Well we got to meet Dallin and I with Charla, she seems so great! it is nice to have the chance to meet the people that are helping Shape my baby! it is hard to believe how much he has change into a boy but here are some of the goals that he is going to work on for the next bit.....
OCCUPATIONAL THERAPY OBSERVATIONS/RECOMMENDATIONS
I had a chance to observe Dallin during his lunch, with the following observations:
Dallin’s repertoire is limited at home. He has several food jags (i.e. he insists on eating the same food in the same manner over a long period of time).
Although mom reported that Dallin has very picky eating habits with a stronger flavour perception (i.e. he will only eat one brand of hotdog and notices if it is different), he did however tolerate eating a brand new pizza flavoured macaroni during lunch without difficulty. He seems, however, to be far less flexible in his home environment then at the Achieve office.
Dallin does not chew his food. For example he carefully took small bites of his macaroni and swallowed them whole. According to mom, Dallin becomes overwhelmed if presented with portions or foods that he is unable to swallow. For example he will only eat and request that his meat be cut up into small pieces (including if the hamburger is too big in spaghetti) and avoids muti-textured foods such as soup. He also refuses to eat cereal until it is soggy, again to accommodate easy swallowing. Therefore his food selection is limited again contributing to his restricted repertoire of foods.
Mom reported that he has chocked on his snack at school requiring the Heimlich maneuver and has made many accommodations to Dallin’s diet to ensure safety.
Dallin had difficulty crossing the midline of the body and positioned his food items to accommodate this challenge. He also displayed poor postural control, although he did not have trouble staying in his seat for over 20 minutes while he ate his lunch.
According to Christine, Dallin’s drooling has decreased over the last year. He still however, displays increased drooling with activities that are challenging or when he is deeply concentrating. He does not seem to notice when his mouth and chin are wet.
Dallin sometimes displayed a “wet voice” (e.g. following drinking or during periods of increased drooling).
He has just transitioned from a sippy to drinking from a regular cup and displayed immature utensils skills.
Recommendations:
Angie to develop a visual script to cue Dallin to chew in between bites and swallows. As Dallin seems really responsive to imitating exaggerated actions, Angie to model “bite = chew…chew…chew…chew = swallow” during mealtime. To improve chewing skills, try creating a mouth box filled with chewable toys for him to practice.
Dallin is displaying some significant oral-motor challenges (chocking, inefficient chewing, drooling, limited food texture, immature spoon and cup feeding skills, wet/gurgly voice) and would therefore benefit from a follow-up consultation by the Glenrose Feeding and Swallowing team. Christine to follow-up.
To support effective and safe eating and swallowing, it is important to provide Dallin with adequate postural support while eating. Therefore ensure that his feet are on a stable surface and his hips, shoulders and head are in alignment. Also consider that the table top is the right height for him to freely use his arms during eating.
To minimize opportunities for food jags, make small changes to Dallin’s preferred food items. For instance, introducing a new brand of the preferred Kraft macaroni like pizza macaroni J.
Prior to quiet sitting, try the following postural activities to “wake” Dallin’s muscles up:
Ø Ball chair games
Ø Silly animal walks
Ø Chair Push ups
Ø Rocking Puppy: On your hands and knees (with your arms and hands under your shoulders, your knees under your hips and your toes flat on the floor, elbows slightly bent) rock slowly backwards and forwards.
Ø Airplane: Lie on your stomach (legs straight and together). Bend your arms 90 degrees at elbows with hands and fingers open pointing forward. Bring your head, arms and chest up at the same time with your legs. Do not arch the neck, simply look straight ahead.
As Dallin does not chew his food and is at high risk for choking, be sure to minimize distractions while eating, provide ongoing supervision and always be aware of the size, shape and texture of foods presented.
NEW GOAL: Dallin will chew soft foods before swallowing.
NEW GOAL: Dallin will accept small changes to preferred food items.
NEW GOAL: Dallin will clear his plate at home, including putting utensils in the sink (not the garbage).
Dallin also participated in a variety of self-help and fine/visual motor and perceptual activities during the session with the following observations:
Dallin is displaying some excellent visual perceptual skills. He had no trouble completing puzzle requiring significant visual discrimination, visual closure and spatial relations.
He transitioned easily from task to task (even from highly preferred activities) and followed the adults lead in play without difficulty.
As described above, Dallin has difficulty crossing the midline of his body and continues to switch hands during most tasks. This is likely related to his poor core stability.
Aside from his motor challenges, he had no troubles attending to and participating in single step activities (i.e. using tweezers to sort coloured “caterpillars” on leaves) When the complexity of the activity increased (i.e. roll dice to determine colour), he was very capable and interested, however, needed more support. Continue to expand and introduce more complex games. As number concepts are difficult for Dallin at this time, games that require number dice may be very challenging. However as he knows all his colours substituting for coloured dice as demonstrated will work well. You can choose games such as candy land, or make up your own (as shown) or even expand on existing games (i.e. roll dice to determine sword to remove in pop up pirate).
He also needed verbal cues and standby support to complete the sequence of brushing his teeth.
Christine reported that Dallin struggles with haircutting, and feels it is likely related to both hypersensitivities to touch on his head and tolerating his hair being sniped.
Christine also reported although Dallin is very compliant and holds it together during school and therapy times, he consistently falls apart by the time he gets home. She reports that he spends a couple of hours jumping and trying to self-regulate. She indicated that he is far less flexible/tolerant, has difficulty with transitions, and that his arousal quickly escalates especially during sibling play. This makes evening/family time very difficult for parents. We discussed implementing sensory breaks during his home program to hopefully decrease the amount of time Dallin needs to self-regulate and calm when he gets home. A sensory diet consisting of a calming sensory break for every three activities presented will be implemented. Charla also to follow-up with OT at school (Christine to provide email).
A toilet schedule was provided to Christine to be complete sometime during the next two weeks in order to obtain an accurate schedule of when Dallin is voiding. Charla to follow-up.
NEW GOAL: While laying on his tummy, Dallin will independently maintain an upright/propped position (on his elbows) while playing a game for 5 minutes.
NEW GOAL: Dallin will complete all the steps in brushing his teeth independently.
NEW GOAL: Dallin will tolerate sensory stimulation to his head without behavioural overreaction.
NEW GOAL: Dallin will tolerate an adult taking small snips of his hair without behavioural overreaction.
NEW GOAL: Dallin will display a consistent hand preference.
NEW GOAL: Dallin will require less time to self-regulate and calm (45 minutes) at the end of his day, when he gets home.
NEW GOAL: Dallin will independently participate in two step game sequences (e.g. Candy Land).
NEW GOAL: Dallin will maintain a tripod grasp on 1-inch chalk or wax crayons.
NEW GOAL: Dallin will stay dry 50% of time between regularly scheduled trips to the toilet.
NEW GOAL: Dallin will cross the midline of his body with both arms during bilateral activities, 25% of the time.
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