Everyone: post your tx ideas here. They are old ideas to you... but not to us!

[Andrea Salzman]

This is an open discussion.

You can post stream-of-consciousness thoughts. You can write essays... post checklists... or just jot down incomplete thoughts. Tell us what you do that works (or doesn't) with the autistic child.

Reply here to post your ideas.

[Andrea Salzman]

FROM HARRIET OTT, CTRS, ATRIC:
Limits and Expectations

An observation I have made of all people is that when we are learning something new, it is often uncomfortable, and scary, especially when it is a physical task. Learning to swim at any age can be scary and uncomfortable until you trust the water and learn how to “be” in the pool.

Thus it is not surprising that an autistic child is going to react to this new environment and these new physical tasks with some kind of resistance. As you have already read, there are several strategies that help children transition or help to get them over the initial fears of being in the water.

I have found that part of helping autistic children to overcome their discomfort of coming to the water and learning, is to have clear limitations and expectations.

I have been working a year with Tyler, who is now six years old. His first couple of sessions were filled with whining, and tears. I started out with a lot of singing, and the only toy he was interested in was the watering can, (an essential tool for a therapist working with autistic children… dripping water seems to be a common attraction). When he finally calmed down we began to add tasks to the sessions.

Each new task was meet with resistance. These are the steps that worked with him and with other.

1 Define the task…. Let’s say kicking

2. Physical put him through the task, followed by the reinforcer, In this case dripping water, or singing a song. Even though I did the whole skill for him, I still give him this fun less stressful moment.

3 Give the same cues for each task AND here is the important thing give it a beginning and end. “Tyler we are going to kick for 10.” This way no mater how hard, new, or uncomfortable the task is, both of you, know what is expected, and when it is going to be over. I have found this to be a very important tool for working with all children of special needs.

4. Follow this with a reinforcer and as much eye contact as you can get from them, along with verbal praise.

5. I might provide total assistance for any given task several times. Then I will provide total assistance for the first 6 kicks and hope that the child will complete the last four on their own. Saying “we need 10 kicks before we can play with the watering can” When the child does not respond then I will totally assist again. Eventually I can. Slowly work backwards until the child does all 10 kicks. Once I see the child understands the instruction, I increase my expectations, towards more independence. When the child starts to accomplish the task I become more demanding of his performance.

Thing that do not seem to work… or that I avoid. Giving the instruction several times. I expect my students to make an attempt at the skill on the first request. I might repeat the task a second time adding the “First ( kicking)………. Then we can (play with the watering can)…… followed by apply the reinforcer. If the child does not complete the task then I will give total assistance.

Avoid getting into a power battle. If the child does not do the task at all… resists completely, then I go back to another skill that they have mastered. Before giving them the reinforcer.

I have used limits counting to 5 then to 10 along with expectations for performance with a good deal of success. After a year Tyler is deep water safe, swimming across the pool with his face in the water, even with goggles on.

Harriet Ott, CTRS, ATRIC
Owner of Community Integration Services
Bellevue, Washington
www.cisaquatics.com
425-830-7746

Community Integration Services has been providing aquatic therapy services for 10 years in Western Washington, to people of all ages. The team of therapist are currently Certified Recreation therapists with Aquatic therapy Certification through ATRI.

We provide services to 60 plus clients that come one time a week More the 50% of our clients are children (under 21) with special needs. We also provide

[Andrea Salzman]

ANSWERS COURTESY: Kari Valentine, OTR/L, Owner Wholistic Therapy Services; Amy Dzingle-Niemoth, PTA, Owner Wholistic Therapy Services; Melissa Moos, DPT of Wholistic Therapy Services; Shay Vanderloo, COTA of Wholistic Therapy Services; Chris Kemp, MS/CCC-SLP-L, Owner of Speech Language and Learning Place; Karol Pickerill, MS/CCC-SLP-L, Owner of Speech Language and Learning Place

How does your facility ensure that different disciplines are not overlapping aquatic services? In other words, if OT is seeing a child in the water, will PT never take that child into the pool? Or do you take turns?
First and foremost, we evaluate the needs of the child. If the child would benefit from OT, PT, and/or ST in the water then the child will be seen in the water by all three disciplines. We discuss as a team what goals are being addressed and make sure that we are not overlapping goals.

