Occupational Therapy
Hello! Welcome to the podcast at for all our kids. You are listening to our teacher-to-parent podcast where we discuss topics relevant to early childhood education in India. In our second season, we will interview professionals who work with young children in different capacities. Our first guest in this series is Dr. Isha Soni, a pediatric occupational therapist, a founding member of the Lexicon Rainbow School, and the head of the Lexicon Rainbow Therapy Centre in Pune. We are excited to have Dr. Soni share her insight into working with children with various needs. We hope our conversation will be a good resource for parents seeking information on how best to help their children.
Dr Soni, thank you for joining us here at for all our kids. Please tell us a little bit about yourself, including your education and your work.
Hello, dear listeners! I’m Dr. Isha Soni, a senior occupational therapist and a mom to a seven-year-old now. I’ve done my bachelor’s in Occupational Therapy from KEM School and centre, Mumbai, known as one of the best occupational therapy centres in entire Asia. During my journey, I have been very interested in pediatrics particularly and that’s what I pursued. I have done numerous courses in pediatrics, which helps me give my best to pediatric clients.
At Lexicon Rainbow, I’m heading the entire rehabilitation team that we have, comprising of special educators, occupational therapists, physiotherapists, speech therapists, and speech-language pathologists doing feeding therapy as well. We have founded this centre keeping in mind to provide everything under one roof to our parents and children so that they don’t have to run to different places to get different therapies and we also firmly believe that we get the best results when we work in sync as a multidisciplinary team to get the best for every child. I have been working particularly in the field of autism for the last twelve to fourteen years, with sensory integration therapy being my key approach to children.
So, you have a multidisciplinary team in your centre! That’s actually really helpful for parents.
Yes certainly.
Can you tell us what sparked your interest in occupational therapy?
Yeah, so, maybe when I was thirteen years…, fourteen years old, I knew I was inclined towards science and inclined towards health professions, and I certainly wanted to do something related to that. But I didn’t want to enter the rat race of being an MMBS doctor or pursuing dental, with due respect to each of the fields. During that time, I came across one of our family friends who was an orthopedician and he actually told me about this profession. This profession, occupational therapy, was doing very well abroad in the US and Canada then. This I’m talking about as early as 2002 and 2003. He sparked my interest in this and told me this is the next thing in the healthcare profession, and not many are inclined to do this.
When I found out more, I researched more on this; I felt that this is where my interest lies. I remember my uncle telling me that an occupational therapist’s job starts just where the surgeon’s or doctor’s job ends. That was something that was close to my heart, and that’s how it sparked my interest in occupational therapy.
That was a good insight, what your uncle told you.
Yes, certainly!
What is your experience working with children? What conditions do you typically treat? Do you specialize in any particular age group?
Yes, I just love working with children. It has been an amazing fourteen years of working with pediatric clients. Every child teaches me something not mentioned in the book, and there are times when I have to just trust my own instinct. I usually treat autistic children, children with sensory processing issues, Down’s Syndrome, Attention Deficit Hyperactive Disorder, or any form of global developmental delays, maybe due to seizure disorder or any hypoxic brain injury at the time of birth. I specialize in the early intervention age group, from twelve months to three years, especially with children who are at risk with autism and have sensory issues.
That is a lovely age to work with. I used to work with the same age group.
Yeah, totally! Yes, yes!
What is the process of intake at your centre?
Right from the start of my career, I have never worked in isolation. I have always been part of a multidisciplinary team. I got this opportunity to head an entire department of behavioural and mental health services very early in my career. So, every child who comes to us is referred either by a developmental pediatrician or a child psychiatrist.
So, they’re already coming to us with a diagnosis, or the child is put at risk for certain developmental delays. The child is first carefully assessed, and the concerns and priorities of the parents are understood as well. The case coordinator then allots the child to the respective therapists, and a reassessment is done for the child every four to six months, as deemed necessary.
Parents are a very important part of the team, from setting goals to being present during the therapy, executing the home program, and addressing the concerns of parents as they arise. The parents also receive counseling from the respective therapists to begin with this entire process of therapy and early intervention. I believe that it is very important for the readiness in the parental mindset. Then only we can see a change in the child.
Yes, we cannot stress the importance of parental involvement in the child’s progress because they do the bulk of the work.
Yes, yes! Totally!
Some of our listeners may not be very familiar with the ins and outs of occupational therapy. What is occupational therapy, and how does an occupational therapist help people?
I’m going to give a very broad perspective on this. Occupational therapy is a healthcare profession working in diverse fields like neurology, orthopedics, pediatrics, medicine, psychiatry, deaddiction, plastic surgery, and ergonomics. The main aim is to bring the function in the client through purposeful activities. Mostly, after a stroke or surgery, patients become bedridden or dependent on their spouse or caregivers for their day-to-day function. The occupational therapist helps to develop or improve the compromise skills as a result of injury or surgery in the client.
