Last week, we began the second season of our Teacher to Parent podcasts. We aired part 1 of our interview with Dr. Isha Soni, senior paediatric occupation therapist at the Lexicon Rainbow Therapy Centre, Pune. Today, in Part 2 of the interview, Dr. Soni addresses common stressors for parents: toileting, picky eating and handwriting. She also addresses how a pediatric OT can guide parents to help their child develop age- appropriate skills in these areas.
OT and Early Intervention
Dr. Soni, the OT structures the sensory diet to meet the child’s needs. Now, can you elaborate on the link between toileting and sensory processing?
Oh yes, I would say that sensory processing is a very important and crucial part of toileting. Yeah. So, I was saying that sensory processing is a very natural part of toileting process. We just spoke about being under-sensitive or over-sensitive to certain sensory stimulation. So, for a child who’s under-sensitive and if we are trying to toilet train the child, or we are trying to take the child to the bathroom, that child would just end up playing in water. The child may be just involved in playing with other toys or just moving around in the washroom rather than sitting on the pot. That is one sign for being under-sensitive. In over-sensitive, for children who are oversensitive, they may not like the cold feeling of the toilet seat, or if the bathroom is wet, they may avoid going to the bathroom. Or, as I just told about children who are sensitive to movement and heights, they would not like to sit with their feet dangling on the seat. They may not like the sound of the flush. These are certain hindrances that we see in the toileting process.
Also, interoception is what we call as the seventh sense. In sensory processing, interoception is the internal cues that our body gives us like That we if we get that rumbling feeling in our stomach, we know that we are hungry or the feeling of fullness which kind of cues our brain that we need to go and empty our bladder. These are certain interoceptive senses when a child who has sensory dysfunctions, the child will not really relate and read these cues. So what happens is they may not have regular toileting habits, and then they end up being constipated. It’s very difficult for them to pass stools.
Some children, they like the feeling of holding on. In that case also toileting becomes very difficult for them because holding the stools for a longer time kind of absorbs all the water out of that and then it results to hard stools. Especially, we also get to see this thing in autistic children…, that they are not very comfortable using washrooms other than their home. And even if there are three or four washrooms in the house, they will use only that one particular washroom. They like same things and they wouldn’t use a washroom in the school, or daycare or a therapy center that they visit.
Yeah, the toileting process is indeed very…, it kind of goes hand in hand with the sensory processing. As we see improvements in sensory processing, we get to see proportionate improvements in the toileting habits as well.
What you said about the interoceptive cues…, about not being able to pick up on the sensation makes so much sense. An OT is a great resource for parents when they toilet train their children. Do you work with children with multiple diagnosis? How do you adapt treatment for children with such complex needs?
Yes. So I do work with children who have multiple diagnosis and the way to go ahead with that is… number one is prioritizing what the child needs now and where the child is stuck. For example, without having a good core, a good core strength, one really cannot work on the fine motor skills of child. We always say proximal stability before distal mobility, meaning that it is very important to have that truncal control or good core strength or a good sense of control at the shoulder before the fingers and the wrists can produce quality work. You got to prioritize and also see where the child is stuck. Without normalizing muscle tone for the child, you really can’t work on the standing balance and control of the child because the muscle synergies are really, really important when we are talking of a complex function like walking.
What is a misconception you’ve heard about occupational therapy? What attitude or action do you wish you could change?
Especially in three tier cities, what happens is occupational therapy is often told or mispronounced as acupressure. They feel we do these acupressure or acupuncture things with our clients and that is something which I have heard from many people. Or certain people, they kind of try to relate it with occupation. As if we are training people for their jobs, like woodwork or tailoring, which was kind of true during the time of World War One, I believe…sometime in 1914 or so, wherein occupational therapist would actually train people to do this. But now occupational therapy is a healthcare profession, and it is basically helping to attain, for a client, maximum independence and function with the help of purposeful activities. The way forward for this is spreading awareness as much as it can. But I personally see that there is a lot of awareness fifteen years before to now…what it was before versus now.
There has been progress in your field as well as mine.
Yeah, yeah, like now everybody knows. What is occupational therapy? We would just talk like OT/PT and things like that, when I was in my college. They used to feel a physiotherapist and occupational therapist are the same, and they do the same work, but that’s not the case.
No, that’s not at all!
We do have our domains and fortes.
How do you measure progress?
