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Archive for category: Occupational Therapy At Work

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P is for Prevention

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

In recognition of Brain Injury Awareness month, I thought it would be fitting to start at the very beginning. PREVENTION. Really, it is the best medicine. For now, let’s forget about the symptoms of brain injury and its’ impact on work, home, school, and quality of life. Let’s not talk about how it is assessed and treated. Instead, let’s focus on trying to stop it from happening in the first place.

But even before that, we need to know what we are dealing with. It is well known that brain Injury is the leading cause of death and disability worldwide. In Canada, Traumatic Brain Injury (TBI) is more common than breast cancer, spinal cord injury, HIV/AIDS, and multiple sclerosis (MS) combined. There are approximately 18,000 TBI hospitalizations annually. In the province of Ontario, 25% of the two million people diagnosed with a neurological condition have suffered from a TBI. In 2000-2001 brain injuries accounted for $151.7-million in direct costs to Canadians (1).

By way of distribution, TBI is most common in children (0-19) at 30%, followed by seniors (60+) at 29%. In kids, falls are the most common cause followed by motor vehicle accidents and then sports. In adults, motor vehicle accidents cause the most TBI’s, and in seniors the causes include falls (76%) followed by car accidents (2).

Knowing the causes helps to look at how we can engage in preventative strategies. As an occupational therapist with a background in health promotion, a parent of four, and athlete, here are my thoughts:

Falls

Kids fall all the time, so how can we prevent that? Well, there is a difference between a child falling when walking, running or jumping, versus falling from, say, a shopping cart, off of a playground structure, or from a tree they tried to climb. Falls from bikes, skateboards and scooters are going to happen – and a helmet can mean the difference between a head injury and not. The bottom line is that falls in kids are best prevented by proper adult supervision. Yes, it is that simple.

In seniors, falls take on a different form. They are not from carefree or reckless behavior, but often happen when someone is just trying to go about their day by having a shower, coming down the stairs, or taking a leisurely walk. Seniors need to be attuned to the physical, balance and vision changes they are experiencing as they age, and need to consider the importance of anti-slip mats in the bathroom, removing scatter mats, installing grab bars or railings, and the benefits of a walking stick or cane when outdoors. Seniors need to engage in regular exercise and activity to maintain bone density, mobility and intact balance. They have to be very careful when living with pets or when trying to negotiate places that are cluttered or dark. Awareness of declining abilities is the first key to addressing these properly such that a prevention plan can be developed that will ultimately improve safety and reduce the risks. Note that the services of an occupational therapist can be pivotal in creating this safety plan.

Motor Vehicle Accidents

Like falls, despite our best intentions, these can and do happen. The issue here is trying to minimize the risk and optimize the outcome. Safe drivers are attentive, undistracted, and alert. They travel at safe speeds, approach intersections with caution, stop behind the line, pass when appropriate, and recognize that rushing to get somewhere on time is useless if it means you never get there at all. Safe drivers don’t text or hold a phone to their ear, don’t eat a hamburger and steer with their knees, and don’t drive when tired. If you are one of these drivers you are going to increase your chances of avoiding a collision, and lower your chances of being the cause. Unfortunately, however, not everyone is a safe driver. So, all the rest of us can do is wear our seat belt, buy a car with a good safety rating, make sure everyone in the car is buckled properly, make sure the headrest is at a proper height, put loose belongings in the trunk (I know of a child who got a head injury from a flying jar of pickles that escaped the grocery bag during a collision), and follow the rules for child seats.

