Blog
Impressions from Dr A. Jean Ayres at 100
On 22 July SAISI hosted Dr Susanne Smith-Roley (indicated as SSR below), a scholar and mentee of Dr Ayres (JA), to celebrate her legacy on what would have been her 100th birthday. The interview was facilitated by Dr Annamarie van Jaarsveld (AvJ), Gina Rencken (GR) and Ray-Anne Cook (RAC). I would like to share some of the impressions from the evening. Please note that these quotes might not be word for word as Dr Ayres said them, but I hope to convey some of the wonderful insight we gained into her career, as a clinician and a mentor.
Dr Ayres as a clinician
Jean Ayres treated children out of a trailer before opening a clinic, and worked 5 1/2 days a week. She was pragmatic and frugal, using what she could find that was either free or re-usable. We see these values carried through in the community service years we do in South Africa today. Dr Ayres was also always very hands-on with her students, with them in therapy rather than in her office.
She modelled collaboration with the child, handing the locus of control to them, either to do something they couldn’t do, or thought they couldn’t do. She provided scaffolding: “Sometimes scaffolding means waiting, even if it’s excruciating, to give the child that internal locus of control” – SSR. “It requires of us to expect a little more, within their capacity.” “Scaffolding is the stepping stone to an adaptive response” – AvJ.
Dr Ayres was a firm believer in explaining Sensory Integration challenges to the child as well as the family. She believed that when you reframed the problem, the solution was different. She explained that the clinician had to believe that the child was always trying their best within their capacity.
Dr Ayres as the creator of new equipment
Dr Ayres had an art degree, and was an elegant seamstress, leading to her dreaming up and creating much of her own equipment. She would ask herself, “What could I make that would give this child…[e.g. inverted rotary vestibular input]?” She used to ride on the scooterboard for 20 minutes each day, and believed the platform swing was the most versatile piece of equipment, as it has so many affordances for praxis. She could bring the ropes closer together to make it more unstable, or place a piece of carpet on it for incidental tactile input. She constantly trying to increase the influence of gravity during her sessions, as she felt the otoliths were easier to target than the saccule.
SSR felt that if Dr Ayres were still with us, she would have loved the affordances of lycra and spandex, and the multiple ways that they can be used. SSR mentioned that her three favourite items are lycra, a square platform swing with a tyre, and a big foam wedge.
Dr Ayres as a mentor
Dr Ayres listened intently and was very sensitive to body language. She (JA) said “It takes every ounce of energy I have, to focus on everything I need to do, to do what I need to, for that child.” She helped the therapists under her supervision to pause, get quiet, and get out of the child’s way. She (JA) explained that children needed time to process, and that their therapists needed to give them that opportunity.
Dr Ayres motivated her students to pursue excellence in research, and tasked them to move forward to high level goals. Her graduates have gone on to continue her work in solid theoretical foundations, systematic data collection, publications and peer reviews. She planted seeds for them to nurture: giving lectures, publishing newsletters and establishing research divisions. She maintained that thorough testing was so important, as well as assuring access to adequate play spaces for all children. And she asserted the importance of Sensory Hygiene throughout the lifespan.
When asked “When should you start looking at Sensory Integration in the child?” she (JA) answered “At about 8 weeks gestation.” And when asked why, she replied, “Well, it takes a few weeks to figure out that you’re pregnant!”
There were so many “gems” throughout the webinar, and I hope that you will take the time to watch the full recording. SAISI would also like to extend our sincere appreciation to Dr Susanne Smith-Roley, for the way in which she has mentored, and continues to mentor, SAISI and its members over the years.
I would like to close with the following inspirational quote from Dr Ayres: “If you are willing to put in the work, the reward will be magnificent, because the children will change in front of your eyes”
Sensory Deprivation for the elderly in COVID times
By Sally Fraser-Mackenzie
Despite the fact that most of my work is based in SI and paediatrics, I’ve always had a strong passion for mental health and the elderly. I have been working closely with some elderly clients in the past few years. Through regular sessions, I have seen how gentle sensory integration can improve the quality of life in the elderly.
When the elderly are confined to their old age homes and have no relatives in town to take them out, their worlds become very small, limited and restricted. Gentle outings, such as a quiet drive looking at buildings or nature, and going down memory lane, can be so visually stimulating and an expansion of their day. A facilitated walk with a walking frame to a nearby coffee shop is the highlight of the month! A warm smile and a new activity can be enough for the day.
