CHAPTER 12

OCCUPATIONAL THERAPY, BEHAVIOUR THERAPY AND SPEECH THERAPY

Occupational therapy

I recommend early intervention as it helps children reach their full potential. During our therapy sessions, we focused on expanding Noah’s cognitive skills. Executive functioning focuses on a set of cognitive processes which are attention control, cognitive inhibition, inhibitory control, working memory, and cognitive flexibility.

I understand cognitive processing as a set of thoughts broken down into steps, enabling learning and problem-solving.

Attention control is concentrating one idea at a time and applying the process of practice into action. Cognitively, Noah forms a mental problem-solving ability to transmit that step into a problem-solving approach.

We set workstations up with different activities displayed on the three tables. One table has a puzzle; the second table is a handwriting task; and the third table consists of clay coloured sand, which is for sensory finger-hand play. We put up numbers above the tables showing first, second, and third, so this assists Noah to stay focused; once he has completed the task at one table, he moves onto the next task. ¹⁷

We are enabling him to guide himself independently in an orderly way—setting workstations with different multisensory activities is an excellent idea to keep children busy while being at home. Looking from a distance, I could see Noah attempting to use his problem-solving abilities to work out the instruction given by the therapist. His mind appeared to be contemplating a solution; as his thought processes were at work, he was hands-on with the sensory activities.

We thought we would promote independence for Noah as we were getting him school ready and assist Noah with occupational therapy after school as well.

We did mixed sessions with the integrated therapy approach.

We are working on areas of intervention with fine motor skills with Noah completing handwriting tasks promptly.

Problem-solving task with a jigsaw puzzle I sat with Noah while he is doing a wooden jigsaw puzzle.

The pieces of the puzzle are spread out for him to see clearly.

Looking at the jigsaw puzzle, I identify where a piece of the puzzle belongs, waiting to see if Noah is responsive and is quick to problem solve. His eyes are moving in all directions, looking a bit lost about where the piece of the puzzle fits.

The movement of his fingers shows he is trying different angles, identifying where the part fits. I see his mind displaying cognition as he is breaking the steps down mentally, collecting his thoughts to process, using the problem-solving approach. I could see Noah’s confidence was changing, as he started seeing himself as a learner.

Noah needed support to maintain attention with reminders to ‘complete the puzzle’, ‘do you think it goes there, this piece of the puzzle’; asking Noah questions helped him focus on the tasks.

Handwriting task

We have made progress with Noah’s fine motor skills as Noah has developed a right-handed dominance for fine motor tasks.

Noah and the therapist have focused on letter formation with handwriting. He has some writing difficulties with horizontal lines and vertical lines.

Therefore, to build the strength of his muscles in his hands and flexibility with letter writing, we did hand dexterity activities such as playdough, paper scrunching, using tongs, and tasks with pegs.

Next, the handwriting is practised on the chalkboard. Noah has a sight alphabet chart on display so he can see the letters. He looks like he has the correct pencil grip held and draws with the chalk a B. ‘You got it right, well done that is a B; you did a great job,’ says Anna.

Activity with clay coloured sand

Next is the magic sand. Noah moves his fingers, feeling the texture while refining his fine motor skills. He is enjoying the sensation of the sand running through his fingers. He keeps doing repetitive movements with his hands and fingers, manipulating the sand, placing sand in his hands, pouring the sand out through his fingers.

He looks contented with what he is doing.

In the occupational therapy sessions, we learn independence, identifying, and knowing the sounds of each letter. One of the best ways to learn is by listening to the alphabet phonics songs. Letters and numbers game

You can play a game with letter cards, matching with a lower-case letter to a capital letter, making a pair. We also practise number recognition with counting in a sequence where Noah says the missing number. For instance, we put number cards (1-50) in a sequence, with a missing number. Then Noah puts the missing number in the right place up. He is demonstrating understanding with sight and sound.

Better handwriting skills

In the occupational therapy sessions, his handwriting skills improved greatly. He is enjoying handwriting more and getting more particular on being a perfectionist with how good his letter writing is. If he wasn’t pleased with his first attempt letter writing then he got an eraser and started over, completing the letter to his expectation.

Noah’s problem-solving abilities developed as he became more cognitively aware and more consistent. I could see his little brain thinking deeply and how he liked the challenge of getting it right.

