, holding the tongue base up momentarily, and repeat if swallowing does not follow first attempt. f. Use lip support - it is very difficult to swallow with an open mouth g. Relax handling after each swallow

Cognitively

a. Extremely important for Piaget's sensorimotor stage of development b. Foundation for pre-operational, concrete, formal operations stages c. Emphasize turn-taking d. Emphasize cause and effect

Physical and Health Impairment

a. Orthopedic or neurological impairments: CP, Spina Bifida, Muscular Dystrophy, Osteogenesis Imperfecta, Spinal Cord Injuries, Head Trauma, Amputations b. Chronic illness and other health-related conditions: Seizure disorder (Epilepsy), Diabetes, Cystic Fibrosis, Hemophilia, Burns, other

Socially

a. Play fosters individual child contributions b. Emphasizes sharing, taking turns c. Social skills are enhanced through acting of various roles

Physically

a. Play promotes gross & fine motor skills b. Play increases strength, ROM c. Play teaches child about their body d. Play promotes praxis

Types of children/diagnoses in the hospital

a. Single injury b. Acute illness/injury c. Chronically ill d. Diagnostic testing or medication adjustment

Recalibration

a. Somatosensory and visual information modulate and adjust muscular effort to compensate for added weight and length of tools

Speech-Language Impaired (Communication Disorder)

a. Speech Impairments: if speech is unintelligible, abuses the speech mechanism, or is culturally or personally unsatisfactory (Articulation disorder; Voice disorders; Fluency disorders) b. Language Disorder: serious difficulty in understanding language (receptive) or in expressing themselves through language (expressive)

Other activities:

a. Tongue press using tongue depressor, plastic covered metal baby spoon or toothbrush 1. Use the "law of opposites" better known as "quick stretch" 2. Facilitate by pressing the tongue depressor intermittently against the lateral surfaces of the tongue and gently pushing the tongue towards the other side of the mouth. 3. Both sides should be stimulated several times. 4. Tongue should attempt to push against spoon.

Emotionally

a. Toys may serve as a frustration outlet b. Play allows the child to work through feelings c. Play promotes positive emotional growth d. Play allows the child to develop control of environment

Calibration of sensorimotor feedback

a. Weight and distance of an arm or leg in space. b. Helps to localize hand in space during fine motor activity.

Micrognathia

abnormally small jaw; undersized mandible. Not related to too much tone.

TBI (traumatic brain injury)

an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; and speech. The term does not apply to brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma.

These tubes are also common in children who

are in a coma to limit calories expended during feeding

Goal:

associate sucking or chewing with satiation in order to ease the transition from tube to oral feeds.

Abnormal jaw pattern/bite pattern =

bite reflex or tonic bite reflex

Affects of gravity on a person: mechanical level

body learns how to adjust

treatment for gagging

calmly and quickly move person forward bring head to midline (is the person ill?)

Prolonged stay

child may recieve therapy 1-2 times educate the family

Before laws were put into place...

children with disabilities were denied access to public schools. If these children were in class, they just sat and did nothing. Parents were unaware if children were in special ed.

"draw a circle, draw a square" requires

cognition

Pica:

compulsive eating of nonnutritive or non-edible substances

treatment:

correct alignment

Durability

delivers continued operation for extended periods?

Reliability

dependable, consistent, predictable performance?

Any hospital - consider child's

developmental level, needs, impact of illness or injury, coping strategies, family needs 1. where do they live 2. link to local resources restrictive visitation

types of children and families

developmentally delayed or at risk for disability babies/kids with respiratory, cardiac, feeding problems

Specific Learning Disabilities:

disorder in 1 or more of basic psychological processes involved in understanding or using language, spoken or written, which may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or to do mathematical calculations.

Effectiveness

does the AT improve function/independence?

Maintenance and fixability

easy to maintain & repair?

Operability

easy to use, adaptable & flexible, affords easy access to controls/display?

General goals of positioning

enhance the development of postural reactions by reducing the demand of gravity and by alignment of the body (stable body)

OT

evaluation/assessment - functional skills levels potential?