I believe getting constant feedback from the parents is extremely important to measure progress. Because the child is there with you in this session only for that forty five minutes or one hour. The child is constantly engaged with you. You are moving on from one activity to another and it goes on. At home, the child is not constantly occupied, and that’s the time where the child is involved in doing certain stims or certain behaviors because the child is all by him or herself.
So, getting the constant feedback from parents that “Yes, ma’am, now he can sit for a longer time” or “Now my child is able to push better.” In the therapy session, we are not actually making the child do the cycling. So getting such feedbacks in terms of function in terms of how nicely the child is able to do the activity or even “Today’s hair trimming session was better than the last one.” Getting such feedback, and of course using standardized assessments. We do recommend reassessment for the child every four to six months. That’s the way we go ahead with reassessing the child.
So, what are the assessments do you use? Are they norm referenced for… well with OT, I’m guessing that they are normed for all children everywhere.
Yes, there are certain fine motor ones. For sensory there is an entire kit that we use for children and. There’s a sensory profile. These are the assessments that we use for children.
Okay. How do you stay current with new research and advancements in the field?
I am an avid reader, who even if somebody tells me that there’s a new course which has come, and I would jump into it. So, like, yeah, I still love studying. And yeah, I do like a lot of research work also. Last year, one of the papers, the research work did get published. It was on identifying signs of autism for children virtually, not seeing the child in person. I am involved in lot of research work and I like reading, attending workshops and I like to attend, certain evidence based practices, if there are any recent advances, going for conferences, this is how I keep myself abreast with the latest developments.
Okay. So, I come back to something we talked about earlier, early intervention. Early intervention is critical for a child to function at the best of their ability. And in our society, there is a general misconception that when we refer a child for therapy, it’s because we find fault with them. What would you advise parents on early intervention?
Yes, early intervention is very, very important for the child, as it can change the complete growth trajectory for the child if it is received early and if it is done well. It certainly helps to improve quality of life. When we are talking about inclusion if we do early intervention, there are high chances of a child going to a regular school. It also depends on what is the degree mild, moderate, severe in terms of autism or how much support or assistance is required by the child.
Right!
Also, it’s very important for parents to understand and I try to tell all of them that “Let’s accept the ideology of neuro differences.” We all are different! I mean, we all fall under the normal, say so-called normal people, but yet we are different. So, we all are different from each other. And the children who show these kind of delays or any developmental conditions they…, their brain are just rewired differently. This is a neuro-difference.
If they like doing something like which we call as self stimulatory behaviors, what our books say so, rather than saying that we can rather say that it is something which helps them to calm down; it is something which helps them to focus so like just rocking back and forth. By doing that, the child is able to process auditory instructions given to the child. The child is able to focus better. Or many children, say when…when they are being spoken to, they kind of turn their face away from the speaker.
What they’re trying to do is they’re trying to eliminate the visual stimulation. So, when any neurotypical person is talking to, for example, an autistic child or teen adult. We are very expressive. There’s a lot going on…, on our face in terms of facial expression, it becomes too much for an autistic child to see that as well as process what we are asking them. They may just turn to look away. Such things we should accept that doing this thing is making this child or this teen comfortable and we should be okay with it, you know, we should not take it as disrespect. “He just turned away his face while talking to me.”
I think educating parents about these things would really help them, again, letting them know about certain success stories, letting them attend certain support group meetings—these are the keys for making them determined and willing to attend early intervention and very important aspect is removing the social taboo to the word therapy.
Right!
I mean post pandemic, there has been a lot of importance and acceptance of something called mental health being equally important to physical well-being. So I think the situation is much better now. The pandemic has certainly taught us what mental health is and why is it important; and why we as humans are wired to be connected to each other. I mean, pandemic led to isolation, social isolation. But then that’s what made us realize that how important it is to be connected with each.
Very true. Have you ever had to address challenging behaviors during the sessions?
Oh, yes! It’s, it’s a joke in our field that we often get bitten or hit by children. Yes, certain children they do have behaviors and it is very important for parents and everybody else who works with the child to know and understand that through behavior they’re trying to communicate something. The behavior is not just happening out of the blue. They are trying to tell…, every behavior is a form of communication for the child, even if it may be just for the attention sake.
I have had certain behaviors to handle like head banging. I had a 2-year-old who would start banging his head on the floor gently if he doesn’t want to do anything. So, like if I’m trying if I’m telling him to do this activity and if he doesn’t want to do it, he would just go and start banging his head looking at me. That is one behavior, another is spitting. Certain children, they just tend to spit or they like to play with their spit. Some children bite in terms of when they are getting angry or when they are trying to escape from a particular activity, or even if it may be throwing toys.