To cite an example, after a knee replacement surgery, a surgeon’s job is done, and an occupational therapist’s job begins, right from the correct joint positioning, weight-bearing, muscle strengthening, balance and gait, and even ascending and descending the stairs. Or, say, after a brain stroke, the patient finds it difficult to complete his activities of daily living, like eating, dressing, driving to work, and using a laptop. The occupational therapist works on the poor musculature, decreasing the muscle spasticity, fine motor skills, and joint control.
And like I always say, the goals are totally different for every client, be it an adult or a child, despite the same diagnosis because every client has a different presentation.
I know that, for children, we say that they must see a pediatric or developmental occupational therapist. A lot of our parents may not know that because I’ve heard…, had parents come and ask me ‘What is the difference?’
Right!
Is there a significant difference between a pediatric OT and an OT who works with adults?
Absolutely. Just in the prior question, I kind of emphasized how an OT works with adults. So over here, in the pediatric field, like every field, there is an expert who is specialized to work with the particular population or condition. Similarly, an occupational therapist who’s trained in the field of pediatrics would have in-depth knowledge about child development, its disorders, its prognosis, and evidence-based interventions that help to improve the child.
Yes, there is a significant difference between the two, owing to the relevant knowledge of conditions, the experience…, there’s a lot of difference between the approaches we may use. For example, with a child, we try to do most things through play; it being the most important occupation of the child. The goals are also totally different in a child versus an adult, right? So, the setup that we may have and the resources that we may use are completely different.
Also, the personality of a therapist varies a lot in terms of an OT who deals with a child versus an adult.
Yes, I’m sure very different skills are required. Yes. So, what does a typical session entail?
Typical pediatric occupational therapy sessions would entail play-based activities depending on the condition and goal set. To the observer, often to the parents, it may just seem that, you know, what is the therapist really doing? She’s just playing with the child! For a sensory integration therapy session, a child may be engaged to go on certain activities, like sitting on a swing.
Being in the lycra swing, a therapy ball, ball pool, jumping on the trampoline, and playing with different sensory mediums like shaving foam, grain, slime, etc. It is then followed by a tabletop task focused towards the development of fine motor skills or visual perception skills, or particularly targeting the handwriting of the child.
So activities like Theraputty, clay, pipe cleaners, puzzles, blocks, pop tubes, and matching activities may be done with the child. A neurological condition like cerebral palsy, for example…, in that, the child may be first worked on his muscle tone, reducing spasticity.
Putting the child in weight-bearing positions, working on his truncal control good voluntary control at the key joints of the body, like the shoulder and hip posture, balance, and things like this, may be worked on.
OK. Do you specialize in specific treatment methods or techniques? I know you’ve mentioned that you work a lot on sensory integration.
Yes. I’m certified in sensory integration therapy from the University of Southern California. I’ve also done a certification course in Brain Gym and in Handwriting without Tears. For the HWT, I was very lucky to be trained by the founder herself, Miss Jan Olsen.
These techniques, they basically help to address the sensory processing difficulties in children and help to improve bilateral coordination. For example, Brain Gym is really, really helpful for reading, and writing attention span, improving the attention span of the child. And handwriting without tears is a fun method to teach children printing or cursive handwriting in a multi sensorial and fine way.
How do you assess a child’s needs and develop a treatment plan?
So, yeah, we do use certain standardized assessments: Parental interviews, in-depth history taking from the parents, and clinical observations. While we are interviewing the parent, just informally, also having a look at the child and doing certain clinical tests on the child, which we call the neurological clinical observations, and considering the priorities of parents, we develop the treatment plan.
A very important thing is to play with the child or spend some time with the child to gauge more about him rather than just going by the paper-pencil test. You know, in India, we have this space to actually assess the child by playing with him.
In many countries abroad, what happens is the therapist has to just go by the paper and pencil test even if she can see that a child qualifies for a certain service. But if it doesn’t fall in the… in a particular core area on the paper-pencil test, the child is unable to qualify for that service.
So, in India, as therapists, we have a lot of room for this to go by our clinical acumen.
Yes, the kid must qualify for services for insurance to kick in. What methods do you use to educate families about their child’s disability and available resources? That’s such an important part of early intervention.
It is extremely essential to educate the families about their child’s condition. It is never suggested to under or over-promise them, but to let them know and make them understand to set realistic goals and let them set the time frame for the same.