Sports

I am an avid athlete and have pretty much played or tried every sport. There are very few sports I dislike and I honestly feel that sports can be the most positive and influential outlet for young people, and one of the most engaging and social outlets for adults. The issue is that sports seem to be becoming more and more competitive, kids and adults are getting bigger and stronger, and the culture of some sports has changed from friendly competition to all-out war. Preventing head injury in sport can include outfitting your kids with proper equipment (many hockey parents spend more on a stick than a helmet), ensuring they are playing at their level, monitoring the coaching influence and team culture to make sure this is appropriate, and my favorite is from the book “The Secrets of Successful Families” and includes that the only job of a parent in organized sport is to “shut up and cheer”. No parent should be on the sidelines encouraging reckless, mean or harmful behavior. The results can be devastating. And if you are concerned about your child’s risk of head injury in sport, know that there are many other sports that reduce the risk but are equally as challenging, competitive, fun and have the same physical, cognitive and developmental benefits.

So, let’s start our recognition of Brain Injury Awareness Month by practicing prevention. It does not have to be easier said than done.

(1) Brain Injury Association of Canada
(2) Canadian Institute of Health Information

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Spinal Cord Injury 101 – Julie’s Picks

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

I think this is a great story.  My husband and I were in Orange County New York.  My husband was knocking “flying in a MIG” off his bucket list and I was there to watch (nervously).  The pilot of the MIG was telling us that the guy whose plane was in the neighboring hanger was an unassuming and humble Hollywood director with multiple Oscars.  Cool!  Well, just before take-off the director arrives.  Amazing!  He never comes on a Friday.  As my husband launches away at some crazy speed, I approach the director and tell him that I am a fan of his movies.  He is flattered and we enter into a conversation that he somehow turns into being about me.  When I tell him I am an Occupational Therapist he discloses that his son was recently diagnosed with a SCI after spinal surgery.  How awful.  I explained that this is actually my area of practice.  We spend the next hour talking about SCI and I filled him in on all the latest research from the Rick Hansen International Conference I had just attended.  I tell him about some of the great devices available, American organizations to talk to, and specialists in the field, and he gives me his personal email to send him links and to stay in touch.  He was elated.  He had no hope, no knowledge about his son’s condition, and didn’t know where to start.  I was shocked.  Shocked that a man with that kind of money, connections, and seemingly unlimited access to resources would not know where to turn, and more shocked that someone so famous found something I said useful.  Since then we have kept in touch by email and every once in a while I send him resources and magazines I think he will find helpful.  I am still blown away by that encounter, and definitely found that exchange more exciting than some plane that flies really fast.

According to Spinal Cord Injury (SCI) Ontario, there are 600 new cases of SCI in the province per year, and 85,000 people living with SCI across Canada.  Of new injuries, 42% are the result of trauma (falls, accidents, or violence), and 58% from non-traumatic causes (tumors, infections, diseases).  The extent of a SCI injury is classified by the resulting impairment, with tetraplegia (or quadriplegia) indicating that all four limbs and the trunk are involved, and paraplegia is when the trunk and legs are impacted but the upper extremities are not.  Contrary to popular understanding, quadriplegia does not mean “no use of the arms” it just means the arms are involved, and the amount of usage will depend on the level of injury.  The incidence of SCI is highest in adolescents and young adults from sporting injuries, car accidents and violence, then peaks again in seniors as the result of falls.

While the direct consequence of SCI is severe – mainly the inability to walk, bowel, bladder, and sexual dysfunction, and sometimes reduced use of the arms and hands, the secondary consequences can be just as devastating.  Physiological changes in temperature regulation and circulation, pressure sores from reduced sensation, weight gain, repetitive strain on the upper extremities as they become used for transfers and mobility, urinary tract infections, bowel issues, and of course the emotional side of adjusting to wheelchair use and reduced physical abilities are all common.

As a clinician with special interest in the field of SCI, spending the last 10 years of my career treating individuals with these problems, I have been able to gather a list of very helpful resources and equipment that most clients find useful.  In recognition of SCI Awareness Week, I wanted to share my top picks here.

Standing Wheelchairs – these chairs provide significant benefit to an individual with a SCI.  Allowing people to stand and bear weight through the legs is known to improve circulation and bone density, along with the added benefits of allowing someone to reach upper cupboards again, or to look people in the eye when talking (as an example, check out the Lifestand Helium chair online at http://www.permobilus.com/heliumls.php.

