Tuesday, July 31, 2012

Sensory Processing Disorder: What you should know!

When parents are new to the diagnosis of ASD (Autism Spectrum Disorders) or other medical diagnosis that have sensory processing deficits as a characteristic, it can be overwhelming to hear so many professional terms and understand what it all means.  As a Speech-Language-Pathologist, I have worked with several children with sensory processing difficulties and wonderful OTs (Occupational Therapists) and COTAs (Certified Occupational Therapy Assistants) that aided in my understanding of the complexities of sensory processing.  I will attempt to impart their knowledge as clear and concisely as I can.

(NOTE:  Often, sensory integration and sensory processing as well as sensory integration dysfunction and sensory processing disorder are used interchangeably.  Therefore, I have used them interchangeably as well.  In addition, I do NOT specialize in sensory integration and am writing this blog for educational purposes only.  I recommend that you speak to an OT that specializes in sensory integration if you have additional questions and concerns.)

What is Sensory Processing?
Simply put, sensory processing is a complex process in which our brains understand what is going on inside our bodies as well as in our external environment through the use of our senses. 
Sensory processing is affected by two things: 
1.       The way our brain responds to sensory input
2.      Our self-regulation strategies (how we use strategies to manage this sensory input).
Keep in mind that sensory processing is a continuum and that we all require proprioceptive (physical, external) feedback to regulate our sensory system.  What we are really concerned about is one’s extreme responses to sensory input and the negative affect these responses have on a person’s ability to communication and participate in daily living activities.
The blow powerpoint presentation will further explain sensory processing vs. sensory processing disorder.

How do I know if my child has difficulty processing sensory information?
Below is a link to a checklist also adapted from Carol Stock Kranowitz’s book, Out-of-Sync Child.  This checklist is very detailed and examines several areas of processing including tactile, vestibular, proprioceptive, auditory, oral input, olfactory, visual input, auditory-language processing, and social-emotional play and self-regulation.  You place a checkmark next to the characteristics your child exhibits. 
IF you feel your child exhibits numerous characteristics in one or more areas, please follow up on your concerns by contacting an OT that has experience in sensory integration.  They can perform a complete evaluation and make recommendations.

Check out Sensory Processing Disorder website for a complete checklist on sensory processing disorder.

Is it important for my child to receive OT for sensory processing disorder?
ABSOLUTELY!  Sensory processing disorder CAN and WILL affect all areas of growth for your child (cognitive, academic, executive functions, social skills, communication, etc.).  If you have concerns about your child’s sensory processing skills, it is imperative that you contact an OT with experience in sensory integration dysfunction in order to determine your child’s needs as well as an appropriate plan of treatment.

Happy Talking!!!

Sunday, July 22, 2012

Teaching Your Child How to Answer Questions

Often, parents express their concerns with the fact that their child is struggling with answering questions.  There are so many steps to actually learning and understanding questions of which we, as adults, are not aware, as we naturally learned this skill when we were younger. This skill is such a difficult one for typically developing children to learn (let alone children with various diagnoses), we first need to talk about the process of understanding what questions actually are before we learn how to teach the skill.

Process of Understanding and Answering Questions:
1.   A Question Requires a Response:
For every child (no matter what diagnosis), the first thing we need to teach a child is that when they hear this question word (Who, What, Where, When, Why, How, Do, Does, Can, etc.) at the beginning of a sentence which ends with a raised pitch, it is a question and does require a response. 
·    The most basic way to do this is to say “I asked you a question.  You need to try and answer me.” (then repeat the question again). 
·    With Y/N questions you can prompt your child to answer with one of those words.  Ex. “I asked you a question and you need to tell me ‘Yes or NO’” (and ask the question again).  
·    All we are looking for is a response (doesn’t have to be a correct response).  If your child responds with echolalia (as children with receptive language deficits, developmental delays, ASD, and many, many other diagnoses will respond to questions this way), repeating the last word/few words you just said, your child has already mastered this concept.  Great!  Move on to step 2.

