Sensory Integration in ADL Series (SCAN) – Topic – Speech / Communication

Hi All,

sharing details of another session which i have recently attended , it was organized by SCAN group. The session details are:

Session Name: Workshop on Sensory Issues relating to ADL (Activities of Daily Living) Training – Speech / Communication
Date and Timing: 26th Sep 2019, 10 am to 12:30 pm
Venue: Mitr, T-18/2, Coastal Road, Kalakshetra Colony, Besant Nagar, Chennai – 90
Charges: 150 Rs per Person ( Refreshments were provided)
About the Speaker: Mrs.Lalitha Sridhar is a rehabilitation consultant and developmental therapist specializing in sensory integration and neuro developmental therapy. She is an educator and counselor for children with development / special needs and their parents. Lalitha has over 30 yrs of experiences in India and abroad. She has worked with children across all age groups, from early intervention to vocational training and has been providing programs across age groups. Her core areas of work are assessment, intervention and developing holistic programs for children with special needs. She has worked with parents in guiding, training and empowering them in their journey.

This session was part of the ongoing Sensory Integration ADL Workshop/Training series, i.e. Feeding > Toilet Training > Sleeping > Communication > Behaviour. Today the area covered was SPEECH / COMMUNICATION.

We had a decent crowd today, there were few participants attending the session for the first time, hence the presenter has to give a briefing about few concepts which was already covered in the earlier sessions. Also she clarified that the session is a Generic
one, it may or may not cover all solutions that are specific to every child.

SPEECH VS COMMUNICATION

Speech and Communication are two different aspects. Speech is an expression of anything by producing sounds which converts it to words. Whereas, Communication is getting across the message which you want to convey.  For Verbal communication, you need a language, whereas for Non Verbal Communication language is no requirement, non verbal gestures using the body is enough.

COMPONENTS OF SPEECH

1) Oral Motor Structure

Oral Motor structure is important for two ADL Skills, Speech and Feeding. A Good oral Motor structure should properly developed: a) Mouth b) Jaw c) Throat Muscles d) Voice box.

2) Good Auditory Hearing

She asked few random participants to repeat the word after her, like she said Apple participant said Apple etc … later she explained the learning from the activity is, you reproduce what you Hear. For better reproduction, you need better hearing.
From her experience, she says that most of the ADHD and other kids does not have hearing problem as such. You need not go for specified hearing tests such as BERA (Brainstem Evoked Response Audiometry) etc. To prove that your kid does not have a hearing difficulty, you can switch on your TV with decent sound, you would see your kid appear in front of TV from nowhere. However they do face challenges in the way the hearing is processed.

3) Auditory Processing

She asked few random participants to say a word exactly opposite to what she said, like she said Coffee participant said Tea etc.. the learning from the activity was that, it took time for the participants in order to respond with an opposite word. This delay is
called processing of information, your brain needs to register the input received, process it and then reproduce. She established that it is common to have a delayed response when the response involves processing of information. This is an challenging area for
your kids, because the time taken by them for processing in order to produce a response are longer than usual.

4) Vestibular Insufficiency

There are three bones that helps in transferring the information received to the brain. These bones needs to be developed by providing more vestibular input.

5) Oral Motor Sensitivity

Production of sounds becomes difficult, you might see kids saying AAAUPLE instead of Apple, similarly R sounds would be harder for them to pronounce. To produce certain sounds, the tongue needs to come in contact with the palate, the sensation that are felt by the kids during this process will not be the same for them as we experience.
When there is an oral motor sensitivity:

• Brushing becomes difficult
• Texture of food becomes difficult
• Eating becomes difficult
• Taste becomes difficult
• Production of Sound becomes difficult

6) Emotional Component

When you put pressure on the kids, impose your anxiety on them, the child will begin to speak however you will find them stutter or stammer. Do not pressurize kids like … Say Hi to Uncle, say Good Morning to Aunty, Say rhymes for Grandpa etc… Avoid bringing
too much anxiety to the child, as it will lead to issues in other ADL activities as well.

COMPONENTS OF COMMUNICATION

1) Association

How many parents are familiar with the issue, that your child hearing is fine, but he does not respond to name calling. It is because his name is not associated with him. He does not know the concept of name, that he should respond when his name is called
for. You have to begin steps that will associate the name to the child.
Some kids might only respond for name calling by their parents and not by anyone else. It is due to the way in which the name is called for, when we as parents call out our kids name, it is a unique combination for the child, i.e. the voice, the tongue, they
rhythmic way etc. whereas when a stranger calls his name, the combination is different. This happens when the association is not strengthened. Teach Association with people first. For responding to name, we can use Naming procedure. You take child’s index finger and point to himself and tell the name. Similarly point towards other people.
You have to go front and back few times, when the association is not enough.