Noah advanced in skills and knowledge with all the therapy sessions and improved his overall learning skills which, in turn, improved his overall performance and confidence.

Pencil control task

‘Noah you are so enjoying this activity,’ says Anna. She says to me, ‘I can see his mind concentrating on the task.’ Noah is in a sitting position on the table holding a pencil, applying pressure on the paper while drawing a picture. ‘What are you drawing?’

Anna asks. ‘A boy with his dog,’ Noah remarks.

Throughout the sessions, there are activities planned for sensory, visual, and cognitive ability.

The occupational therapist asks Noah to sit at the table. I see from Noah’s facial expression that he is eager to participate. He has a smile on his face. Anna explains. ‘Now this is what we are going to do: some letter writing practice. By using our hands and fingers in the air, we are pretending to do an A. This is how we write A.’

Noah has held his fingers in the air and using his fingers in the direction of an A using his magination. ‘Perfect,’ says Anna.

‘Now, Noah, we get to play a game of snap. Here are your cards.

I have ten cards as well, then when we both get the same picture, we see who can snap first.’ With a quick reaction out loud, Noah says, ‘SNAP, I won, you’re too slow.’ We all laugh hysterically.

In the occupational therapy sessions, we learn independence, identifying and knowing the letters/words and numbers, visual formation with sight and sound, practising readable handwriting skills, following verbal and written instruction.

Social game—guess what face I am.

We played games to improve social skills by taking turns in reading each other’s facial expressions. Noah displayed a sad face then the therapist said, ‘Noah you have a sad face.’ Then Anna displayed an angry facial expression. ‘You have an angry face,’ says Noah.

Noah is a visual learner, so Anna showed social story pictures of the body language signals of Children. Noah had to interpret the children’s body language. Body language is a form of non-verbal communication.

In the picture, the sad-faced child has their arms crossed, looking away in the opposite direction when spoken to, with arms crossed, not engaging with the teacher.

Each diagram is broken down into pictures creating a story, with examples of body language. Noah concentrated on each image and linked it together with the connection of the story.

He could understand, ‘The boy was sad with his armed crossed not listening to the teacher.’ Noah grasped social cues: ‘The boy’s eyes are not looking at the teacher.’

‘That’s right, Noah. It is essential when talking to someone to give eye contact, isn’t it?’ says Anna.

There was another diagram indicating how the boy should have acted with the teacher. Anna pointed out to Noah. ‘The boy is looking at the teacher with eye contact and arms not crossed and a happy face, which indicates positive body language.’

The visual clues were helping Noah with maintaining healthy relationships.

Cognitive repositioning skills

We played a game with a box to practise Noah’s cognitive repositioning. The therapist placed a toy under a container and said to Noah, ‘Can you guess what’s under the box?

Noah said out loud, ‘A dinosaur,’ then he turned the box over.

A turtle with a bright grin appeared. Then Anna said to put the turtle on the left side of the box. With quick thinking reaction, Noah put the turtle on the left side of the box. ‘Well done, Noah.

I bet you can’t put the turtle on top of the box,’ said Anna.

A moment of hesitation, then his facial expression radiated as with a fast reflex action he switched the turtle to the top of the box. A playful grin appeared on his face. ‘Now put the turtle on the right side of the box.’ Noah instantly responded, grabbed the object, and tricked Anna to place turtle on the right side of the box.

‘Now, I bet you can’t put the turtle over the box,’ remarked Anna. With anticipation, appearing proud of himself, he quickly put the turtle over the box.

‘Close your eyes, Noah. Guess where the turtle has gone?’

His eyes opened, and an intense look full of mystery appeared on Noah’s face. Delighting in not being beaten, he responded by flipping the box upside down. ‘A turtle, you didn’t trick me!’ said Noah.

Noah has learnt to reposition; he comprehended these skills, showing practical understanding by following through with completing a task. His confidence was improving and growing all the time.

Improving literacy skills

Literacy is reading and writing. As we assisted Noah with these skills, we noticed he had a blockage with letter-sound awareness.

When Noah saw letters, he couldn’t immediately recognise them and say the letter sound. However, with lots of repetitive practice, saying the sound, one letter at a time, he learnt to recognise all twenty-six letters.