But what of COVID times? Many of my elderly clients have had extra lock down in their care homes, despite the easing of the Alert levels. They can’t manage smart phones and don’t have computers, so telehealth sessions are nearly impossible – unless a carer has a device and data, and is tech-savvy, and can be available to facilitate an appointment. Even then I have had a few instances of my clients falling asleep while I was talking to them on a video call, and no matter how I sang and danced, I couldn’t rouse them. Better sessions have included playing dominoes over a video call – “These are your dominoes, which one would you like to play?”, and memory games like Kim’s game which can be surprisingly effective. But despite all these efforts, my clients have deteriorated physically and mentally, becoming more sleepy, opting out of interactions, talking less, showing less interest and showing all the signs of depression. Their families are also struggling to communicate with them.
One old age home has claimed they will stay in lock down Level 5: no one allowed in or out, no walks around the block, relatives only allowed when they are on their death beds, for the next 2 years! Where does that leave an frail, elderly lady of 88 desperate to see her family? Well, it leaves me rather defiant, and determined to keep bringing her some quality of life, contact and smiles. But how? Between her carers and me, we have arranged illicit meetings on either side of the fence near the back compost heap! We sit about 4m apart, in a lovely patch of sunshine. I bring my camping chair, sometimes we both bring a cup of tea, and she smiles and chats a little. Despite the lack of contact and the big fence in between us, it works!
At another care home, I am permitted to see my client once a week briefly in the visiting bay through a Perspex screen where I can’t hear him very well, but it’s an outing for him in a way. He gets to go in his wheelchair up in the lift and to the conference room where the visiting bay is, which is something of a sensory expansion at least. The visitor’s bay is chilly, and I am almost sitting outside, while he is inside, so I usually dress warmly. Last week, I visited and they had double booked the visitors bay, so I was allowed right inside to his room. It was a cold day, and I had a spencer on, a top and my puffy jacket, and of course my mask. After multiple hand sanitizations, I had to then don a shield as well, a white synthetic coat with tight long sleeves and gloves. I was ushered into his warm room, and immediately started steaming up! I was completely overheating in all this but couldn’t take anything off, and we spent most of the session laughing at my claustrophobia, the steamed-up shield, and how crazy this all was!
Sensory Integration doesn’t have to be fancy paediatric equipment. It can also be the gentle world around us, the birds in the trees, fresh air or a breeze, the smell of roses and the movement of walking. These can be enough for our elderly, and through these difficult times, they are even being deprived of these, needing to stay shut in their rooms. My heart breaks for them as they have so little autonomy, little choice and minimal stimulation. As OT’s though, we can continue to be creative and inventive finding ways to overcome these barriers for the sake of the sanity of our elderly.
Back to work we go!
By Sally Fraser-Mackenzie
Post-COVID transitioning back to therapy
I’ve been back at work for 2 months and there have been the expected and necessary adjustments post-lockdown, and then other curve balls where I have had to make my own adaptive responses on the spur of the moment, which will be more interesting to read about!
Some of the expected changes that we have had to make include:
1) spending a small fortune on digital thermometers,
2) times between clients to spray and clean,
3) attendance and temperature registers set up,
4) writing up new COVID contracts pledging our commitment to a germ-free practice,
5) sanitizers,
6) cloths for each client to dry their hands,
7) clients being fearful and not coming,
8) clients being broke and unable to pay bills, and
9) a much more clutter-free practice with less surfaces to clean!
I put out a table with a basin of warm water for each client outside. We use all sorts of fun ways to wash when they arrive: kaleidofoam, glittery soap, squeezy foam soap that disappears after about 20 seconds, water toys, boats, and spraying activities. I’ve been presenting “cleaning” activities that serve my goals but are also fun on arrival. Then I spend the session keeping tabs on what’s been touched, putting away toys for a week that have been played with, and encouraging my clients to keep their masks on, often to no avail. During some vigorous somersaulting, a little boy’s mask slid over his eyes, and we both had a good chuckle!
The unexpected curve balls are interesting. A sibling of a client came to visit at the end of the session, then chaos reigned and everything got touched, played with, and I could no longer keep track. I needed to write the mom and dad a diplomatic email saying I understood that the sibling would so love to play, but during these times, I simply can’t allow it, and then listing the reasons. Of course, they were very understanding, but I still felt sad for that sibling.
Another little 4 year old girl arrived and took absolute fright at the thermometer gun. She even refused to let me take my own temperature. The new goal for her therapy suddenly became desensitizing this aspect of COVID, as she will be exposed to this when she goes back to school and at shops. We spent the next two sessions playing doctor-doctor with dolls, and in the end she loved taking their temperatures. We are still working on taking her own!