Mainly, it is about what the child needs. If it is the child’s best interest to see OT in the pool first and then PT, we will each bill the aquatic charge of 97113 and then possibly a Ther Ex charge of 97110.

In this case, we will have to use a Modifier 59 documenting the distinct and separate service from aquatics (i.e. 15 minutes in water (97113), 15 minutes on mat or side of pool lifting buckets of weight (97110). If it is in the child’s best interest to co-treat, we sometimes have to split the time.

As you know, billing is different from state to state and insurance to insurance. Ethical billing is of utmost importance to us, so if we are in doubt about billing in the water or overlapping, we will choose to only bill the minimum amount (i.e. OT 1 unit 97113, PT 1 unit 97113, even if we see the child for an hour) (Kari)

Where is the pool you are using? Who owns it? Is it onsite at your clinic/facility or are you leasing use of it? What temperature is it? What temperature do you wish it was? What depths do you use the most with your children?
We have been in 3 different pools. We do not have a pool on site (maybe in the future!), so we have had to utilize the YMCA public pool during recreational swimming (a little too distracting), a pool at Hasting College (too cold), and another YMCA pool where we have a designated time and are alone to treat the child without distractions.

It has helped us tremendously to get involved with our community (taking students from the college and doing in-services for the well elderly day for the YMCA). When you are involved outside of work, the community will step forward to help children with special needs and do whatever possible to assist in their treatment and well being. (Kari)

[Andrea Salzman]

ANSWERS COURTESY: Kari Valentine, OTR/L, Owner Wholistic Therapy Services; Amy Dzingle-Niemoth, PTA, Owner Wholistic Therapy Services; Melissa Moos, DPT of Wholistic Therapy Services; Shay Vanderloo, COTA of Wholistic Therapy Services; Chris Kemp, MS/CCC-SLP-L, Owner of Speech Language and Learning Place; Karol Pickerill, MS/CCC-SLP-L, Owner of Speech Language and Learning Place

Tell your favorite (sad, silly, powerful… whatever) story about working with an autistic child in the water. It can be as long or short as you wish!
I had a 6 year old little boy in the pool with autism. I had my hands around his waist and he was trying to put his face in the water. He then said “let go of me” repeatedly. I proceeded to let go with my hands very close. He let his legs hang down in the water and his arms with his face in the water. He then started moving his arms back and forth propelling him forward. When he lifted his face out of the water he said “I’m a jelly fish.” It is wonderful how this amazing little guy came up with jelly fish when the majority of his speech is perseveration or echolaliah. (Melissa)

One of my favorite treatments was with a child with high functioning Autism and a right below elbow amputation. He had a really difficult time with bilateral coordination, balance, visual motor control, and using his body powered hook prosthetic device as an active assist for bilateral tasks. I would have him stand up on the flow through mat with different colored fabric hair ties around his forearms and ankles. I would throw a beach ball to him and yell out a color. He would have to kick or hit the ball back to me with the leg or arm with the corresponding color. I would combine colors so that he would have to use both hands or try to use opposite sides of his body (left kick and right punch) or catch the ball. I would have him don and doff the hair ties on his arms and legs. He would have to figure out how to use both hands for the activity. If possible at the pool I could address doffing the hair tie on his left arm with his right prosthetic. He also improved with his ability to put on socks and shoes using the hair tie as a pre-requisite skill for lower body dressing. This child had been in therapy on land for a year before we started the pool. I was able to discharge him with moderate independence in 80% of his functional bilateral tasks using his prosthetic. (Kari)

[Andrea Salzman]

ANSWERS COURTESY: Kari Valentine, OTR/L, Owner Wholistic Therapy Services; Amy Dzingle-Niemoth, PTA, Owner Wholistic Therapy Services; Melissa Moos, DPT of Wholistic Therapy Services; Shay Vanderloo, COTA of Wholistic Therapy Services; Chris Kemp, MS/CCC-SLP-L, Owner of Speech Language and Learning Place; Karol Pickerill, MS/CCC-SLP-L, Owner of Speech Language and Learning Place