We did repetition exercises to teach the letter sounds, enabling Noah to become a better reader. Storytime reading is essential, as children grow to have a love for books. The more consistency there is with reading and writing, the more impulsive it becomes and enjoyment flows with learning.

Letter sound awareness and skills were taught rigorously.

Anna said to Noah, ‘What is this letter A for apple—AAA?’

Sounding out loud the sound AAA, Noah had a confident high tone sound in his voice. ‘Great job’ said Anna.

‘What’s this letter B for ball—BBB?’ Sounding out loud the sound BBB, Noah says, ‘B is for a boy.’

‘That’s right, fantastic work, Noah.’

We carried on until all the twenty-six letters were known and recited.

Noah was amused, relating to sounds of the alphabet in a fun approach through assorted picture cards with sounds relating to visual clues. He was looking interested as the picture cards were colourful and animated with images.

At times, his barriers were due to the anxiety of getting it wrong.

While doing a task he sees as difficult, he becomes anxious. The therapist recommended small amounts every day for perfectionism.

Letter sound knowledge becomes more successful with small and cute frequent sessions of reciting consonants and vowels.

He wants so much to get it right the first time, which can cause stress. We overcame these barriers by working on his strength, which was letter segmentation, to build Noah’s confidence, easing the anxiety levels. We also encouraged him to squeeze a stress ball in the palm of his hands when thinking of the letter.

I would often give specific praise with respect. ‘Noah, it is better to try than not to attempt to try, when learning. This makes you a bright spark that is so smart.’ At times, before arriving home from school, we would stop at a park to do his homework.

We would have gaps in between learning with a reward system allocating ten minutes’ playtime then returning to homework.

There were times we would say to him, ‘Do your homework first, and then it can be playtime.’ We made judgment calls based on Noah’s mood, and applied flexibility with the approach to get the best results of completing the task as he is very much an incentive type of person.

Anna and Noah continue forming their relationship; both are comfortable with each other and have a bond.

‘How was your day at school?’ said Anna.

‘I enjoyed playing with my friend, Baxter,’ says Noah, winding down from a busy day at school. Often, he goes into quiet mode before arriving at the therapy session. It is his way of recollecting his thoughts for the day and mentally processing. I observe him in the car. He is in a non-talkative state, a calm and peaceful way of watching Mum drive the vehicle.

Anna spoke about the expectation of today’s therapy session.

‘Noah, today we are going to do two set tasks, then you can choose a preferred job.’

‘Okay,’ replied, Noah.

At the start of the lesson, Noah required help seeking movement with sensory regulation; this builds a mental focus to regulate himself to complete a task called a ‘sensory meal’.

We set a game up, placing a bin a few metres away from where Anna and I were standing. I had scrunched paper that looked like a ball in my hands; this builds hand dexterity skills.

Noah was hypersensitive, hiding under a chair. We were trying to entice him out from his hiding spot.

‘See, Noah; we are throwing paper in the bin to see how many points we get. I will win.’ At this point, we were getting competitive. Noah was getting curious, I noticed, as he kept looking at us to see what we were doing.

Noah’s senses were a little overwhelmed and he was in a withdrawn state of not wanting to interact. We didn’t give him attention; instead, we played a game of UNO. Noah was still under the chair. We laughed and got to know each other better as a parent-therapist friendship.

We enjoyed chatting, observing Noah was still in his cave, not wanting to engage with us. I had not had the chance to connect and ask about his day at school yet, as there was a short gap from picking him up from school and making it to the appointment. I wondered how his day at school was.

Noah was by my side and is prodding me with a finger, but not saying any words. His facial expression appeared agitated, he was relentlessly prodding me underneath my arms for five minutes, it was escalating. He was becoming more physical towards me. I asked him, ‘What’s the matter, why are you acting like this?’

No response, then he started hitting the computer keyboard on Anna’s work desk. He was becoming more extreme. ‘Noah, you can’t do that to Anna’s desk.’ Then all of a sudden, he became  physically rough. Anna and I were trying to calm down the out of-control behaviour, but he walked out of the therapy session.

I was humiliated, but Anna comprehended. ‘I’m in the stage of I don’t know what this is all about,’ I apologized on Noah’s behalf to Anna, and we said goodbye.