Free Wheel – for manual wheelchair users, terrain such as snow, gravel or sand can be difficult, if not impossible to manage.  The free wheel is a simple add-on that elevates the front wheelchair casters to make these terrains easier (http://www.gofreewheel.com/).

Smart Drive – manual wheelchairs can be difficult to use for long periods as our arms were never designed to be our source of mobility.  So, some people use a manual wheelchair indoors and for short distances, and a power wheelchair for longer distances and outdoors.  The Smart Drive bridges the gap between manual and power chair by providing a power-assisted method of propelling a manual chair.   This is helpful for long distances, up inclines, or to just get places faster. This is another simple add-on and only weighs 11 pounds making it easy to take on and off.  In Ontario it is also now approved by the Assistive Devices Program.  Check out http://www.quarthealthcare.com/index.php/smartdrive for more information.

Sensi-Mat – Pressure sores can be a significant problem for people with SCI as they lack feeling in their lower body that would normally tell them to shift their weight to relieve pressure.  Without pressure relief, areas of the skin can die due to lack of blood flow.  If not treated, the sore can bury deep into the skin and underlying tissue, become infected, and treatment usually involves sitting restrictions, significant bed rest, or even surgery to correct and cure.  The Sensi-Mat works to prevent pressure problems from occurring by providing the wheelchair user with data about their sitting patterns, including cuing about when to shift their weight.  If an ounce of prevention is worth a pound of cure, the Sensi-Mat is a must for all people with SCI.   This new product will be available in June 2014 (http://www.sensimatsystems.com/).

SCI University – This is an online resource created by people with SCI to help others understand how to manage the many aspects of this condition.  Covering everything from nutrition to catheterization, this is also a “must check out” anyone with a SCI (www.sci-u.ca).

Abilities Magazine – This circulation is packed with useful resources, inspiring stories, and solid examples of people with SCI who are achieving amazing things.  Each issue highlights things from travel to sports and work, and includes helpful tips for not only disabled people, but is also very informative for the general public and rehabilitation professionals (http://abilities.ca/).

People in Motion – this free show, held on the first weekend of June in Toronto is packed with vendors highlighting the many wonderful products that exist for people with disabilities, including those with SCI.  From vehicles to home accessibility and wheelchairs, this is worth the drive to Toronto (http://www.people-in-motion.com/).

Of course, no person will experience a SCI the same, and the recovery from this, and ability to function safely and independently following, will depend on multiple factors.  Custom problems need custom solutions so if you have a SCI considering contacting an Occupational Therapist with experience in your condition to get solutions for living!

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Turtle Twins (Part 2) – Treating Auditory Processing Disorder

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

In my previous post I explained that auditory processing disorder (APD) is like a game of “Operator” where a message is misinterpreted when travelling between the ears and brain.  This causes problems with communicating in noisy environments, following multi-step instructions, and wrongly hearing words, sounds and sentences.    The good news is that APD can be improved organically and through modifications to the functional environment.

Personally, my daughter was diagnosed in Grade 3 (age 8).  To understand her problems, I read several books on APD and copied some chapters for family.  I disclosed fully to my daughter the results of her testing and explained that sometimes her ears and her brain are hearing different things.  I wanted her to understand that at times, when things people say might seem funny, confusing or strange to her, she might have heard them wrong.  She was encouraged to ask questions about her ADP, and to never be shy about asking people to repeat themselves if needed.

At school, the teacher started wearing an FM unit to help best deliver instructions and teachings to my daughter who wore corresponding headphones.  The teacher and I put tennis balls on the classroom chairs to reduce noise.  My daughter was relocated near the teacher’s desk and away from the busy hall.  The door was closed (reducing background noise) during lectures.  She was allowed to write tests in the quiet resource room.  The teacher was provided a list of other classroom modifications to implement, including ways to breakdown instructions into smaller chunks to improve her retention and follow-through.  I talked to the teacher about the fact that when my daughter was reading in class (when she was supposed to do other things) to tune out classroom noise and / or because she missed the directions.