Seriously Emotionally Disturbed (SED):

exhibits one or more of the following characteristics over a long period of time and to a marked degree, which adversely affects educational performance: a. An inability to learn which cannot be explained by intellectual, sensory, and health factors; b. An inability to build or maintain satisfactory interpersonal relationships with peers and teachers c. Inappropriate types of behavior or feelings under normal circumstances d. A general pervasive mood of unhappiness or depression e. A tendency to develop physical symptoms or fears associated with person or school problems

extended medical ventilation

extended mechanical ventilation - equipment management - watching TcPO2 monitor - MR, RR, BP monitor - feeding tubes -IVs

Normal tongue movement includes:

flexion, extension, lateral excursion, and circumduction

Normal jaw movement includes

flexion, extension, some jaw lateral excursion, diagonal, and rotary movements.

Normal lip movement includes:

flexion, extension, spreading, adduction, rounding

OT goals

functional measurable influenced by family is and environment important to know (this will help you understand the needs of the child)

Hyperactive gag reflex

gags very easily (happens at the front half of the tongue or lips)

Home health / home based

growing area of practice setting is included in public law for 0-2 years home bound kids in school

During swallowing, there is a lack of mouth closure,

head extended, and the movements are slowed down, or blocked

Affects of gravity on a person: physiological level

helps body adjust to gravity

Real marks: order progression

imitate copy draw

Problems with ICU environment

immobility, need for bed rest - decreased endurance, generalized weakness, poor tolerance for sitting -intervention includes positioning recommendations, splints, AT, grading activities

Suck-swallow reflex:

implies child must suck before initiating a swallow (no dry swallowing)

Toy selection

important as it impacts a child's values and needs

Improve safety

laminate paper items reduce unnecessary stuff

Visually Impaired

legally blind (visual acuity is 20/200 or less in the better eye, even after the best possible correction OR visual field is restricted to an area of 20 degrees or less) a. Educational definition looks at how student makes use of whatever vision s/he has

Medication can be:

liquid from (by mouth, IV, tube), crushed up into food (applesauce), chewed

Prior to manipulating the gastroscopy, confer with __________ _________

medical professional

Child with spasticity will have ____________ facial expression

minimal

NG tube

nasogastric tube - inserted through nose, past pharynx and esophagus, into stomach used for feeding and/or administering drugs, or emptying the stomach *used most often*

NJ tube

nasojejunal tube

How can you tell how sick a child is?

nursing ratio - 1:1 = very sick 1:2, 1:3 less sick

IP rehab facilities

o Assessment and intervention roles o Teams present o Advantage: Can order ahead and teach client to use it!

Public schools

o Most widely used setting for providing AT services for children o Child uses device in natural setting (attend daily) o Team members may not be the "expert" in AT o Collaborate with medical or regional centers

Medical centers

o Predominantly an assessment role o May complete in 1-2 visits o Make recommendations for specific equipment to other agencies or 3rd party payers o Limited access for: follow-up, consult with teacher, consult with family

Regional AT centers

o Some states have these or AT lending libraries o Teams have broad experience with various diagnoses, ages, resources, types of AT, adapted methods of AT use o Most include AT advocacy, consumer awareness, focus groups o Some have limited follow-up once child receives device, may have limitedtraining for child/family/team

Things to consider when toileting include:

o Transfers? o Undress/dress? o Stable once seated? o Relax enough to void? o Clean self?

Preparation:

offer three large and 2-3 small bolus feeding each day. this allows child to feel hunger

_____________ ____________ is extremely important when feeding

parental support

Chronic illness

periodic hospitalization for acute episodes

Comfort and acceptability

physically comfortable, no pain, aesthetically pleasing?

OT intervention:

prevent secondary disability, restoration of function - exercise - skin care - safety/ stress reduction

function of therapy

prevention: disease likelihood of accidents improvement in affected areas

Safety

protects user, care provider, family member from potential harm, injury, infection?