2) Imitation

There are two types of Imitation i.e. Oracle Imitation and Body Imitation. If Oral Imitation is less, body limitation will also be less. Work on the body limitations first and then work on the Oral imitation. Body imitation refers to the gross motor movements. If you want to push the boundaries of motor movements through imitation, make him stand in an uneven surface and make him do the activities.

3) Comprehension

Gross Motor movements are lot easier, whereas the facial expressions are more difficult. Facial movements are made when there is an expression, which has an associated emotion / meaning. Your face is an index, where one can easily find out Hunger, Sleep, Tiredness.  She made a demonstration with a volunteer from participants, where the participant initially acted out Tiredness, it was easily identified by everyone. Next she acted out with Drowsiness with facial expressions alone, everyone was able to figure it out. Next she was given a task to act tiredness again this time without facial expression, the volunteer was unable to do it. We cannot detach NON VERBAL from VERBAL, the ideal % is that our communication is 70% Non-verbal and 27-30 is Verbal

Children has difficulty in comprehending NON VERBAL Cues. DO not merge both when you are facilitating speech. First focus on verbal component and then move to non verbal component. Also avoid using too many words, the more words means more comprehension required for the child, which is an overload might result in meltdowns.

• 0-7 Age group, only try with oral communication, don’t use non verbal techniques
• 7-14 Age group, % of verbal should more, use non verbal as well
• 14-21 Age Group, the ability to speak is there, hence you work on the verbal.

4) Joint Attention

If we point an object, a child should see the place we are pointing. It should develop during 6 months of the child.

CHALLENGES IN COMMUNICATION and SPEECH

Ability to make others understand

The biggest frustration a child experiences is when he is unable to make others understand. This is often looked as a behaviour issue, whereas actually it is not. Assume a kid id frustrated because he is unable to make you understand his need, so he throws
stuff, you think child is doing a tantrum which is behavioural, so you deal it inappropriately, as a result child continues to throw bigger things. The child who is unable to communicate is going through an important challenge, we have to help them to overcome it and look ways for it. Please approach the child in positive manner. If you are in a position where you feel low key and about to give up, don’t drop it off, take help and move forward.
Also when a child does his best to communicate to us, but our response / reaction is not right, he will not be keen to make future communications as there was no encouragement or attention given.

For example, a parent said … when i say Apple .. he kid said HAPPA and jumped…. You can identify it as a kid unable to repeat a word as it is said, he is having behaviour issues…… But what actually happened, is that kid likes apple, so when the mom told
she packed Apple for lunch, the kid was Happy which was referred as Happa and jumped in Joy. If you address it as behaviour, the kid will not repeat it in future.

SIMPLE METHOD OF COMMUNICATION

There is a simple mechanism of communication which can help you get through with majority of the barriers without frustration. By Using two simple words YES/NO, if not even a gestural Yes/No. You can teach once concept at a time first. NO is lot more easier,
hence teach that first, then move to YES. Later mix them both.

To teach YES, you should ask questions that have obvious answers as YES. For example, when the kid is starting and wanting to eat, if we ask him “Do you want to eat” , it will be an YES. Similarly after his tummy is full, if you ask if he requires more food, it will be a definitive NO. Use Yes/NO, appropriately to the children and not generalize it by using flash cards.

For Example,
Assume you do a 3 day experiment with your spouse at home,
Day 1 – You do not speak/respond to anything
Day 2 – You speak/respond normally
Day 3 – You only say Yes/No alone, no other words.

The day you use Yes/No, will be the most comfortable day of all.

TRAINING AND DEVELOPMENT

Training and Development are two different things.
A skill should be trained, whereas Development can only be facilitated, but it is happening vice versa in the name of fancy therapies. You cannot train a development.