Effective communication is the key.

I was in the car with Noah on the way home when he had an emotional outburst explaining to me that the reason why he was acting that way with Anna and myself was because he was getting bullied at lunchtime at school.

I asked him what happened and who was involved. He explained that there were all these friends playing together, then a boy assaulted him, and he fell to the ground.

I said to Noah, ‘Did you tell the teacher or confront the boy who was treating you that way?’

‘No,’ he replied. ‘I just walked away and said nothing.’

So, I said to him, ‘Next time, say to that person, “you are bullying me; stop it don’t treat me that way. I don’t like it, and if it continues, I will tell the teacher”.’

Children need to have confidence and stand up for themselves and not to be bullied. I said to Noah, ‘It was mean to be treated that way.’

‘Yes, Mum.’

‘So, a lesson learned, you treat people how you like to be treated.’

Noah said sorry, and he was back to his normal self. I emailed Anna, letting her know the reason why it was an explosive ending to the therapy session

There was continuous support for Noah as he attended occupational therapy, behaviour therapy and speech therapy regularly.

Behaviour therapy

We desperately required parent intervention strategies to help our precious child grow to his full potential therefore we implemented behaviour therapy strategies. We had smart goals for Noah’s development. The three small goals needed to be realistic, achievable, and appropriate for where he was developmentally.

Our first goal was working on independence for Noah in the home base setting and at school. The second goal was reducing his emotional meltdowns in the home setting as at school he had no emotional meltdowns. Thirdly was for Noah to follow the home base structure throughout the weekday.

Helping independence

Visual supports are the best; you can use visuals in every setting type. Visuals can be used at home, consisting of images of morning expectations of showing what tasks are needed to be completed before school began. Using my motherly instincts, I put together a visual flip schedule with a behaviour specialist so Noah could see the expectations I required of him before arriving at school.

Visual flip schedule for mornings

On the visual flip schedule are pictures of Noah:

• Waking up.
• Eating breakfast.
• Reading.
• Getting dressed.
• Brushing teeth.

Noah is a visual person, so he was able to see what his tasks were. Once Noah had woken up, I would show him the visual flip schedule. In a typical morning routine, once Noah had completed each task, his hands would close the flip schedule down. I used a plastic container, usually used for pills, with the pictures displayed on the outside of each section using Velcro dots. Noah could see each picture and identified the task he had to complete. The incentive to get him to complete the task was five Skittles (a type of lolly) in each section of the pill container.

This prompted him to be responsive to gain the reward system.

I changed the incentive by changing the lolly type from Skittles to chocolates to create a surprise factor so he didn’t get bored with participating with the same reinforcer and to increase the likelihood of him wanting to complete the morning tasks before school started. He enjoyed the structure as it provided more security for him and reduced his anxiety and unwanted behaviour.

Using this strategy, the mornings seemed to be more relaxed and peaceful in the home Environment. In the car, on the way to school, I would allow Noah to have game time on the mobile phone, but I would monitor how much time he spent playing games on the mobile or iPad. I used a visual clock timer and said to him, ‘You have half an hour,’ or at times one hour and put the clock on the timer. Time on the visual clock would expire and I would say to him, ‘Please hand me the iPad or mobile, as fair is fair; that is the rule. No more; if you don’t finish now then next time in the car you will go without.’

If Noah didn’t listen to me and give the device back immediately, I would display a sign in the front windscreen saying ‘No-phone or iPad’ as a visual picture of this rule. The next day, he would see the follow-through punishment of no technology

in the car, via a sign displayed in the front windscreen.

To reinforce this rule in the car on the windscreen, I had a sign with a phone with a line through it and the word ‘NO’.

I would say to Noah, ‘Check the car and see if today you are allowed the mobile phone or not.’ The visual clearly shows him YES OR NO on the days when we are commuting in the car.

At afternoon pickups from school, we applied a positive reinforcer again, encouraging Noah through clear visuals of what his expectations were after school. Visual supports are the key to making the parenting instructions more accessible instead of using verbal expressions, because it helps the child retain and process information.

Visual flip schedule for afternoons

On the visual flip schedule displayed the pictures are of Noah:

• Home.
• Relaxing.
• A picture of a television.
• A picture of a snack.
• A picture of homework.