In sports, we noticed an issue with her playing basketball.  The sound of the balls bouncing on the floor made it difficult for her to hear her coach and the background noise in the gym during practice was a struggle for her.  At Karate, she would look around to see what the other kids were doing as she would miss instructions.  All of her coaches and Sensei’s were advised of her APD and started speaking more directly to her, asked her to repeat instructions, and tried to reduce background noise when possible.

We also made changes at home.  We took extra time to reduce background noise (difficult in a family with four kids), would reduce the number of instructions we gave her at one time, had her repeat these back to us, and developed a “roger that” mantra that she would say to indicate she got her instructions.  Our audiologist recommended Fast Forward, an online game designed to help improve APD.  While research does not conclusively confirm that this is helpful for APD, we decided to give it a try and she found it very helpful.  Ultimately, and for reasons other than just her APD, we moved her to a small school with very low class sizes and she is now thriving.  We still notice her APD at times, but she is very aware of this and is mature enough to understand that if something sounds wrong (i.e. turtle twins) she should politely ask for clarification.

 

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Turtle Twins (Part 1) – Auditory Processing Disorder

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

In recognition of Speech and Hearing Month, I wanted to tell the story of my personal experience as a mom of a child diagnosed with auditory processing disorder (APD).

APD is best explained using the example of the game “Operator”.  If the first person is the ears, and the last the brain, everyone in between is the channel by which the message travels.  And remember what happens?  By the time the message reaches the “brain” it has been altered.  So, really APD is just that – when a message or sound changes as it travels from the ears to the brain resulting in the brain getting the wrong message.

Signs of APD can include difficulty with: communicating in noisy environments, following multi-step instructions, and wrongly hearing words, sounds and sentences.  As an overlap exists between the signs of APD and other disorders, and this may coexist with other problems, it can be difficult to diagnose.

Being a clinician, I recognized early that my daughter struggled with “hearing”.  Yet at 18 months her hearing test was “fine”.  When she was three I remember telling her that her “ears and brain were not talking”.  In school she would become easily distracted, would struggle with multi-step instructions, and did much better in classes that were smaller, less chaotic, or when she sat closer to the teacher.  At home the presence of her APD was apparent when my instruction “change your shirt” would be met with the response “I am not wearing shorts”.   Or, when the instructions “brush your hair, grab your lunch and put your coat on” might result in one, maybe two, but rarely three of those instructions being followed.  But my favorite remains when my daughter told her sisters they were “turtle twins” as she had misheard the word “fraternal”.

The diagnosis of APD is made by an audiologist when the child is at least 7 or 8 years old.  However, psycho-educational tests can also be helpful to rule out other or comorbid problems.  In adults, APD also exists, and can be the result of many factors, including acquired brain injury.  Also, some research suggests that men start to struggle with APD after age 35 and women after menopause.  My next blog will focus on ways we managed our daughter’s APD at home, in sports and school, and these same strategies could also be used by others who have, treat, or know someone with APD.

 

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Life is a Terminal Disease – Palliative Care and Occupational Therapy

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

It was a life-changing experience. I was 19 and essentially never stopped. I had goals, drive, energy, and big plans for my future. I was a varsity athlete, had three jobs, was a full time university student, owned a student house, and had bought myself a dog. Knowing I wanted to work in healthcare, and after strongly connecting to some school courses in death and dying, I decided to pursue a volunteering opportunity at the local Hospice Society. This required a comprehensive training program followed by placement in the home of someone who had a terminal disease. My first (and only) placement was with a mom, age 37, who was dying of cancer. She had a 7 year old daughter and a husband who was also ill. I would attend their home once a week to spend time with the daughter, help to prepare meals, and would even assist with running errands and groceries. I provided emotional support and mentoring to a scared little girl, and was an extra set of hands for a dad and desperate husband. I was fortunate enough to be involved with the family for many years as the mother passed about a month after my wedding – four years after I met them. My husband and I tried to stay in touch with the daughter following, but dad really struggled and eventually his phone was disconnected.