Share a clever idea (or more!) you have used to overcome the obstacles inherent with autism (e.g. need for ritual, self-abuse, trouble with noise, etc.)
We see a child with Autism that is infatuated with monster trucks. We pretend we are monster trucks in the water by climbing over the flow through mat and jumping in the pool on objects such as rubber boats. Many times he also is allowed to bring in a toy monster truck that he has to drive over the mat or has to drive over floating objects. (Melissa)

I have always tried to use the objects that children with Autism focus on as a type of motivation to reach my social and language goals. I have spread out different pictures of lego parts of Thomas the Train, for instance. The child would then swim to the picture, look at it, say the word of the picture (if possible), and then go to the “parts store” to get the part (i.e. wheels, engine body,etc.). The “parts store” would be operated by a lifeguard or PT, OT, and the child would have to either hand the card to the person or ask for the part. The goal would be to have the child get all the parts by communicating with the “parts store” person and build a train. (Karol)

When preparing the child for therapy in the pool, I have made up a group of pictures of the activities that the OT or PT might have the child do in the pool. I leave one picture blank for the child’s choice. When the child goes to the pool, he has the pictures of what he could be doing. The OT, to work on strengthening, visual recognition, and motor planning, will have the child take all the possible toys for the OT activities out of the locker (working on grasping-lateral pinch for key to unlock) and carry them to the pool. The OT or PT will then pick 3 of the 5 activities (normally one will be “Child’s choice”. This is a great way that I have found to change the child’s routine little by little. (Karol)

[Andrea Salzman]

ANSWERS COURTESY: Kari Valentine, OTR/L, Owner Wholistic Therapy Services; Amy Dzingle-Niemoth, PTA, Owner Wholistic Therapy Services; Melissa Moos, DPT of Wholistic Therapy Services; Shay Vanderloo, COTA of Wholistic Therapy Services; Chris Kemp, MS/CCC-SLP-L, Owner of Speech Language and Learning Place; Karol Pickerill, MS/CCC-SLP-L, Owner of Speech Language and Learning Place

Share one (or more!) fun game that you use to teach autistic children through the use of water.
Mummy wrap up: For proprioceptive, tactile, and vestibular input. I have wrapped a child in different textured wet towels around the body. They have to break through the towels getting them off to save the ruby (a toy jewel floating on a mat). The child then has jump into the pool and swim to the ruby (Shay).

The Wet Pillow: For all ages. For my children with tactile processing deficits, I have had them get inside a large pillow case in the water. They then have to swim to various objects while inside the pillow case. I am holding on to the top of the pillow case to keep the head above water. While they are moving their legs and arms, they come into contact with the texture of the pillow case. I will work with the PT and we will tell the child to lie stiff like a board and we lift the child out of the water. The pillow case will suck tight on the body of the child when out of the water, which provides proprioceptive input. (Kari)

Sensory Stations: I always try to keep therapy in the pool entertaining, routine, but slowly introducing a new activity. We have various flow through mats shaped like animals. We will line the animals up making a train of flow through mats. Depending on the goals, the child will either crawl, walk, slide on belly with a weight on the back, like a “donkey”. The weight gives deep pressure to calm and assists in shoulder stability. After the animal train, the child will go to the water gun area. I will squirt the hands and feet, legs and arms with water from the water gun to help with desensitization. We then go to the slide (little plastic slide placed at the edge of the pool) where the child has to fill up buckets or laundry detergent jugs with water, lift the buckets of water up and pour down the slide. Then the child can go down the slide. One of the ideas that we have had, but not yet tried, for tactile processing is the “kid wash.” The therapist would place window clings all over the flow through mat. The child would roll over the mat with his wet body (hopefully the clings will cling to his body) and then he would jump into the water to remove the clings. The bigger the window clings the easier it would be to clean the pool after treatment. (Kari)

