Q&A with Gwen

QUESTION: New Protocol for Weighted Vests?

QUESTION:

Are there any new protocols for children wearing weighted vests?

GWEN’S ANSWER:

I am not aware of any new protocols for the wearing of weighted garments. The general recommendation is up to 10% of the child’s body weight in the vest to be left on for 20–50 minutes at a time and then removed for at least that long. I only recommend them for kids whose sensory assessments show they are actively seeking more proprioceptive input and who have normal muscle tone. For kids with low muscle tone, I feel like compression garments are more appropriate rather than weighted ones. I hope that helps!

Best Wishes,
Gwen

QUESTION: Two Families with Three Head Bangers?

QUESTION:

A colleague suggested I get in touch with you about head banging. I have a couple of children that do this. One is a 7 year old that bangs his head to go to sleep. He has done this since he was an infant. He also will only sleep on the carpet. If he is not near something he can bang his head on, he will move to something. He is verbal and maybe low average IQ. His parents are concerned but maybe not committed enough to do brushing.

The second child is a 2 year old. Let me preface this by saying that there are other children in the home and mom is very overwhelmed. He will bang his head to the point of bleeding. We are going to try to get mom to keep a journal to see if we can get insight about when this is happening. We do know that he is sensitive to sounds. We tried brushing one day, and he immediately withdrew from the brush. He does have an average or above average vocabulary. He is not seeing a behavior interventionist. I’m not sure this mom would be committed to trying brushing either, but we are going to offer it to both families. We are going to have them Google some information about it, which will help us know how committed they are, to see if they put forth the effort to do this.

Head banging is definitely an area of weakness for me, and I could really use any information that you can share whether it be websites or just things to try. I really appreciate anything you can offer.

GWEN’S ANSWER:

Head banging, as well as all self-injurious behaviors, can be difficult to treat for two primary reasons:

  1. There are many causes of head banging, so until we determine the cause, it’s difficult to intervene.
  2. Even if the cause is sensory related, we cannot safely match the intensity through alternative strategies equivalent to what they are providing themselves through head banging.

On the Sensational Brain website, we a handout on treating head banging from a sensory perspective. For more in-depth information, we do have a webinar available on this topic:

https://www.sensationalbrain.com/shop/view-on-demand-webinar-self-injurious-behaviors-2/

I hope that helps!

Best Wishes,
Gwen

QUESTION: Integrating Fine Motor and Motor Planning Skills?

QUESTION:

I’d like to get your thoughts on a boy I’ve been treating privately since October 2015. I wrote to you about him nearly 8 months ago because of his regulatory issues. He’s doing so much better with that, but he has significant motor planning, visual motor, fine motor, and postural issues. He is not on the spectrum but might have the weakest skills in the above areas of a child not on the spectrum that I’ve ever seen. He is at least average if not high average cognitive ability.

Basically, any activity we do that requires him to assume a position is difficult. So, if I have him in prone position in the net swing with a cushion in it, he cannot extend his arms forward with elbow extension. If I have him cross sitting opposite me and have him imitate me clapping my hands like a seal, he has a very hard time knowing how to position his hands. I made some fish and a hook out of pipe cleaners and showed him several times how to hold the hook to catch the fish, but he kept turning the hook the wrong way. If I work on drawing any kind of line or shape, I have to separate the actual fine motor from the motor planning skills.

So I might have him draw a line or a shape in frosting, chocolate pudding, or foam soap, and he can usually do it, but as soon as I give him a small crayon piece to draw on paper, he has difficulty holding the crayon and can’t control it enough to draw a shape.  As you can see, he can’t integrate fine motor and motor planning skills at all. Again, he’s doing better at the tasks when I separate them out, though he still needs lots of demonstration and practice. Usually, when I’ve been working with children for this long, they really start to improve and put it together.

Do you have any suggestions at this point? Thanks for any ideas and help.

GWEN’S ANSWER:

This child does seem to have severe dyspraxia. Here are some suggestions:

  • Dyspraxia is typically rooted in poor body awareness. Lots of heavy-duty proprioceptive and calming vestibular input (linear, rhythmic) prior to motor planning tasks may help.
  • The Spio products (http://www.spioworks.com/), compression garments, and weighted items (wrist and ankle weights) may be helpful as they give the body more input about where the body parts are in space. If he has low tone, opt for compression rather than weighted garments.
  • Test for the presence of primitive reflexes. Some of the issues you describe may be improved through reflex integration exercises.
  • Since development happens in a proximal to distal manner, focus your treatment on his core and gross motor planning to stay at the just-right level of intervention.
  • While you are focusing on the development of proximal muscle control, he may need adaptations and modifications in place in his educational environment depending on his age/grade.