Basically, what I believe is that they’re just trying to escape…in the therapy session, they’re just trying to escape from a certain situation or a certain activity, and that’s why they show behaviors they don’t want to do it. You know, rather than sitting at the table and working on a fine motor skill, they enjoy running in the therapy room. That’s the reason they throw down all the resources kept on the table.
It’s not a case of being disrespectful.
No, not at all! I mean, every behavior is trying to tell something. So you’ve got to read the child and understand the child and try to be at the child’s level. A very important approach, which we didn’t speak about before, was the floor time, Dir Floor time method. I think that’s the best way to connect with the child to get down at the child’s level and do what the child is doing, and you see magic unfold. The child will look at you or the child will connect to you.
So, floor time is an essential part of the treatment for children with autism. I’ve noticed that many parents who contact us with questions, they’ve done a lot of research on the Internet. They find ideas from a mom blogger or a video on fine motor activities. They try those for their kids because they’re excited that they can fix their child’s problem. But then, after a point, their child’s progress plateaus because they’re not necessarily providing the help the child needs. Have you had to, have you had to educate families on the need for assessment and appropriate treatment?
Many times, as I told you that the child comes to our center from a pediatrician or a psychiatrist, and then when we say that, yeah, you know, we need to do an occupational therapy assessment. They often end up saying, “Oh, you know, the pediatrician just did an assessment for us. And why can’t we just begin with the therapy?” This is not just about OT. After the assessment, we talk about the speech therapy assessment.
It’s difficult for parents to digest that why one child, the same child needs so many assessments. You need to kind of make them understand that look, every therapist is going to work on a different skill set or in a different domain for the child, and we need to understand what the child is doing, what the child is finding difficult, and where do we need to start from. So that’s how we can educate the parent and let them know about the importance of assessment.
Talking about mom bloggers or following certain YouTube channels, in India, certain WhatsApp groups are very famous where the parent would take the video of the child…of their therapy session and would then post it in this common parent group saying that this is what my OT did today and the othersCcn try it. But it is not at all a “One size fits all” approach that works with children. It’s…it’s not just to cite a simple example that we all have different tastes in terms of eating. For example, if I like one dish, it doesn’t mean that even you are going to like it. So, the same way when we are talking about sensory differences for the child, if if a particular child is liking a particular sensory activity, it doesn’t mean that the other child is also going to like it.
That’s the very reason that we do a sensory profile in detail for the child to understand the child sensory preferences, not just differences, but preferences as well. What does the child like to do? We have to just strike it, right! We always talk about just the right challenge for the child in a sensory integration therapy sessions. So, we’ve got to fine tune our activity for the child, just that it is not very easy for the child, nor is it too difficult for the child.
So just doing certain sets of activities by seeing some other child’s video is not going to help your child. As you told, the progress kind of plateaus later on. Initially some activities may be helping the child and the parent feels that feels excited about it. “Oh look, I didn’t have to go for the therapy session and I’m able to fix the issues of the child on my own.” But you certainly need that expertise of the therapist to help you guide your child reach the maximum or the optimal level of functioning. So, I think the parent unknowingly is compromising the child’s abilities or is having very limited expectations from the child, whereas the child has got a lot more potential.
Even yesterday, I saw on a parent group some mom had written that their child couldn’t do something. And she had asked for referrals, and immediately there were 10 or 11 responses saying, “Oh, why are you sending them there? You can do this. You just do this. You do that.” No, please! You know, your pediatrician gave you really good advice. Find the professional who will guide you.
Children who don’t have a diagnosis…parents write to us asking for help with their kids, writing skills. And then as we talk, they describe how the kid puts their head on the desk while writing. And we bring up trunk stability; are they able to sit, how’s their muscle tone? Do they have low arousal? They can’t see how that can affect writing skills, and they get very defensive when we suggest an OT. Can you elaborate for our parents on how strong core muscles are essential for handwriting and attention?
Right. Last week we completed the IEP review meeting of our students at the Child Development Center. So, this is like a three monthly review that we do for our parents and we give them an insight about what are the gains that the child has made over the last three months. So, we had one of the fathers telling us that, “Yeah, whatever you told. Is fine, but why aren’t you still doing writing activities with my child?” We had to explain in detail that “Look, the child is finding it so difficult to even maintain a correct seating posture. The child is slouching. The child has low muscle tone in his arms. So, how can we straight away jump to writing?”