Some families feel that therapy, like medicine, has to show its effect magically within a few days. So, we’ve got to explain to them that we are rewiring the brain and that it is a time-taking process.
You know, the very fact of matter is that the child is having a delay; the child has not attained certain milestones till the prescribed age group or age limit. So, when we are trying to rewire the brain, it is going to take time. We resort to methods like counseling by a psychologist or connecting them to a parental support group at our center, which helps them to give a ray of hope and willingness to pursue therapies.
Right. We, our parents have…, they really struggle when they hear therapy, when they hear the word therapy.
Yeah. Yeah. There’s such a taboo attached to it.
And it takes them some time to see that therapy improves quality of life. It’s not about finding fault with the child but about improving the quality of life.
Certainly, certainly!
What is the role of parents and caregivers in the child’s treatment? How do you involve them in the sessions, and how do you provide feedback on the child’s progress?
I believe that they are the main doers. We are just providing them with guidance.
At our center, the parent is present inside the therapy session and learns about various activities. What works for the child? What doesn’t? What makes the child upset? What makes him cooperate with the therapist? How the therapist guides him into an activity, or how the therapist leads him to the completion of the task, when to help and when not.
There are so many things that the parent can learn, like signs of being overwhelmed or sensory overload, differentiating between a behavior or a sensory issue, a tantrum, or a meltdown. So, by talking to them, educating them, and even celebrating small triumphs for the child, a parent gets motivated to be involved in the session as well as to do the home program given at home.
Yes, that home program is so, so critical! How do you handle difficult conversations with parents about their child’s diagnosis? That early intervention is such a, you know, they’re so vulnerable at that time.
Yeah, I know. It’s easier said than done. I mean, no parent or family would ever want to listen to this, but it’s extremely important to let them know this because if they don’t, then no action would be taken for the child.
I usually explain to the parents in a subtle way, give them a gist of the diagnosis, let them know that every child is different despite the same diagnosis, and request them not to Google! Because, sometimes Google gives a very ghastly picture; they would show the severest of the cases, and then that would make the parents completely lose hope. They become overly anxious, or some of them even go into clinical depression that such is the condition their child is going through.
They would get discouraged rather than encouraged in that case. Often, I see that parents try to find a reason for the condition or disorder, and there’s no clear-cut reason, like in the case of autism. So, the best way to handle it is by telling them that what has happened has happened and what will happen next is in your hands; letting them know success stories of early intervention gives them the hope and determination to move forward. That’s the way I handle it.
It is a hard time for parents.
Right.
And then, when they see progress, it is so wonderful for them.
Yeah, yeah.
Our Indian extended families can be a source of support or strain for the parents and child. Has family Dynamics had a significant impact on your treatment plans?
Yes! I strongly believe once a child is facing any developmental issue, it’s not just the child but the entire family going through it. You know, right from the phase of the denial coming in, then slowly going towards the acceptance, they have their own journey. It’s not easy.
So, I have seen both scenarios of extended family being an immense source of support or, in some cases, being a strain for the parents and hindering the child’s development. A good family dynamic goes a long way in maintaining the balance in the daily routines of the family. The parents are able to work. Therapies are not cheap. It’s…, it’s like an extra source of income, which is certainly needed. So, if the parents have support at home, the child can be brought for therapies by the grandparents or just be available for the child at that time the parents are able to go to work.
When the family dynamics are screwed, the most common reason is denial and a failure to accept. Sometimes, I have even seen certain families disown the parents and the child as they feel somewhere it’s a matter of pride for the family. Having a child with delays is bringing down the family name and is considered to be taboo. So sometimes, other family members are only passive viewers and are not of any help in managing any logistics. Other times when family members are supportive, we still see hindrances in the delivery of home programs for the child. While the mother is taking therapy, if they hear the child crying, they help the child to escape, further escalating certain unwanted behaviors.
Mostly, we call the primary as well as the secondary caregivers of the child, especially when we are trying to eliminate unwanted behaviour in the child. Because if one person follows it at home and the other four don’t, that behaviour is never going to get eliminated.
Right, that is true.
Yeah, because you know the child has an audience for that behavior. So yeah, it is going to motivate the child to keep on doing it.
Sensory Processing
I know you talked earlier about sensory integration. Many times, we get questions from parents. They hear terms like sensory processing difficulties, sensory overload, and sensory diet. They don’t know what those terms mean. Can you shed light on these terminologies and how sensory processing impacts a child’s functioning?
Absolutely!
So, sensory processing difficulties primarily mean…, we are constantly receiving some form of sensory stimulation from our environment, either through our eyes, through our nose, in the form of smell, through our skin, through our muscles and joints, or through our ears. So, we are constantly bombarded. Having a good sensory processing system would eliminate the unwanted stimulation that we are getting from the environment and help us focus on what’s important to us, so we are able to function in the environment accordingly.