I hope this helps!

Best Wishes,
Gwen

QUESTION: Criteria for exiting sensory breaks/tools intervention?

QUESTION:

One of our building teams that is participating in the PPSC (PBIS) grant is working on defining their Tier 2 supports. They are listing sensory breaks or sensory tools as Tier 2 intervention. Within the system, they are working to define:

  • Criteria used to determine which students should get sensory break/tools intervention
  • Data to track students’ progress, and
  • Criteria that would determine when students can appropriately exit this support/intervention.

What criteria would you typically recommend to determine that a student no longer needs a sensory break or sensory tools.

GWEN’S ANSWER:

That’s a tough question! My initial thought is that ALL kids really need sensory breaks. Integrating movement into the classrooms may alleviate the need for Tier 2 intervention for most kids. But if that is already happening, and some kids need more than what the general education classroom is getting, here would be my suggestions:  Criteria to determine need for sensory support:

  • For kids having difficulty with staying on task, you may want to have teachers fill out the sensory symptoms checklist. If it indicates kids are seeking vestibular or proprioceptive input, movement breaks would be indicated.
  • If the checklist indicates over-responsiveness to auditory, visual,or tactile, sensory tools such as noise-reduction headphones, etc. may be indicated.
  • Progress tracking . . . Ideally, you would use data-tracking forms for on-task behavior or in-seat behavior, but it depends on how in-depth data-tracking will apply to Tier 2 intervention. It could also just be as simple as a teacher’s assessment of whether the supports help or not. In general, if the teacher feels the supports are beneficial, they are.
  • Exiting the support is also tricky. For the most part, we don’t outgrow our sensory needs. So if a child needs more movement or sensory strategies than what his educational environment provides, he may always need those supports. Sensory breaks or tools are not really a “fix.” We don’t typically see progress from them, like we would see from a curriculum to improve math skills, which brings me to my next point.
  • If you are going for a “fix” rather than a support that may be needed forever, I would recommend a program to teach self-modulation like BrainWorks or Zones of Regulation. Maybe the kids who qualify would go to a group weekly to learn strategies they can use independently in the classroom. This would still be somewhat dependent on the teacher’s willingness to allow kids the flexibility to manage their needs in the classroom, such as standing up to work, straddling their chairs, taking stretch breaks, etc. This makes exit criteria easier. A good criteria might be “Student can identify his/her needs and select strategies to meet them.”

I hope that helps!

Best Wishes,
Gwen

QUESTION: Head banging when angry or upset?

QUESTION:

But my question today is about a child with abnormally high pain tolerance who appears to seek/enjoy banging his head when he is angry or upset. I have seen this before in children from abusive or neglectful orphanages and in children born affected by or addicted to alcohol/drugs. I do not yet know the background of this young man as I just received the referral. Can you explain the physiology behind this behavior, and why would some children find this activity desirable or calming while individuals with normal systems would find it painful? If not, can you refer me to some articles or resources where I might find more information? And as always, what if any sensory strategies might be helpful to stop or minimize this behavior? I read one of your answers about skin picking online, and you stated something I have also found to be true: When the input the child is seeking is extremely intense, it is very hard to replace or substitute for it. Thanks for any light you can shed on this subject!

GWEN’S ANSWER:

More often than not, kids are using a preferred form of input (intense proprioceptive and vestibular input) to override a nonpreferred variable (whatever is making him upset). The intensity of head banging causes a release of some of our feel-good neurochemicals like seratonin, dopamine, and endorphins. While for most of us, the neurochemical rush isn’t worth the pain, for some reason it’s worth it to these kids. Most likely, he is UNDER-responsive to proprioceptive input, which makes pain register more like touch for him. Sometimes these behaviors also become behavioral if they are reinforced somehow through attention, task avoidance, etc.  As you mentioned, because we cannot match the intensity, it can be very hard to reduce or eliminate these behaviors. Your best bet will be to give him more of the input he is seeking (in a safer manner) while also developing a plan of rewards and consequences for the head banging.  I do have a webinar titled Self-Injurious Behaviors if you’re interested in more information on the subject.