2.  Every question word means something different: 
The next step is to teach a child what each question word means. We don’t do this all at once but rather systematically by targeting one question word at a time.  (This will be further explained in Step 3.)
So what does each question word mean?  (Taking a trip back to Grammar 101)
·     “What”: means a person, place, or thing (for younger children (PK age) I explain that “what means a person, an animal, or an object”, place is something I introduce later with “where”).
·    “Where”:  means a place.
·     “Who”:  means a person (or an animal).
·     “Why”:  is a cause to an effect.  (even for typically developing children, this cause and effect concept is extremely difficult to express so I don’t expect children to begin to answer this question until approximately 4 years of age)
·     “When”: is a time. (Time concepts are very, very hard for younger children.  In my experience some children don’t understand concepts of time (yesterday, today, tomorrow) until Kindergarten.)
·    “How”: is a process. (Answering this kind of question is typically the last skill to develop as children need to understand ALL the above question concepts to answer “how” something happened.  Children in Kindergarten can struggle with this skill as well.)

3.  Teach the skill:
·    Unless a child is showing me that they understand one question word as compared to another, I follow the sequence of most simple/concrete questions to most abstract:
o    Beginning with: WhatàWhereàWhoàWhyàWhenàHow

·    Begin with ONLY one type of question
o   As previously stated I usually begin with “what” questions because they are the most concrete questions to teach and understand

·    Use visual cues and concrete questions:
o   Pointing/showing:  is the most basic concrete cue. 
§  Object Labels (names):  Ex.  “What are you playing with?” (pointing to the object in a child’s hand),  “What am I playing with?” (showing object in your hand).  By using these cues you are teaching your child that the answer to this simple question is to use the object label (name).
§  Action Labels (verbs):  Once a child has mastered the “what” questions that refer to object labels with concrete objects, I introduce questions that refer to the actions of objects.  Ex. “What are you doing with your car?” (driving), “What is mommy doing with these dishes?” (washing), etc. 
§  Accept the most basic single word answers then echo/expand on them:  As a technique introduced in a previous blog the “echo/expansion” technique is a great way to encourage correct answers your child gives you while expanding upon their answers.  Don’t necessarily expect them to repeat your expanded answer.  You are just modeling more language for them.  Don’t forget to encourage their answer. 
·  Adult: “What are you doing with your car?”
·  Child: “Driving.” 
·  Adult: “Yes, you are driving!  Driving up the ramp.”
§  If their answer is incorrect, no attention is brought to the incorrect answer but you do model the correct answer for them.
·   Adult: “What are you doing with your car?”
·   Child: “car.” 
·   Adult: “You are driving.  Driving the car.”

o   Looking/gesturing:  once a child can answer questions about the concrete objects and actions they are doing, you can move to asking these same questions about pictures (which is still a concrete question but more abstract than if you had the objects directly in front of you).  As your child understands questions about object and actions labels you can alternate these types of questions when looking at book.
§  Adult:  “What does the girl have?”
§  Child:  “Ball.”
§  Adult:  “Yes she does have a ball. What is she doing with the ball?”
§  Child:  “Kick,”
§  Adult:  “You are right!  The girl is kicking the ball.  Nice talking!”

o   Picture paired with question word:
§  Sometimes children do a great job answering concrete questions but once you take away the object/picture they struggle with answering a question because their “visual cue” is gone. 
§  One way I attempt to encourage generalization is to use a picture cue during the above two steps in order to provide a visual cue once the object is removed.
§  Use the visual cues that work for your child (here are some examples):
·  ASL signs of “what, where, when, why, how” (can find on internet)

·   The words “what, where, when, why, how” printed out separately on different colored pieces of paper

·   Other pictures: you can find great pictures on the internet to represent each question word. 

·         Moving to more abstract questions:
o   When it is time to move from concrete questions about objects and pictures in books to more abstract questions, I continue to the use the picture cues I have paired with the question word to facilitate carryover.
o   Asking questions immediately after:
§  Immediately after playing with an object or looking at a book, take away the object/book and ask the SAME questions.
§  Ex. Adult:  “What were you just playing with?”
      Child:  “Car”
      Adult:  “Yes, you were playing with the car!” (now showing the object).  If question is answered incorrectly show the object and state “You were playing with the ball.”
§  Ex. Adult:  “What was the girl doing in the picture?”
      Child:  “Play with ball.”
      Adult:  “Yes the girl was kicking the ball!”