Early intervention

public law - developmental delay (25% delay) - biological delay (ex: grade four hemorrhage, down syndrome) - environmental risk

Affects of gravity on a person: physical level

pull towards earth (tends to fall down)

Affordability

purchase, maintain, repair without financial hardship?

acute rehab - 3 needs

recovery and rehabilitation of child with rapid onset disorders redirect care for children experiencing complications for chronic disorders environment for specialized medical and surgical procedures

Intellectual Disability Mental Retardation:

refers to significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior, and manifested during the developmental period. a. Adaptive behavior: the effectiveness or degree with which the individual meets the standards of personal independence and social responsibility expected of his age and social group

Prone scooters

require use of arms, ability to lift head

acute illness/surgery

requires extended rehab

Securability

secure from theft/vandalism?

Single injury

short stay predictable treatment course

Portability

size & weight allow user to carry, move, relocate, operate in variety of locations?

why could coughing and choking occur

soar throat, excess mucus, poor respiration, aspiration

During chewing, the food is

squeezed against the roof of the mouth

Puzzles

stability - double-sided tape - dycem - plastic suction cups - c-clamps - attach to a surface using velcro or sticky putty

High tone

stiff and resistant to stretch

early intervention principles

support services should be given to all based on needs of child and family on-going

Prone stander:

supporting surface is along ventral side (requires child to hold head up on own or head can rest on tray)

Supine stander:

supporting surface of stander is along dorsal side (can come with head support)

Types of taste:

sweet, salty, sour, bitter, umami

evaluation

team and family develop IFSP within 45 days of eval

Velum (soft palate) is ______

tense

Child with spasticity will have ____________ lips

tense (mobility reduced in the upper lip)

Hypertonicity

the lips are pulled into a thin, compressed line. It is often too difficult to see the lips. This is called lip retraction and/or purse-string action of the lips.

Hypotonicity

the lips do not move in response to stimulation.

try introducing __________ __________ first

thick liquids (gradually reduce thickness)

consider handles

too short - use garden bamboo to make pencils longer - can buy long handled paintbrushes at art supply store

age range for state institutions

typically about 7-8 years to 90+

treatment of coughing and choking

use Heimlich move body and head slightly forward

resumption:

using available skills & independence in easy tasks help get optimum independence grading can be used

Diagnostic testing or medication adjustment

usually not admitted unless needing anesthesia

Child with spasticity will have trouble with ________ and _________ tongue movement.

vertical and lateral

Crawler trainer

want almost full elbow extension, hip 90 degrees, knees 90 degrees

meet _________ needs of the child

water

Defines educational programming: Sec 614(b)(3)(D):

xassessment tools and strategies provide relevant information that directly assists persons in determining the educational needs of the child 1. Assessment scores have been de-emphasized - unnecessary testing is eliminated 2. Less emphasis on label driven services, more on educational need

Walkers

• Hand-held walker - either held in front or behind the child (posterior walker) Posterior walker can lock its casters when child leans back on it. • Support walkers • Child needs some ability to move legs reciprocally, but also needs support at pelvis, chest, maybe UEs and head Can get abductor wedge to prevent adduction Adjustable pitch - leans upper body slightly forward • Feet are behind pelvis & trunk, increasing ability to move forward Can also get walkers with upper body support (trays)

Things to look at - Appropriate positions to enhance function

➢ Look at developmental progression of posture skills ➢ Look at effects of gravity and sensory stimulation ➢ Where did dysfunction occur? ➢ How dysfunction affects goal achievement? ➢ Explore positioning options that are most effective ➢ Handling identifies postural responses in different positions ➢ Look for compensatory movements during handling/positioning ➢ Use objective observation ➢ Respond to what IS happening, not what is expected to happen ➢ Use trial and error ➢ Provide control centrally first ➢ Frees distal parts of the body from assisting the trunk and from the influence of associated reactions. ➢ Proximal stability promotes distal mobility ➢ Use gravity to the client's benefit ➢ May reduce the need for more intrusive pieces of equipment ➢ Modification of client's sensory environment