I hope this helps!

Best Wishes,
Gwen

QUESTION: Suggestions for fidgety kid who’s also learning?

QUESTION:

I work in a school system primarily with grades 2–5. I recently received a request from a parent to brush her child because she does it at home and she sees immediate changes in his demeanor. He is very “squirrelly” in class and needs constant redirection, but feedback from the teachers is that he is learning and answering questions appropriately. I am not a fan of the brushing protocol, am not certified, and am not even in the school every day to do the protocol. Sensory breaks and strategies are provided throughout the day, but maybe I need to step it up a bit. Is there something you can suggest for calming this fidgety kid. Thanks!

GWEN’S ANSWER:

My first thought when I hear about a “squirrelly” kid who is actually learning (as the teachers report) is that we should let him continue to be squirrelly! The movement is serving a purpose for him. To prevent it from being a distraction to others and to reduce the frequency of redirection required, here are some suggestions:

  • Implement classroom-based movement breaks. These should be short but frequent. Based on our recent research, I recommend a brain/movement break once every 15 minutes for kindergartners. For higher grades, add 5 minutes per grade (every 20 minutes for first grade, etc.) until you hit once every 50 minutes, which then continues to be our need throughout adulthood. These brain breaks are especially good for kids like the one you are asking about, but they are also helpful for nearly all of the kids in the classroom. Just be sure you are recommending movement activities that are mainly proprioceptive in nature: yoga, deep pressure through head, wall push-ups, etc.
  • Provide alternative seating. I really like standing desks for kids like this. Kore Wobble Chairs are also great. These options allow him to get the movement he needs while staying on task.
  • Ensure that recess is never taken away as a consequence. Kids like him need that time to reach their high thresholds for sensory input.
  • Trial compression clothing or a vest with him. If he does respond well to the brushing program, it’s probably because the deep pressure input helps him connect to his body more effectively. Compression may be able to accomplish the same goal.

I hope this helps!

Best Wishes,
Gwen

QUESTION: Choosing and scoring assessments?

QUESTION:

This is my first year in an early childhood center. I have been using the sensory profile for evaluating kids at an early childhood center, mostly because that is what they tell me to do. Prior to this I was in a state school setting and a 0-3-year-old home visit program. In learning to use this test, I find it a bit difficult to know to what degree of “definite difference” or “how many” results in the child’s need for sensory integration at some level. Especially frustrating to me is making decisions usually without even having set eyes on the child, but maybe this is better—less subjective.

The other difficulty is the difference in “Caregiver” and “School Companion” scores. I usually base them on the school companion, because it is needed to function in the classroom. But I feel there may be times it is a student-teacher personality conflict. In most cases, I suggest a sensory diet for them to use with the child at school. Any thoughts on this? Thanks in advance!

GWEN’S ANSWER:

In general, we should only be using sensory processing assessments to help us determine what’s causing the problems that need to be addressed, not to determine whether or not intervention is warranted. Some children score in the “definite difference” range, but the issues are not impacting their function in the school environment and therefore no intervention is warranted. I begin my assessment with getting input from the teacher and parents (depending on the setting) about the issues needing to be addressed. I then spend a little time observing and interacting with the child. If I suspect that sensory processing may be contributing to the problem, I administer the Sensory Profile or Sensory Processing Measure (or just a good sensory symptoms checklist) to help me figure out the underlying issues. Then I use the results of the assessment to help me design a sensory diet to support the problematic issues specifically. This is the primary difference between school-based OT and medically based OT. In the schools, our only job is to address the issues impacting education. In a clinic, our job is to address the deficits themselves.

Regarding assessment options: The Sensory Processing Measure–Preschool version is a little easier to understand. However, I find it doesn’t always give me enough information to determine whether a child is over- or under-responsive to each form of input, which is the information I really need to develop a sensory diet. There’s more on that in my webinar titled “Sensory Diets 101.”

I hope that helps!

Best Wishes,
Gwen

QUESTION: Suggestions for a Tic?

QUESTION:

I work with a child with autism that has developed what seems to be a tic. It started after he had chapped lips and was putting on chapstick frequently (I don’t know if it is related). Now he is constantly making slurping noise with his lips and tongue and driving his friends crazy. He says it feels “tickly.”  So far, none of the sensory solutions we have tried (pursing lips, drinking from a resistive straw, gum, deep breaths) gets rid of the feeling, he says, and the noises continue. Do you have any suggestions that we have not tried? He has not demonstrated tic-like behavior in the past.