The impact of this experience on me personally was huge. The things my parents had been telling me were true: “stop to smell the roses”, “don’t sweat the small stuff”, “make sure you have fun too”…I was intense and driven to the point of missing it. My experience in Hospice changed my outlook, my appreciation for my health, family and all those blessings that we take for granted daily.

Recognizing it is National Hospice Palliative Care Week, I wanted to showcase the role of Occupational Therapy in this challenging but

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rewarding field. To do this, I reached out to a colleague who has spent many years practicing occupational therapy in palliative care settings. Her reflections are as follows:

What I have learned is that Palliative Care is not particularly a specific intervention but rather a perspective of care that can be provided in a multitude of settings where end of life is faced such as our homes, hospitals, hospices or long term care facilities.

The Canadian Hospice Palliative Care Association defines End-of-life care as aiming to relieve suffering and improve the quality of living while dying for persons diagnosed with an advanced or terminal illness or who are bereaved.

Who defines how the client is suffering (physically, emotionally, spiritually) or that what we as healthcare providers do is indeed improving quality of living while dying? In a truly client centered approach, it is the client or their substitute decision maker that determines this. A collaborative interprofessional team has the potential to honour the client’s hopes and decisions in an identified plan of care.

The Canadian Association of Occupational Therapists identifies various interventions in palliative care, based upon clinical setting, that the therapist can provide including addressing activities of daily living (ADLs), psychological and emotional issues (including stress and anxiety), exercise programs, splinting and positioning, energy conservation, relaxation techniques, seating and mobility, comfort, adaptive and assistive equipment, support and education for the family caregivers, connecting the client with community services and supports, and conducting home assessments.

What this can look like is, for example, providing mobility devices such as a walker or wheelchair to address declining physical abilities while maintaining engagement with family in a safe manner. Considerations also include provision of therapeutic surfaces whether on a bed, wheelchair or favourite recliner to help reduce the development of pressure ulcers once time spent sitting or lying in bed increases. It can be planning and preparing with the client and the team to assist the client attend a final function such as a family wedding where comfort, endurance and being relatively symptom free are the goals.

Ultimately, as roles in life are challenged due to losses with life limiting illnesses, the Occupational Therapist attempts to facilitate meaningful engagement that reflects a client’s goals in a dignified manner.

Carla Floriani, OT Reg Ont

I want to thank Carla for providing this insight and for guest-blogging on our site. Personally, I miss my volunteer work in Hospice but know that this is something I will eventually return to as it impacted me in a way I have not forgotten. The harsh reality is that life is a terminal disease – but we should not need to be given a deadline to act that way.

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Seeing Yellow: Occupational Therapy and Cancer Recovery

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

When my mom was diagnosed with breast cancer, she was required to have a mastectomy.  Feeling helpless but wanting to support her, I sent her a list of the things we could do together pre-surgery.  This included anything from loading up an iPod with her favorite tunes and stand-up comedic acts, sorting my ridiculous stack of family photos, scrapbooking, and of course some retail and spa therapy.  I figured the less time she spent just waiting for surgery, thinking and processing what was to come, the less this diagnosis would impact her now and into the future.  She responded to my ideas with something along the lines of “you should help people through tough times for a living” and I reminded her that my job as an OT allowed me to do just that.

The yellow daffodils in April signify that this is the month of Cancer Awareness.  Defined, the word “Cancer” is a blanket term used to describe the abnormal growth of cells in any part of the body.  There are more than 100 types of cancer, which may affect specific tissues, organs, blood, or lymphatic systems. Cancer remains the leading cause of death in Canada, responsible for about 30% of all deaths in our country.  Many of us have been affected by cancer, either personally, through friends or a loved one. My mom is only one example of how cancer has affected my family, and sadly I have countless other stories of friends and colleagues who have also been impacted.