AREAS TO FOCUS FOR DEVELOPING COMMUNICATION

1) Pointing

It is very important, keep training the child on this, even if you do not see any desired outcome. This is an area where you continuously develop like providing vitamin supplements to the child.

a) Naming
Use the index finger of the child, which receives the tactile feedback. Name the object which the child touches. The most important time to try this is during feeding. When training the child on this only name the object, don’t use too many words.
When you name the object the child touches, the auditory processing starts to develop and the word which you teach by touching is registered in the brain. For example, you make the kid to touch the apple, and say “Apple is in the plate” the child is confused as
he will not understand all the words you spoke. He might register the touch of apple associated with the word Plate, next time when you point your child’s finger to apple , he will say PLATE.
The common saying that more your speak with the child, increases the child communication is totally wrong. When we point our fingers and ask the child to look at it, it becomes visual. When a child point it, it becomes tactial.

b) Do not Repeat Instructions:

Don’t say 1000 times apple. Give time for information to reach brain. The moment you start giving more instructions, the information processing channel will shut off. Auditory process can happen only with registrations.

c) Start with Simple Instructions:

Begin with simple to complex instructions

• Like 2-3 words
• Tone modulation should be there appropriately.
• Provide appropriate response

After providing instructions please wait for 30 secs of time for the child to respond. Like that you can repeat it for 3 times, even after which if he does not respond, give him a firm touch and hand-over-hand make him do it. Do this repeatedly on the objects that
he sees on a daily basis.

2) Receptive Skills

Work more on the anatomy and sense of Oral Motor structure like biting, chewing, eating, blowing etc. Oral sensitivity is a bigger issue. You can provide foods of different taste on each day. You can apply Honey, around the lips, gum for 5-6 times a day, it stimulates their tongue to link in the mustache area..or upper lips. Every time a stimulus happens, it sends signals to the brain.
For weekends, you can try Hot water and Cold water stimulation. You keep doing this, the body will neutralize, as you are making the brain aware. Provide less auditory input to the child, excess input and overload will also result in self taking.

a) BRUSHING

Use Finger brush, instead of tooth brush. Use warm water with salt in it, which provides the child a sensory input. Some kids want to do it again and again for the taste of it, some kids avoid it. In order to train spitting, add more salt to the water.

She is against usage of vibrator brush. Also suggests that stick brush when used with force damages the mouth which is a too much for the child to deal. Do the brushing when you are not in hurry.

b) BLOWING

You can use candle, for blowing exercises. It is some times risky due to the fire.
To teach blowing to the kids, you can blow air in the child’s hands, as it gives them the tactile input. You can use a straw for blowing as well. Initially blow with smaller gap, and widen it later.

c) SUCKING

Sucking is equally important as blowing, it should always be learnt together. It will improve the sound produced by the child i.e. syllables. Use shorter straws to being with where lesser effort is required for sucking, later increase the length of it. Also use
a wide diameter straw which is easier to begin with.
If it does not help, try buying juices that comes in tetra packs (Frooti, mazza etc), ignore about the sugar consciousness for the time being. Place the straw inside the tetra pack and ask the kid to suck it, initially you squeeze the tetra pack slightly to that juice pops out of the box and kid gets the taste of the drink. Once that happens , kid will make an attempt to suck further. If not tetra pack, you can try filing zip lock overs with water and place straw inside and practice sucking.

3) Expressing Skills

• Yes / NO
• Expressing his needs related to ADL activities.
• Give Choices:
  Do not give options that are not readily available. Instead of asking whether the kid wants sambar or rasam you can show them and ask them to choose. For example, Read book OR play., which dress you want ? red dress or blue dress etc ..?

FACIAL MASSAGE

You need to keep the brain aware of what is happening to the body, as the feedback mechanism is less for such kids. So to activate the sensory systems we shall provide Facial Massage or Taping/Strapping. Steps involved in the massage are:

• Pre-requisite:
  You arrest one side of the face and do the massage on the other side, else the input would be confused. When you arrest one side of the face, do not arrest it in sagging manner.
• Stroking:
  Apply strokes from from chin to ear lobe. Child may not allow, he will be sensitive , in which case stop it. Do if from Jaw to ear, Cheek to ear and Forehead to ear, 7-10 times.
• Kneading:
  Use 2 fingers, start from chin , use in circles, go up till forehead and come down and then relax. Do it before sleep, it helps in sleep.
• Tapping:
  Use last 2 fingers and tap, start from chin.
• Compression:
  Use index and middle finger and keep pressing Chin, cheek and forehead to ear lobe. Use all fingers and press the cheek.
• Strapping

The massage helps to activate the muscles and also to emote. Take step by step, everything need not be done in 1 day. Use lavender oil or cream, it is very strong and induces sleep.

