DEAR ERI COMMUNITY:
Client with Feeding Difficulties:
I am seeing a child who is now 15 months of age. She was born at 36 weeks gestation, with very low birth weight and a very weak suck – was never able to breast feed successfully. After transitioning from hospital to home, mom found that only one orthodontic nuk nipple would work for feeding her 50/50 mix of breast milk and formula. The child was very sensitive to different bottle nipples, many of which would make her gag and vomit. Since 1 month of age, the child has been vomiting almost daily (previously was after every feed). She was diagnosed with reflux (GERD) and put on medication (Prevacid), which was recently discontinued due to doctor’s belief that the reflux has improved now. The child was able to take in enough with the frequent liquid feeds, and she is still currently an age-appropriate weight. Mom has been trying several strategies and for over a few months to transition her to accepting anything solid (started with trying pablum, which child could not accept without having a gag and/or vomit response). Mom has applied all recommended sensory strategies (z-vibe introduction and exercises, tactile exploration, sensory play, introducing new smells/tastes in graded steps, and use of wilbarger oral protocol, etc.). The problem now is that the child’s transitioning to solid foods and thickened liquids is ongoing, but slow. As well, the child has been vomiting daily since 1 month of age. Now, when the child coughs too much, gets too upset, or has something stuck in her mouth that she can’t get out with her tongue, she uses vomiting as a default strategy for getting anything uncomfortable out of her system. The mom would like to know if there are any strategies/tools or approaches that can be used to 1) stop the vomiting from occurring once she can see early signs of that response in the child (i.e. if the reflux is just starting, the mom can sometimes stop it if she distracts child by putting her feet in water — she would like more strategies like this); and 2) prevent the child from developing a voluntary behavioural issue with vomiting, as she matures.
Any advice, recommendations, feedback from other health professionals familiar with these issues would be greatly appreciated!!!!! Thanks
DEAR ERI COMMUNITY: I currently have a client with Rett Syndrome and this is my first case in my career to treat the child. She presents with very high functioning skills, she is able to transition from the floor to stand via bear stance, she can walk over uneven surfaces with out falling over, she can gallop and increase her walking speed without falling. She has a #3 DAFO on one foot and a #4 DAFO on the other. Cognitively she does not follow verbal commands and requires hand over hand assist to stay on task. This child is 10 years old and the previous therapy place was seeing her on a weekly basis. I reached to them to ask their recommendations and opinion on realistic goals and if she requires continued therapy on a weekly basis. The therapist philosophy was to treat this child on a weekly basis due to her progressive neurological decline and that if she saw the child, that the child would not regress. I treat what I see, I also work in an outpatient clinic which insurances drives to see improvements. Is skilled services required at this time with her current presentation?
DEAR ERI COMMUNITY: I’m looking for any advice regarding a current student I work with. He is a 9 y/o boy with severe Autism, hard of hearing, and cognitive delay. His stims have been increasing lately, approximately the last 6-8 weeks, we’ve seen new stims including drawing on himself and in the air, arm flapping, running in circles, can not stand still longer than 2 sec (I know these are “typical” stims). His normal stims are drawing on white board over and over, looking at his drawings with his peripheral vision, and rocking. The stimming is constant throughout his day and nights, compared to previously a handful of times throughout the day. We are a residential school, so he is here 5 days/nights a week. He has also started touching other boys in their genitals, repetitively. He has developed an unhealthy relationship with another classmate, who he needs to be next to at all times, is constantly touching him, if the other child leaves the room, he begins to cry and perseverates on that boy until he returns. The teacher and aides have them separated in the classroom so there is no touching that can happen, unless this boy runs over and grabs the other boy. The other boy does not encourage these behaviors. He is caring toward the other student, but often wants a lot of separation between the two of them.
I know that stims change, come and go, intensify at times, one needs to be replaced with another. We have always been able to redirct him in the past, we’ve worked with increasing his sensory diet and he communicates his needs most of the time now. He is never denyed sensory when we feel he needs it or when he requests it.
So, the real question is: does anyone have any ideas what can be causing the increase in stimming and behavior, plus treatment ideas please. Our behavior specialist is helping with the changes as well, but hasn’t come up with anything effective yet.
Are parents asking you about how this new definition will affect their child’s therapy?
As you know, revisions in the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders, set for publication spring 2013 has changed the definition of autism and will categorize Aspergers, PDD-NOS and Autism into one lump category of ASD (Autism Spectrum Disorders).
One pro of this revised definition is that there will be fewer misdiagnosed patients. “Better diagnosis can help give better numbers on those affected, causes, potential diagnosis and effectiveness in interventions” according to the Center for Autism.
One major concern is that some who may need occupational therapy, may not get the health care coverage needed to afford it. Many therapists believe that there will be a rise in high functioning children with autism that will become ineligible for health insurance coverage for their therapy treatments.
Another worry is that these patients that may be high functioning ASD cases will not be referred to therapists because they don’t fit the new definition.
At this point there is speculation as to what the new definition will include. The New York Times posted an article that showed the proposed Autism definition’s changes this past January. However we will not know for sure until the new version is released to the public next spring.
As a therapist what do you think of the new definition of Autism? Is your center doing anything to promote a grass roots effort to challenge the definition and educate the public?
DEAR ERI COMMUNITY: I have a client right now that I am having trouble teaching how to chew. He was on stage 2 baby foods at 14 months old when I first started working with him. He is now eating mashed table foods, but often needs pudding or appleasuce on the spoon with the foods to tolerate. His mother has done the Therapressure Protocol with him in the past and we saw great improvements with tolerating touching foods, diaper changes, etc. I have asked his mother to start the Therapressure Protocol again. Now that we are gradually making his food chunkier, we have noticed that he does not chew. I gave his mom a NUK brush and gave her suggestions on working on tongue lateralization to improve oral motor skills. He will briefly hold something between his front teeth, but he pushes the chewy tube forward with his tongue when I place it on his back molars. I have his mother inserting the spoon to the sides of his mouth so the food is placed on his molars and she said she thinks he chewed one time over the past week. Any tips or suggestions would be appreciated! Thanks!