To make our listeners understand, I would probably term it in a very simple way that our head, neck and shoulder rest upon a core. For our head, neck and shoulder to be in a good working position, we need to sit erect and that is not possible without a good core muscle strength. In the same way, when the child is made to sit to do writing tasks, if the child is slouching, or if the child is falling out of the chair or the child is sitting only half on the chair… half of his bottom is somewhere in the air, or the child is constantly moving his legs, how is the child going to produce good quality work? We always say good shoulder stability or a good wrist stability for the child to write.
I often tell the parents to imagine writing similar to fishing. You cannot have a good catch with a flail fishing rod. So, the same way if the shoulder, the elbow and the wrist are not supporting, or they are not having that good muscle strength, or the good muscle tone, quality work cannot be produced by fingers. Writing is a complex task. There is eye hand coordination involved. And many of our listeners wouldn’t know the head position actually determines the tone in our entire body, especially our upper torso and the arm. That is how our body is made of anatomically. If the child doesn’t have a good head, neck control and shoulder stability, writing is always going to be an issue.
I hope our listeners take note of that, because the go to response when a child struggles to write is to give them more writing. Another significant stressor for parents is their child’s eating habits. You mentioned that you do feeding therapy. What factors contribute to picky eating habits, and do you have any tips for parents who struggle to feed their children? And I ask this because I know many parents who mash everything in the blender. I once met with parents who were concerned their eight-year-old was unable to concentrate in class and had disruptive behaviours. As we talk, they mentioned that the kid didn’t eat anything except for chips and a few other crunchy snacks. Turns out, they waited until the kid. Was in deep. Sleep and then gave a feeding bottle with an energy drink. Or sometimes the kid would wake up famished at 2:00 AM and gulp down whatever they said. I asked them to work on sorting out the eating before worrying about concentration. A child whose nutritional needs are not met will not be attentive in class.
Yes, So, there are many, many factors contributing to picky eating habits. And I think where I should begin from is for the parents to realize the fact that it is not okay for a two and half year old or a three-year old, or even five year old to eat mashed foods. So, we all are leading a fast life. Also, most of us are in a nuclear family. There is nobody at home to tell the parent that by this age now the child should be able to chew, or now you can increase the bite size of the child or now we must reduce giving milk to the child. Another major contributing factor for picky eating habits these days is screen time. So, we have had children and with histories saying that the child doesn’t eat at school at all, but eats at home. The most common contributing factor is the screen, because in the school the child doesn’t get to see any screen or watch any mobile or TV, and so child is not eating or completing his lunch box versus at home.
In our Indian culture specially, we say that when we eat, we eat with all our five senses. So, when the child is watching the screen, other senses are actually getting subdued somewhere. The child is not really registering the taste of the food or the temperature or the texture of the food, or how much I need to chew it in order to gulp it. Rather the child is just washing it down by drinking lots of water. So, this is how the screen can impact picky eating habits.
When I mentioned about fast life, the mother is in a rush to get to her work or she has other hundreds of jobs to be done at home. Feeding mashed food is convenient for both of them, the mother as well as the child, because it doesn’t take so much time for the child to finish the food versus waiting for the child to chew. That’s the time the mother is not doing anything but just waiting for the child to finish chewing it. It’s a very easy fix. Just grind the food, mash it up and give it to the child, and the child is going to eat it quickly. And as I told in the nuclear family, some parents really don’t have any guidelines about when should a child move on to the solids and when should the child’s milk consuming quantity be reduced and moved on to more of veggies or other fibrous foods.
How about oral sensitivity?
Yeah, oral sensitivity is also a very important thing. Some children, they kind of just gag at certain…, at the sight of certain foods. Or they don’t like the tempering in the foods, especially in Dal we have or even in our vegetables or vegetable curries, we put the coriander or we put the cumin seeds or the mustard seeds. That is not uniform. So children who have oral sensitivity would prefer uniform textures and they wouldn’t really like any tempering into it. And that’s the reason they are kind of aversive to certain fruits that have seeds. For example, guava or a pomegranate! But they would easily eat a banana because it has a uniform texture; and a uniform taste also to a certain degree versus a mango or a grape. If I have to say that some mangoes maybe not very sweet, or grapes, certain grapes are sour.