FLASH CARD BASED INTERVENTIONS

Lot of teaching/therapy techniques involve teaching with flash cards, she feels there is no real use of it. It is better to work with live objects and people rather than flash cards. Use people and real life objects to facilitate communication. For the age group of 0-7 years of age, do not get in to non verbal techniques such as Flash cards. When you start work with situation and experiences, the start itself is challenging, but understanding is full. Flash Card app gives immediate response but no development. Even if you start using cards, wheel it off faster.

OTHER TIPS / RESPONSE TO PARENTS QUERIES

1) Child has been taught to different sounds, for example pa, bha, pey etc, but when the child produces the sound he only makes pa sound. The issue is with imitation component, you need to work on the auditory processing, as the child might hear all three different sounds has a single sound.

2) Our human body is like a thread, so we have to work as a whole and not in isolation. We only look at motor skill or sensory skill or emotional component, which will not yield permanent results.

3) Few children have no issues in their hearing system or vestibular system. It becomes a challenge to work on those children when you cannot find visible issues in their body. In which case we need to stimulate their current threshold to see improvements. The more you stimulate and push against the current threshold, you would see improvements that are beyond physical limitations. At the same time there are a very lower percentage of children, where you find no anatomical dysfunction, but who can never speak at all.

4) Do not blame yourself when you are unable to achieve at some thing with your child. When you are unable to reach the goal, inspite of putting effort , it is time for you to sit back and rest the routine for couple of days, rethink why you were unable to achieve the goal, and revisit a newer approach. Do not pressurize yourself, there is no one size fits all approach available, you will do over multiple approaches until you find the one which produces results for your child.

5) You see many normal children that has stammering, which is due to the Anxiety and Pressure caused by other external factors. Schools stresses the parents, parents pass on the stress to the children. For example, your child might not be able to write like all others in a classroom at the Kindergarden level, this is often seen as a complaint and immediate action is taken by parents where the kid is pressurized. The writing readiness comes up only when the child is 5 years old.

6) Always focus on age appropriate developments, without development you cannot train on any particular skill. But most parents are working only at the higher level, where they focus only on the skill and ignore the development completely. When a proper therapist advise them to focus on development as well, many parents switch parents who can work on the skill.
On the long run what happens is that, you have a child who is not fully developed and trained on few skill improperly, as a result he does not fit in anywhere. Finally you end up stopping the kid from school and keep him at home.

7) Understand your child’s development in order to understand the problem. If your child wants to write, you focus on whether he is developed enough to write by himself or not, if your child can eat by himself, writing comes automatically. So focus on eating
skills first.

8) One of the parents said, that their child does body imitation like an exact mirror image. i.e. when you raise your left hand/leg, kid raises his right hand/leg because the mirror image of your left hand is his right hand, when you stand opposing each
other. To avoid that confusion When training the kid,

• Stand in front of the mirror and train, side by side.
• Stand behind her in front of the mirror and train

9) After doing 10-15 mins of sensory activity, if you make your child to perform fine motor skills, you will see better results. The more you work with your child’s hands, the more regulation and focus comes.

10) For 0-7 years range, you should only work on development of the child, i.e. you need to have an IDP (Individual Development Plan). Only beyond 7 years of age, you should focus on an IEP (Individual Education Plan). Provide as much as sensory environment and opportunities for the children in 0-7 age group, which helps them to develop. Do not take IQ assessment for 0-7 age group, it has no value and meaning.

11) It is never too late to start. Do not day that your Child is 21 years of age, hence OT will not work. Every child is capable of development till his last day of life. Please put it to Practice, Don’t say age and stop providing services required for your kid. Keep moving ahead with the child.

Don’t leave/ignore the basics. Without foundation we cannot address issues at higher level. Behaviour, we cannot see as Behaviour alone. We generalize behaviour as an habit and we not find or make an attempt to find cause of it. After completing the 4 parts in the series, when we do behaviour, i want the parents to come up with solutions .

MY PERSONAL FEEDBACK

Communication happens to be a vast area, and it was very challenging to cover in a single session, i felt a sense of in-completion, at the end of it. She rightly justified that there are different levels of communication, what she covered is very basic in nature.
This session was more interactive, participants were involved in demonstrations etc.

I thank Scan for organizing this session and looking forward for the upcoming sessions
Regards,
Saranya and Karthik
karthiksaranyaparents@gmail.com