Cancer and cancer treatment can lead to changes in how we do our daily activities due to physical, cognitive or emotional changes resulting from the diagnosis, resulting surgery, medications, chemo and radiation. For a cancer patient sometimes just doing daily activities leaves little energy for leisure, social, or work-related tasks.  Common side effects of cancer or its treatment include fatigue, pain, weakness, cognitive difficulties, anxiety or depression, and changes in self-esteem or self-image. Each person diagnosed with cancer will experience different challenges in his or her participation in various daily activities and life roles over the course of the disease.

Occupational therapists have knowledge and expertise to allow individuals with cancer to do the things they want and need to do to maintain their level of independence and quality of life. Occupational therapy services are helpful for individuals throughout the continuum of cancer care, including those who are newly diagnosed, undergoing treatment, receiving hospice or palliative care, or who are survivors reintegrating into previous roles. Caregivers also benefit from the training and education provided by OT’s as this arms them with the essential tools to offer support and assistance to their loved ones when performing daily, important, and meaningful activities. Some of the things occupational therapists can help with include:

  • Education on management of activities of daily living (ADLs) such as bathing and dressing through adaptations to the activity and environment, and/or the use of assistive devices.
  • Sleep and fatigue management such as education in and demonstration of energy conservation and relaxation management techniques to support health and the ability to participate in purposeful roles.
  • Cognitive strategies to address memory, organizational executive function deficits, and low-energy tasks that focus on restoring engagement in daily occupations such as sitting in the park, reading a newspaper, or conversing with a friend.
  • Therapeutic exercise and positioning to maintain functional range of motion, mobility, and strength such as home exercise programs, splinting, wheelchair fitting, bed positioning, etc. to provide support and comfort.
  • Mental health treatment to encourage the return to life roles that will help increase mood, reduce depression, restore hope, and lessen anxiety.

Other roles for occupational therapy also include return to work involvement post-treatment, education on general health issues, and training on use of a prosthetic if an amputation was required.  Some therapists are also specifically trained to provide lymphatic drainage to reduce the swelling and pain that can result from the disease, its’ surgery or treatment.

So, for the month of April let’s honor those fighting and remember those that fought.  Buy some daffodils, donate, wear a ribbon, or call or visit with someone you know that has been impacted by this prevalent disease.

References

American Association of Occupational Therapists (2011). https://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/MH/Facts/Oncology%20fact%20sheet.pdf

Canadian Cancer Society (2013). http://www.cancer.ca/en/cancer-information/cancer-101/cancer-statistics-at-a-glance/?region=on

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Best Of The Blog: Pin The Tail On The OT

After a year of blogging I’ve been approached by many colleagues who have thanked me for spotlighting the wonderful profession of occupational therapy on the web and social media.  I am hoping that my efforts will bring increased awareness to the benefits Occupational Therapy.  The following post from September 2013 is a favourite that gives an overview of OT and how it works to provide solutions for living.

Pin The Tail On The OT

I dream of the day when Occupational Therapy (OT) becomes an understood profession and is a conversation at the dinner table (“maybe an OT could help?”).  I feel that the internet, Facebook and You Tube will help this to become so.  I love the inspirational videos and stories that are being posted online.  Stories of people overcoming adversity, showing how attitude and ambition mixed with creativity can conquer challenges and overcome barriers.  I thought instead of talking about OT, I would show its power.

Watch this video and know that OT is:

  • Helping people to maintain a positive attitude, and to have hope, despite personal circumstances.
  • Overcoming the “can’t” to become the “did” – no matter what that “did” looks like.
  • Showing people how to open the door of a fridge, car, microwave and building when they can’t use their arms.
  • Providing equipment to facilitate driving when the traditional steering wheel, gas and break, cannot be used normally.
  • Teaching people how to use a computer, and designing a conducive workstation, when their use will be unconventional.
  • Designing, sourcing, and providing equipment to facilitate independence in: eating (or dressing, grooming, showering, anything), lifting and carrying personal items, washing a car, or managing in the community.
  • Helping people with unique challenges to find a suitable profession, secure a job, and sustain work.
  • Creatively solving problems to participation (i.e. riding a bike).
  •  Fostering mental health through participation, engagement and function.
  • Reducing dependency on others through facilitating independence in daily activities.