Again, after the completion of a task, Noah closed the flip schedule and opened up the compartment container to get five Skittle lollies or whatever surprise he found. Once that task had been completed, I gave him words of affirmation to make him feel that it was an amazing achievement and that ‘Mum is so happy with you.’

In the school setting, we used the visual prompting with a visual flip schedule through which the teacher would instruct him what to do, step by step, with an activity to be completed. This encouraged more independence. The teacher would say to him, ‘Have you done that one?’ pointing at the visual. Noah would say ‘yes’ or ‘no’ then the teacher would prompt Noah to the next visual to complete the task.

What-to-do stories and social stories

In class, the teacher would read out to Noah what-to-do stories or social stories which helped him engage in a group and participate with social interaction. Reading out loud to Noah what-to-do stories supports his independence skills.

We read social stories at home as well such as ‘How are you feeling today?’, ‘Why Bully Me?’, ‘Be Careful and Stay Safe’, ‘Be honest and Tell the Truth’, ‘Be Polite and Kind’, ‘Cool Down And Work through Anger’, ‘Join In and Play’, ‘Talk and Walk It Out’, ‘When I Feel Afraid’, ‘Understand and Care’, and ‘Try to Stick with It’.

Verbal instruction

When giving Noah instructions to perform a task, we found what worked best was to break down the steps to him in a simple way. This helped him not to get overwhelmed by providing too much information all at once. I give him a one-step or two-step instruction, helping him not to have an emotional meltdown and reinforcing positive behaviour. When Noah is over-stimulated, all worked up and overwhelmed, an explosive outburst would always happen. At times it would be a case of an extreme meltdown, so we had to start from the beginning; we had to teach him how to control himself. We learned to identify the trigger signs of intense anxiety. There was a point of accumulated frustration that would lead to an overwhelming state of meltdown.

Parenting sensory strategies suggestions

Noah enjoys movement-based play like jumping, spinning, etc.

He requires a release with being physically active while mentally processing information.

Within the home environment, Noah requires sensory activities for him to emotionally self-regulate, therefore making day-to-day activities more effective in achieving success. I will share what sensory activity suggestions I have tried. Using sensory activities helps Noah complete tasks, follow parenting instructions, and enjoy his day.

The advantages of adding consistent sensory processing activities on a regular basis helps him to function and perform to the best of his ability in terms of helping himself regulate neurologically. Whenever he is performing a sensory activity, his nervous system is much calmer.

One sensory activity was a sensory alphabet hunt—to rehearse the alphabet, making it a fun way to recall the letters of the alphabet. We used a sensory tub with raspberry-scented, yellow-coloured rice. Noah was able to feel the sensation of rice through his fingers plus it was a fun way of learning.

Noah also found holding a fidget toy in his hands that would spin around, would help him concentrate and regulate his thought processing skills when engaging in conversation.

While watching a movie or television Noah would sit in a bean bag, he would move his body in all angles and positions helping him to physically regulate with movement; this action would result in him being in a relaxed of state of mind.

When we were learning about colours, we had egg-shaped containers full of different coloured dinosaurs, and inside each dinosaur, there were smaller coloured dinosaurs. We would have a big tub, fill the tub up with jelly, then placed all the big and small dinosaurs in the jelly tub. Then using his fingers and feeling the squishy feel of the jelly, Noah had to pull out each dinosaur, placing each one in the right coloured egg.

If you have not yet done a sensory test with your child then it would be a good start, which would give you an indication of what type of sensory props are required for your child. Each child’s sensory profile, and what is required on an individual basis, is different.

We would see the warning signs like restlessness and agitation before the frustration started. Noah gradually recognised the signs, which would stop him from having an overwhelming state of a

meltdown. We taught him to self-regulate by identifying the signs or triggers of becoming upset. If we intervened at an early point of capturing these emotions, then Noah could manage himself and remain in a calm, collected state of mind. That’s when we introduced teaching him self-control and breathing techniques.

Noah soon grasped an understanding of the structure of routine through everyday activities.

Again, we used sensory activities, social stories, and visual supports to help him with his smart goals.

Speech therapy

Speech therapy uses visual aids to help with communication so children are set up for success. Children learn imitation skills by copying adults; it could be by body language or non-verbal and verbal communication. Children love to see pictures, so visuals can be a form of communication.