o   Asking questions after a delay:
§  The next step is to remove the objects/book you were looking at and wait about 30 seconds, and ask the same questions.  This duration may be too long initially for children, so you can begin with a 5, 10, 15, 20 second delay.  Begin where the child is successful and add a few more seconds over time during your activities.

o   Expand the delay:
§  Continue to expand the delays, 5 minutes, 10 minutes, and 15 minutes and so on, while playing with other toys.
§  Ex.  Adult: “What were we playing with before the guitar?”
       Child:  “Car”
       Adult:  “Yes we were playing with the car before we started playing with the guitar!”

o   Introduce sequencing words:
§  Now you can introduce sequencing words, such as “this morning, afternoon, yesterday” etc.  These are very difficult concepts for ANY child!  This will take a lot of practice to understand concepts of time.

o   Using a calendar/picture schedule to aid in recall and sequencing:
§  Many times children cannot recall what they did (yesterday, today, this morning, etc.), but if we give them a visual cue they can be successful answering these questions.
§  You will see preschool teachers using these types of picture calendars to remind their students what they did in school so parents will know the events of the day.
§  Some parents use pictures on a calendar or color code days on a calendar.  Maybe you went to the story time at the library yesterday, so you have a picture of a book on the calendar and you point to it when you ask “What did we do yesterday?” or “Where did we go yesterday?”
§  If you want a child to recall events they participated in during one day, I recommended some type of visual/picture calendar for that day. 
·         You can begin with the most simple type (what you did this morning, this afternoon) and have two pictures “book” for story time in the AM and “store” picture for trip to the grocery store in the PM.
·         Or you can put a picture for various activities throughout the day. 
·         Either way you create your visual calendar/schedule, you want to refer to it when asking your child these questions of time so they are successful.
·         Eventually you will be able to ask them what they did this morning/afternoon, etc. and they will independently look to their calendars for the answer.   
·         Then one day, you will realize they just answered your question without needing to look at the calendar!!!!
·         When that happens your child will be able to begin to tell you things/events that happened to them during the times you were NOT with them.

Things to remember when you are working with your child: 
As one can see, teaching the skill of answering questions is involved and extensive and it is truly amazing that any of us actually learn such a difficult skill at such a young age. Although examples are based on “What” questions, one would follow the same sequence when teaching each question word.  Just a few things to remember:
1.       Meet your child where they are.  Your child needs to be able to answer concrete questions before he can answer abstract ones; he needs to be able to label objects and actions before he can answer questions about them.
2.       Goal:  Success regardless of use of scaffolding.  This means, provide as many cues as your child needs to be successful.  You can always fade out cues later on.
3.      Mastery at concrete level is indication that next question word can be introduced:  You don’t have to wait until your child can answer “what” questions about things that happened “yesterday” before you introduce “where” questions.  If a child can answer “what” questions about real objects and pictures in books, you can begin to introduce the next question word at the most concrete level. 
4.      Stick to age norms:  Keep in mind that if the skill is not age-appropriate, you can introduce it with the goal of modeling but don’t expect your child to answer these questions correctly.  Example, a three year old is NOT going to be able to answer “when, how” questions b/c they don’t have a concept of time.
5.   "Which" question not included:  As you may have noticed I did not include the question word "which" in the above model.  This question word tends to develop outside of the typical model above.  Once children understand how to make choices between objects you can introduce "which" immediately ("Which one do you want?").  Most of the time children develop understanding of this question word very quickly.  However, if your child is struggling with this concept, feel free to use the above techniques to facilitate understanding and language growth.
6.      Praise and Reinforcement:  Don’t forget to praise your child’s ATTEMPTS.  It doesn’t matter if the responses are correct, it matters that your child is participating in the process.  The more excited you are, the more willing your child will be to participate.
7.      Give yourselves the credit you deserve and have realistic expectations.  Learning how to answer questions is SO difficult that it takes typically developing children years to do it.  If you have been working with your child and he/she can answer ANY question (no matter how concrete), give yourself a pat on the back!  You have just “moved a mountain” and you need to celebrate your success along with your child’s.  Remember it is a long process and won’t happen overnight.  When your child is an adult, no one will care that it took him a year to answer the question “What are you doing?”.  They will only care that he can answer it!

Happy Talking!

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