These are just a few examples.  Really, OT is everywhere.  Many people actually “OT themselves” by finding new ways to overcome challenges.  We all might do this every day even if we are not disabled.  OT is a great profession – why struggle to solve problems of function, take longer than needed to complete tasks, rig up unsafe solutions, or become unnecessarily dependent on others?  Consider OT.  We are here to help, and love nothing more than sharing our skills and knowledge.

 

 

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Best of The Blog: When Children Can’t Communicate Pain

Recognizing it is Autism Awareness Month, we wanted to re-run a popular blog about children, communication, and pain.  Recognizing that communication is key in all aspects of life, it is essential that children learn how to display this when needed.  However, sometimes, especially for those with Autism Spectrum Disorder, communicating feelings, discomforts and pain can be quite difficult.  The following post written in November 2013 discusses non-verbal pain communication and helps parents to know what to watch for.

When Children Can’t Communicate Pain

A few years back my daughter (age five at the time) seemed a bit “off” when she came home from school.  She was withdrawn, tired, and “didn’t want to talk about it”.  She is my kid that struggles to communicate her needs, especially when she is upset, so I tried to give her some time and control over when she would be comfortable talking about it.  Eventually, I went over to her and in stroking her hair realized this had blood in it.  I pulled her bangs aside and noticed a bump, large bruise, and blood on her head, in her hair, and around her temple.  When I asked her what happened, she burst into tears.  Through some coaxing, I got her to tell me that she had fallen on the playground, hit her head, and was so embarrassed about this she didn’t want to tell anyone.  Her teacher picked up on the fact that something was wrong and sent her to talk to the principal.  To the principal she reported nausea, a headache, and was visibly upset, but wouldn’t tell the principal what happened, and the bump and blood on her head and hair was not noticed.  After I got her to calm down, and did some basic mommy first aid, I explained to her the importance of telling adults about these things in case they are serious and need immediate attention.

The ability to communicate pain and discomfort is invaluable – it not only allows a person to express how they are feeling in order to receive medical attention, but also can help them to obtain medication or treatment to make the pain more manageable.  However, many children (and some adults for that matter) are unable to express their pain due to a difficulty with communication, or a developmental or intellectual disability.  This can make it very difficult for health practitioners and family members to decipher their level of pain following an injury, medical procedure, or with illness.

For children that cannot verbally communicate pain, there are other methods that can help.  For example, the Non-communicating Children’s Pain Checklist (NCCPC-R) was designed for children who are unable to speak due to a cognitive disability.  The NCCPC-R can be completed by a caregiver within the child’s home environment, and measures observations of the child’s vocalizations, social interactions, facial expressions, activity level, appearance of body and limbs, physiological signs, eating, and sleeping.  In addition to the home-based version, a postoperative version of the NCCPC-R also exists.

Interestingly, studies have shown that the expression of pain by children with Autism Spectrum Disorder is not significantly different from typically developing children or even from children with intellectual disabilities. However, what does seem to be different is the length of the behavioral reactions of children with Autism, after the source of pain has been removed. This information may be surprising to some, as it is often thought that children with Autism are insensitive or have a high tolerance to pain.  Therefore, caregivers and healthcare professionals need to be aware that although a child with Autism (or any developmental disability for that matter) may be unable to verbally communicate their level of pain, we cannot assume that they are not in pain.  We need to be able to look beyond verbal communication.  One method, using observation, is the FLACC scale (Face, Legs, Activity, Cry, Consolability).  With this, pain in children and adults who are unable to communicate are observed through are range of symptoms that are scored from 0 to 2.