They kind of prefer the uniformity of textures and they don’t like the food being on their tongue or in their mouth for a longer time…, and hence they prefer mashed foods versus chewing the food; because if the food has to be chewed, the food is going to stay in the mouth for a longer time. Yeah. And they also avoid brushing teeth…children who are sensitive to oral stimulation.
Okay. So when kids have such difficulties with…, with their eating it’s good for parents to approach an OT.
Yeah, and OT as well as an as a speech and language pathologist who is certified and trained in feeding therapy. Because it…, it is not just about eating mashed food. Some parents may have a perspective that I mean, what’s the big deal if the child is having mash food but you are compromising the nutrition of your child. And nutrition, they are the building blocks or that is what is going to help them to grow, give them, I mean their entire degree of wellness depends on nutrition. Nutrition is a major factor for our physical well-being.
Absolutely! We must meet the child’s basic needs before expecting them to concentrate or pay attention in class. And now, or let’s look at our schools. Special education teachers usually know how OT benefits their students in relation to attention, self-regulation, handwriting and more. Where do you think Occupation therapists can help young children and their teachers in their regular education stream.
Even in the regular education stream a child may not have a diagnosis, but a child may certainly have a sensory processing issue or a low muscle tone because children do not get so much of outdoor play versus what we used to get before. Now, they are, their way of play is mostly limited to screens versus going down and playing in the park or if I have to say, like twenty five – thirty years back, it used to be like climbing on the trees or jumping off from heights or cycling, good group games also that we used to play then which seemed to help in lot of physical work and that in result…, and that would actually help to improve the core muscles as well as the muscle tone of the upper extremities. So, educating the teachers about the proximal stability before distal mobility is one thing.
There may be children in the classroom who don’t have a diagnosis but who are constantly fidgeting. So, having certain classroom adaptations like giving them movement before they need to focus…, for achieving an optimal level of arousal. Just listening and listening to the teachers and sitting in that in the same position for long hours will certainly take away the attention span of the child. It’s very important for the teachers to understand that movement is very crucial to learning and there has been a lot of research done on this.
Earlier we used to believe that having a good attention span means sitting the longest hours possible. But that’s not the case. Now it is being proven the other way round that if you give movement to the child…, short bursts of movement the child is able to pay attention better or focus better on a task.
Okay!
If the teacher is aware about these things in the regular school, the teacher can kind of give roles to the child in the classroom. So, for example, if there’s a child who’s very fidgety, then the teacher could just ask the child to come and clean the blackboard or to get something else from the staff room or from another teacher. What the teacher is trying to do is giving this frequent movement breaks or you know to play certain simple games like Simon Says in the class before starting the class.
Also, following the 90-90-90 rule. So, this 90-90-90 rule is very, very important for having a good seating posture for the child which will lead to better attention span and good handwriting in the child. So, by 90-90-90, I mean that the feet should not be dangling in the air. The foot has to rest on the floor, the knees at 90° and the hip is at 90° for the child. I think here I would like to tell the teachers or caregivers or parents that sensory processing difficulties can purely exist without any accompanying diagnosis. I do have children on my caseload who have sensory differences but they are neurotypical. But then these sensory differences are contributing to their growth in the various fields.
It’s good for parents and teachers to be aware of this. Parents can seek timely intervention to help their child, and teachers can find ways to support these kids in the classroom. Is there anything you would like to add that you feel would be beneficial for our listeners?
Yeah. I would just say that every child is different. Go by your instinct for the child. The mother certainly knows what the child needs. If you feel that there is something amiss in your child in the early development years, don’t hesitate to show it to a pediatrician. It is better to know the problem than remaining in the fear of unknown…and taking an action on that and do not compare your child’s progress and limitations with another child. Every child has their progress journeys also. So I think this is what I would like to tell our listeners that early intervention is the key to determine the growth trajectory for your child and do not compare your child with another child having the same diagnosis.
Dr. Soni, thank you so much for taking the time from your busy schedule to talk to us.
My pleasure. We are doing this for awareness…for the parents, because many of them, they still don’t know such problems do exist and there are therapies for it as well. So, it was lovely. Thank you for this opportunity where I can do my bit of spreading awareness.
You’re welcome and thank you for joining us and giving us such clear information.
Thank you so much.
Click here to read more:
Handwriting and Fine Motor Skills
Click here for other episodes in this series:
Occupational Therapy and Early Intervention: Interview with Dr. Isha Soni, Part 1