Gross motor games include placing flippers on the child’s feet and swim paddles on their hands while the therapist supports the child’s trunk from behind and then placing floating objects in the pool (ex: rubber ducks, boats etc) and having the child either try to kick or hit the objects. This activity works on strengthening the upper and lower extremities as well as the core muscles. You can also include crossing midline and alternating upper and lower extremities to work on motor planning. (Amy)

Have the child scrunch their body into a tight ball while hanging onto the wall and then push off the wall with lower extremities backward. This encourages lower extremity and core strengthening along with increased deep pressure and proprioception from the water. (Melissa)

[Andrea Salzman]

ANSWERS COURTESY: Kari Valentine, OTR/L, Owner Wholistic Therapy Services; Amy Dzingle-Niemoth, PTA, Owner Wholistic Therapy Services; Melissa Moos, DPT of Wholistic Therapy Services; Shay Vanderloo, COTA of Wholistic Therapy Services; Chris Kemp, MS/CCC-SLP-L, Owner of Speech Language and Learning Place; Karol Pickerill, MS/CCC-SLP-L, Owner of Speech Language and Learning Place

What creative ways have you used to deal with suboptimum depths, water temperature, loud settings etc?
Suboptimum depths: We have used a variety of objects to assist with water that is too deep. We are making a platform out of PVC pipe to help toddlers with standing, gait training and weight sifting (Melissa). We have also used a standard plastic lawn chair to have children stand on. We have used various flotation devices (duck chair, flow through mat, noodles, and sit boards) which help the child be able to float while participating in a game. For example, one of our children with Autism comes in requesting the ducky chair. He is unable to swim, but he will sit and float on the “ducky chair” and have to kick his legs to collect all of the ducks placed around the pool. (Melissa)

For older children and a child with higher functioning Autism/Aspergers, I have purchased water stilts that PT will make the child stand and walk on the bottom of the pool. This helps with balance, motor planning UE/LE coordination, and LE strengthening due to water resistance. I (OT) have implemented the use of water stilts to improve UE strength, sequencing, team work, and social skills. I made two children with Aspergers, each having one stilt, work together to pick up a ball using the water stilts. They both had to be on opposite ends of the ball and put the stilts parallel to the water. They had to work together to squeeze the ball between the two stilts, pick it up and lift it above their heads and carry it to a target. This was a great way to get two kids who prefer to solve problems on their own have to work together to complete the task. (Kari)

Temperature: We have only had a problem with the pool being too cold. We have purchased used wet suits for the children to help maintain body warmth. The wet suit also provides deep pressure input throughout the entire treatment, which reveals a parasympathetic nervous system response (rest and digest) calming a child with sensory processing deficits. I have also had a child on the flow through mat get various textured towels wet in the water and pull them out (strengthening and heavy work), then the child will lie down and pull the heavy, water soaked towels over the torso. This will also provide proprioceptive input and keeps them warmer while out of the water floating on a mat. (Kari)

I try to have the child spend his aquatic therapy time performing increased gross motor movements and more aerobic exercises (noodle races, kickboards, and running in place) all while in the water to maintain a higher body temperature. I also try to prevent the child from getting in and out of the water repetitively (Amy D-N).

Loud Distractions: If the child does not have many tactile processing issues and/or auditory defensiveness, I will try to utilize water-proof ear plugs or a water cap that extends over the ears to muffle excess noise. We have also seen a child that had a neoprene head band that covered her ears. She used it to keep her ear plugs in, but it could also be used to help decrease auditory defensiveness (Amy D-N).

To keep our children on task and less distracted by noise, we have utilized laminated pictures to help the child with choice of activity, a picture schedule for the child to know what is next, and for social skills bringing a typical developing child of a similar age to play with the child with autism and to keep focus away from others using the pool for recreational swimming (Chris)

For the child that has an increased ability to understand sensory modulation, I have utilized a “take a break” card that the child has access to anytime during the treatment session. The child will hold or take the “take a break” card when sensory arousal is increasing and approaching sensory overload. He or she then will have a safe quiet place to go for a specific amount of time (using a timer) to calm down. (Kari)