Previously angelic children are now more inclined to say “no” and show belligerence and refusal. They’ve been at home, watching screens and sometimes having either no or undivided attention from adults. So gently revisiting manners and boundaries is necessary.
Some of our clients (often with ASD or highly sensitive) are loving this new and gentle world. No insult to the senses, no other children rattling their cages, just quietly staying at home doing the odd zoom call. Academics can soar; individual time can be spent on aspects they struggle with; learning at their own pace suits them better. The prospect of returning to school has been hard and many parents are opting for home schooling in the future.
I will be looking for COVID-related stories for our SAISI Newsletter later in the year, so if you have any stories, or interesting case studies, please start documenting them and get in touch with me. We live and work in interesting times indeed!
Thank you Sally for sharing your experiences with us. Anyone who would like to contribute their stories to the newsletter please email saisi@uitweb.co.za. We’d love to hear from you!
Ode to the OT’s of 2020
Today’s blog post is a creative outlet. Maybe you identify with part of it. Maybe it inspires you to reflect on your own journey through this pandemic. May it give you hope!
It started off with disbelief.
We were sent home, to the quiet, the questions and the calm
It felt like an early holiday to some, to others – financial ruin.
Which side were you on?
Did you Netflix all day?
Did you bake bread, make jam, lounge at the pool?
Did your case load shift to hours of zoom?
Or did you spend your days anxiously cleaning every room?
Did the kids drive you crazy, with noise and incessant snacking?
Or were you alone, isolated, craving company and family?
Were you grateful for the extra time with your babies?
Were you panicked by interrupted meetings and daily changes?
A time of tons of new rules, regulations.
Face masks, and hand washing and sanitisation
Did you find a way to play via screen?
Read bedtime stories? Online magazines?
We’ve drafted consent forms and practice plans,
Opened windows, disinfected handles,
Packed away excess,
Covered with plastics,
Bought expensive thermometers,
Put up screening charts and posters,
Banned water bottles and shoes
And high-5’s, the list feels endless
Hours of cleaning to be able to welcome
Those precious little people we miss so much
Their smiles hidden behind visors and masks
Be safe! Don’t sneeze! Don’t touch!
What are they thinking? How do they feel?
Do they know it’s me? Are they keen to play?
Some eyes betray their childish confidence
Some seem oblivious,
Dive into the safe space they’ve missed
How will this affect them? What are we teaching them?
That the world is dangerous? That a cough can hurt them?
That hugs and kisses are only for family?
That being yourself, spontaneous, is potentially damaging?
For toddlers and preschoolers and older kids too
This monster steals away playtime, friends are few
What far-reaching consequences will affect their mental state?
What strange new normal can we try to mitigate?
Come on! We’re OT’s! Our toolboxes are HUGE.
We’ve got approaches and devices,
Webinars and mentors,
Skill sets,
Research bases,
Support systems in various places.
Adapting, being flexible is what we do best.
We’re advocates,
Frontline fighters,
Activists,
Programme writers.
Looking back, hindsight’s going to be 2020
We’ll acknowledge this year came with lessons aplenty.
Did you work through the discouragement?
Did you give yourself a breather?
Are you ready to come back
Stronger together?
An introduction to the legacy of Jean Ayres
You may or may not know that on 18 July 1920, Dr A. Jean Ayres was born, making 2020 what would have been her 100th birthday. As we gear up for celebrations in July 2020 and 2021, we take a look at some of the organisations, groups and congresses focused on continuing her work, ensuring her legacy and promoting education and research in the field. The following information has been taken from each organisation’s respective websites. You can click on each link to learn more, or join their Facebook pages/groups to stay up to date with their events. Many of the organisations have wonderful resources, as well as online learning opportunities during lock down. So here’s our list of “ASI’s”:
SAISI (South African Institute of Sensory Integration)
The South African Institute of Sensory Integration’s vision is to provide training and education in Ayres Sensory Integration® of an internationally accepted standard in order to provide a service of excellence to the ultimate benefit of the client. Our mission includes:
- To equip occupational therapists with basic as well as advanced up-to-date Ayres Sensory Integration® interpretation principles and treatment techniques.
- To promote awareness within the multi-disciplinary framework in order to play a leading role in the application of Ayres Sensory Integration® theory and practice in South Africa and in the rest of the world.