For example, when you and I are talking, we are trying to eliminate any background noises. Or we are trying not to focus on other things in the room, we are trying to eliminate other sounds. So, that’s how we are able to talk to each other.
In terms of a child in a classroom, we always say that the child has to be attentive in the classroom, but the child often gets distracted by what’s…, who’s going outside the classroom. What is a child doing in front, sitting in front of the child? If the child sitting behind is moving the legs, even the desk of that child is moving, or the screeching sound of the chalk on the chalkboard, if somebody else is eating or peeling an orange, there are so many things which can distract a child and not help the child to pay attention. This is what I’m trying to explain about regular sensory processing for anyone, be it a child or an adult.
When we say sensitive processing difficulties means…, either our system is oversensitive or under-sensitive to a particular simulation, and it starts impacting our day-to-day lives. A very common example is children not going for hair trimming sessions because they may be getting too overwhelmed by the sound of the hair dryer, or they don’t like the trimmed hair falling on their face or touching the nape of their neck.
Usually, children are in the salon; in the common salons, the height of the chair is too high for a child to sit on, and that leaves their feet dangling. So, for a child who is not very sure about his body movements and balance and processing, it’s like a fight or flight response for the child, “I must come out of the situation as soon as possible.”
Or it may even be just wearing any festive clothes, cutting the tags, or being overwhelmed by the day-to-day sounds in our home like a cooker whistle or mixer grinder. These are the over-sensitive examples that I have cited.
The under-sensitive children may be constantly seeking movement. You will never find the child sitting at home. The child is constantly pacing or moving his head to feel oriented. So, it’s like a visual-vestibular stimulation, which the child is constantly trying to take. This child will certainly have issues paying attention because the child is constantly moving. That’s an example of an under-sensitive system. This is what is called as sensory processing difficulty.
Coming on to the next term of sensory overload, by overload, we mean that it is too much of something. So, when the sensory stimulation from the environment becomes too much for the child, for example, going in a festive procession or going to a mall, the child’s senses, all his senses, are bombarded at the same time, and it becomes too much for the child. It’s like an extremely noisy room with everything moving around us if I have to just say it in layman’s terms.
A sensory diet is a set of prescribed activities given to the child that can be incorporated into his daily routine, which helps him to stay grounded, be focused, or participate in activities to which the child is aversive to. So, that is what makes up a sensory diet.
And yeah, I did speak about how it impacts a child’s functioning. It would impact a child’s functioning in terms of play, like, you know, playing in the park. If the child is a little aversive to movement or is not comfortable with his feet off the floor, or off the ground, the child will not climb to, climb on to equipment like a slide or swinging, or if the child doesn’t have very good muscle and joint sense, the child may not be able to peddle his cycle.
Or in the class, when the child has…, when the child is oversensitive to certain touch responses, the child will not stand in the line. This child is always seen standing outside the line. Because, especially younger children, they just tend to stick to each other, and this child doesn’t like that. The child at the front is sticking…, the child behind is sticking to the child.That is then often seen as disobedience. “Why aren’t you standing in the line?” The child just gets reprimanded by the teacher. So yeah. that is how it impacts the child’s day-to-day functioning.
So much of children’s behaviour is related to their senses!
Yes! Absolutely! I mean, it forms the base of the developmental pyramid for children.
So, how do you incorporate sensory strategies into treatment?
Yeah. It is extremely essential to understand the child’s daily routine, and then only we can incorporate these activities. So, for example, for periods where the child has to be focused or be involved in any form of tabletop activities, we suggest giving the child some form of proprioceptive input. Proprioceptive input simplified is…it means heavy work activities; doing any pushing, pulling stuff, helping to push buckets of wet clothes, or doing any whole body movements or big joint movements like wiping a table, wiping a blackboard, things like that, or doing some simple push-ups on the floor or pushing on the hand of the teacher or the therapist. That will make the child ready for doing any table task or a writing task.
It is like a readiness activity where the muscles and joints of the arms kind of get activated to deliver a good fine motor task. Or even if the child is going to go for a hair trim session or doing a nail trim session, you know the deep pressure at the shoulder would help the child. Or even giving certain or even using any form of vibratory tool, like a massager, that would also help the child intake that stimulation or the process of going through a haircut. This is how sensory diets work, where a therapist who has a good understanding and knowledge of how the sensory systems work in sync with each other. She would then give these activities to the child so that the child is able to perform in a good way.
To be Continued…
Click here for other episodes in this series:
Occupational Therapy and Early Intervention: Interview with Dr. Isha Soni, Part 2