GWEN’S ANSWER:

I wish I had something to suggest, but it looks like you’ve already tried all of the things! I tend to think this started off as a sensory issue (chapped lips) and became a habit or preferred form of sensory input. I would treat it like an undesirable habit. Explain to him that it drives people crazy. You may even want to make a social story about it. Talk about how it is disruptive to others and cannot be allowed. Keep the other strategies in place and encourage him to use them as alternative forms of input to his lips. Put a system of rewards and consequences in place for “quiet lips.” These will have to be based on what matters most to him.

If this approach isn’t successful, consultation with a doctor would be advised. Even if he hasn’t demonstrated tics in the past, this may be one that could benefit from medical intervention.

Please let me know if you find something that helps for this child!

Best Wishes,
Gwen

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QUESTION: Weighted Clothing?

QUESTION:

I found your site while doing a search for compression clothing for my 9-year-old daughter. I read somewhere that there are weighted clothes that can be worn under clothes. And/or some more stylish looking weighted wear. Do you know where I can find these?

GWEN’S ANSWER:

Click on this link to see some weighted garments available:

https://store.schoolspecialty.com/OA_HTML/xxssi_ibeCategoryPage.jsp?docName=V700839&minisite=10206

Weighted garments are typically bulky and it is hard to find stylish options. I tend to recommend compression garment to be worn under clothes instead. Both compression and weight provide proprioceptive input which is organizing to the brain. I don’t like kids to wear weighted garments for more than 30–40 minutes at a time because the weight will change body dynamics. However, I’m comfortable with them wearing compression garments all day. Here is a link to some compression vests:

https://funandfunction.com/calm-and-focus/weighted-products.html

I also really like Under Armour brand clothing. These are typically athletic base-layer garments and you can buy them at most sporting goods stores or online:

https://www.underarmour.com/en-us/girls/g/3i

Under Armour clothes are basically tag free, seam free and provide compressive input which is comforting to most kids. The added benefit is that it doesn’t look therapeutic!

I hope this helps!

Best Wishes,
Gwen

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QUESTION: Cannot Tolerate Clothing?

QUESTION:

I have started working with a  5-year-old girl with tactile sensitivities, among other things, but this was the primary reason the parents sought OT. She cannot tolerate wearing underwear and will only wear very specific loose dresses. This of course is a big issue. She also is a very picky eater, but other than that she tolerates other tactile activities without difficulty. She loves to swim but is very bothered by the swimsuit touching her body. We have started the Wilbarger Therapressure protocol and will be starting Therapeutic Listening this week. During our last session she teared up and said if the clothing touches her stomach she can’t breath. I am also providing the family with a sensory diet focusing on calming activities as I do believe she has some over-responsiveness to vestibular and auditory. I was wondering if you might having any other suggestions. I appreciate any and all input.

GWEN’S ANSWER:

You are already doing all the right things. I would keep up with the  Wilbarger and Therapeutic Listening. I would also set up an overall sensory diet approach, like the BrainWorks File Folder, to help her learn self-regulation through the use of red-arrow (calming) activities. With the combination of these strategies, I would expect to see significant improvement within a couple of months. For now, I wouldn’t push the underwear issue, but as soon as you start seeing some adaptive changes, here is what I would do:

* I would make a social story about the need for underwear. I would start only with underwear and deal with pants and other clothing later.
* I would show her a calendar and mark a day when underwear are no longer going to be optional. I would remind her about this change frequently and allow her to choose some underwear at the store in preparation for this.
* Create a schedule strip for dressing with about 5 spots on it. Put “Get Dressed” on the 3rd spot. Put the brush on spot #1 to indicate the Wilbarger Protocol. Let her choose a red arrow activity for spot #2. Allow her to choose any highly preferred yellow or red arrow activities for spots 4 and 5. Explain to her that clothes might feel uncomfortable at first, but if she stays busy it will give her brain something else to
think about while her skin gets used to the feel. If she is stressed after getting dressed, just keep diverting her attention and reminding her to keep her brain busy.

I hope that helps! Please keep me posted if you find something that works well for this child.

Best Wishes!
Gwen

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