So while my daughter is capable of communicating verbally, emotional upset and embarrassment prevented her from taking the important step of telling an adult about what happened.  Through her behavior and presentation, her teacher, the principal and I were able to see that something was wrong, and eventually, when she was comfortable talking about it, I figured out what happened.  Thus, behavior, verbal or not, is a key indication of how a child is feeling.  It is important for parents and healthcare providers to be aware of the signs of pain in children, verbal or non-verbal, as their bodies can very well communicate their level of pain when they cannot do so through words.

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Service Dogs are in the Grocery Store, Why Not the Schools?

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

In a previous blog called “Dog Awesomeness” I outlined how service dogs are being used more and more to help disabled children and adults function more independently and safely in their home and communities.  These dogs have been so widely recognized as useful for people with disabilities, that they are now allowed in public places, on airplanes, and even privately owned commercial establishments.   People with disabilities have fought long and hard to make this happen, and society has accepted these animals as working assistive devices – well trained and not to be tampered with or touched.

More recently, there has been growing research to support the use of service dogs for children with Autism to help them manage both inside and outside the home.  To recap, Autism is a complex developmental disability that typically appears during the first three years of life and affects a person’s ability to communicate and interact with others. This disorder is defined by a certain set of behaviors and is a “spectrum disorder” that affects individuals differently and to varying degrees. There is no known single cause, and no cure.

Inside the home, Autism service dogs can help to modify behavior in these children. Many parents have reported that the service dog provides a calming influence as the child pets the dog, or has it lying close by. This comfort can also allow a child to cope with transitions between places, activities, changes in routines, and may even help to improve sleep patterns. The child is able to get through anxieties that may be associated with daily activities with the help of his or her dog.

When outside the home, the service dogs is trained to respond to commands given by the caregiver or educator, particularly “stop”. As a result, this prevents the child from entering into potentially dangerous situations and gives the caregiver or educator time to intervene if needed. The service dog also prevents the child from wandering away from the family while out in public settings, and provides opportunities for parents and caregivers to teach their child about staying with their service dog and walking safely outdoors. The dog also acts as a companion for the child, constantly next to them to pet or cuddle which relieves anxiety.  Essentially, the dog forms a physical anchor, making public outings easier to cope with for all involved. Because the child also shares in the responsibility for caring for their service dog through exercise, grooming and feeding, this increases the opportunities to enhance the child’s independence, while also allowing them to achieve a sense of responsibility.

Considering the immense benefits of these dogs for children with Autism, I was surprised to read a Toronto Star article that reported that Canadian parents of these children have had to fight to get service dogs allowed at school. While parents are getting some legal help to lobby for a fair and standardized policy on this, nothing has been developed and most parents are having to fight on an individual basis as each school, and school board policy, is different.

My mom told me a comical (and gross) story of a puppy service dog (“in training”) who she saw in the grocery store.  As the trainer was obtaining items from the bulk bins, the dog was head deep in another bin eating mouthfuls of something while drooling and slobbering all over the place.  The owner didn’t notice.  As the man walked away with the dog, my mom alerted a clerk who had the bin emptied and cleaned.  But the story leads to the question – if service dogs are allowed in the grocery store, why not the schools?

If service dogs are truly “assistive devices” aimed at improving independence, behavior, providing comfort and safety, and reducing anxiety in a child with Autism, then the schools should be required to accommodate.  Now I recognize that some other children could be allergic or fearful of dogs, but this will be the minority and with some careful planning, classes could be organized to meet the needs of all.  I think society, and the parents of today, are more apt at supporting these accommodations – we have already adapted to nut-free schools, litter-less lunches, nutrition policies, technology for learning, multiple page trip waivers – evidence that we are open, understanding and willing to evolve the meet the changing needs of our times, and our children.

References

Autism Dog Services www.autismdogservices.ca

The Toronto Star:  The Toronto Star:  Parents With Autistic Kids Fight To Get Service Dogs in Schools