Communication is essential for children to express their needs and wants. Speech therapy works on the power of communication, which works in conjunction with sensory processing needs.

All children have different needs with sensory processing, and speech therapy encourages lots of sensory activities to meet the needs of the individual.

‘Hi, Noah, how was your day?’ asks Vicky, the speech therapist.

‘Good thanks,’ says Noah as we arrive at our usual weekly speech session, which focuses on reading and literacy. Sounding the letters out and segmenting is a vital point of Noah’s learning.

We all are sitting all in Vicky’s room. We start by Vicky sharing an overview of what today’s session looks like. Vicky tells Noah he’ll do a little bit of reading, a little bit of a game!

Noah is responding by acknowledging Vicky, commenting, ‘Can we play UNO?’ It appears Vicky is giving Noah a choice of what games he wants to play.

Noah walks over and, glancing with interest, he picks a crocodile game and an octopus sensory toy. Vicky says, ‘Your choice is UNO cards, crocodile game, or play with octopus.’

Noah loves to play the game during his therapy session.

Vicky writes letters on a board: T M S B P N.

Then Vicky asks Noah what each letter says, and Noah sounds them out.

Vicky writes the word: PAT

Then Noah sounds each letter to make the word PAT. ‘It is “pat”,’ says Noah.

This is called ‘blending and segmenting’ where individual sounds are put together to make a word.

During prep, when Noah first commenced early years of education, we identified the initial stage of saying the sounds from A to Z. He was okay but struggled with saying the sounds of T, F, and Y.

Noah’s strength is putting the sounds together: segmenting.

‘Can we play with the crocodile now?’ says Noah. Vicky gives Noah five minutes play before returning to the therapy.

‘Now, Noah, we are going to do five words, and then we can play with the octopus sensory toy.’

Vicky writes these words on the board:

MAT

SIT

LID

NAP

TAP

I sense a bit of anxiousness, as Noah’s facial expression appears serious.

‘I will help you, and together we can do it,’ says Vicky.

Noah starts with the first word: M A T

Sounding out M, ‘Say M.’ Vicky is putting her hand on her mouth; Noah is imitating the action by putting his hands on his mouth and saying M. Then the A sound, then the T sound.

Noah is saying out loud the sounds of the word MAT then saying the word MAT.

He is successful in saying all five words then plays with the octopus sensory toy. ‘It feels soft,’ Noah says. Noah’s fingers are pulling and grasping the tentacles, which seemed therapeutic.

The speech therapy is over; I praise Noah with a positive confirmation. ‘Well done, Noah, a great effort, you did well, trying hard. Let’s go and have a look in the crystal shop, as a reward for trying hard.’ As we enter the shop, he shows his fascination with gemstones and admires the fine details.

Noah is observing all the different types of gemstones. I ask him which ones he already has. ‘Amethyst, turquoise, amber, rose quartz, tiger eye, and aquamarine,’ he replies. ‘Mum, what is this one?’ picking up a new gemstone he has not seen before. ‘It looks like smoky quartz. Can we buy this one?’ With a sense of being proud, ‘It is brown,’ says Noah.

I give him $10 to pay the sales assistant. As he gives over his purchase and the money, he has a smile on his face. ‘Here is your change, and keep it safe in this gift bag,’ the shop attendant replies.

‘Thank you,’ Noah says.

We quite often enjoy having our intimate one on one time as we laugh, joke around together, and I see this means the world to him as he knows we are truly devoted to each other and senses the togetherness.

During the speech therapy sessions, Vicky reassures me that for reading and literacy to become routine, it needs practice by sounding the letters and segmentation words together every day for fifteen minutes at home.

As a mother, I planted the seed for learning. As we continue attending therapy sessions, I can’t wait to see his progress with learning.

Time to reflect.

1. Do you think committing to regular occupational and speech therapy would be helpful for your child?
2. What areas are your child’s main concerns and what support networks are there available?
3. What are your child’s weaknesses and strengths?

Time to act.

1. If you think therapy would be beneficial, make an appointment and start the process.
2. Contact the support networks to guide you in the right direction for your child’s concerns
3. Work out an action plan for your child to turn weaknesses into strengths.
4. Make enquiries to seek professional support to implement change to support your child

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