- To make Ayres Sensory Integration® accessible to the network of individuals (including caregivers, parents and teachers) involved in the context of the client.
ICEASI (International Council for Education in Ayres Sensory Integration®)
ICEASI came together in 2008 to both develop and safeguard the standards of education in Ayres Sensory Integration®. The members represent organisations with national profiles of providing training and education in Ayres Sensory Integration®. ICEASI meet every year around the European Congress of Sensory Integration (ESIC).
CLASI (The Collaborative for Leadership in Ayres Sensory Integration®)
CLASI provides innovative and customized partnership, scholarship, and mentorship opportunities for mastering, applying and advancing knowledge in Ayres Sensory Integration® (ASI) theory and practice in order to support and develop leaders, promote knowledge development, disseminate evidence-based information and facilitate learning and skills. Co-founded by first-generation students of Dr. A. Jean Ayres, CLASI is committed to following her tradition of excellence and research in practice. CLASI offers educational programs online and in more than a dozen countries around the world. Course materials are derived from Ayres’ original publications and subsequent research in basic and applied science related to sensation and the impact on human function. CLASI is a member of the International Council for Education in Ayres Sensory Integration (ICEASI) which provides global standards for education in ASI.
ASI-WISE (Ayres Sensory Integration – Wales, Ireland, Scotland, England)
ASI-WISE is a not-for-profit organisation established in 2017 to provide affordable, accessible hands-on education and CPD about Ayres’ Sensory Integration for occupational therapists, physiotherapists and speech and language therapists across the UK and Ireland. Kath Smith and Ros Urwin have led the development and application into older adolescent and adult/older adult clinical populations including trauma since 1999 in the United Kingdom, supporting and developing this awareness and teaching into Europe and further afield. Through the Sensory Project, ASI-WISE are building a community of support, mentoring and collaboration to equip and empower practitioners in Ayres’ Sensory Integration, enabling them to deliver the best possible, evidence-based therapeutic interventions to each individual.
SIGN (Sensory Integration Global Network)
In March 2004, during the yearly Research 2000 (R2K) conference series on sensory integration and related research, 20 people from North and South America, Asia, Africa, and Europe who are practicing and teaching Sensory Integration in the tradition of Dr. Ayres, gathered in California for an International Networking Meeting. At this meeting these individuals founded an organizational body to promote and protect Ayres’ theory and it’s applications in practice: the Sensory Integration Global Network (SIGN).
SIGN is made up of a group of volunteers who are dedicated to protecting the integrity and promoting the work of Dr. A. Jean Ayres in Sensory Integration Theory and Intervention. The originators of this group include former co-workers and students of Dr. Ayres, who are now among the leading experts in the field, and occupational therapists committed to providing occupational therapy services from a sensory integrative perspective in a manner consistent with Ayres’ core principles. In addition to the support of the Successor Trustee of Dr. Ayres’ estate, who now holds the trademark term Ayres Sensory Integration® (ASI), participation at the ground level has also included businesses who manufacture tests and equipment related to sensory integration.
ISIC (International Sensory Integration Congress)
The very first International Sensory Integration Congress was hosted by SAISI in Cape Town, South Africa and opened by SAISI’s own Dr Annemarie van Jaarsveld, a real research leader in the field. Twenty four countries were represented, and the latest research in ASI® was presented. In 2019, ISIC was hosted in Hong Kong, and a very special celebration was planned for Rodondo Beach, California for July 2020. ISIC 2020 had to be postponed unfortunately, due to the COVID-19 pandemic, but we look forward to the celebrations in 2021.
ESIC (European Sensory Integration Congress)
The European Sensory Integration Congress is an event that joins therapists and specialists from worldwide that are interested in sensory integration. The first meeting was held in a castle near Vienna in 2003, in a meeting titled “Sensory Integration Original – Today” and hosted 100 participants from 10 countries. SAISI was represented at the congress in 2013, 2014, 2015 and 2017. The 6th ESIC (2019) took place in Thessaloniki, Greece and we were proud that Shanna Louwrens represented South Africa in her presentation on SI profiles in children with cerebral palsy. Previous venues have included Algarve (Portugal), Naantali (Finland), Birmingham (United Kingdom), and Vienna (Austria).
As mentioned above, the year 2020 marks what would have been the 100 year birthday of Dr. A. Jean Ayres. In commemoration of this milestone, the following vision is proposed as part of the Ayres 2020 Vision:
Ayres Sensory Integration® will have a strong, international presence with demonstrated scholarship, means for valid, comprehensive assessment and pathways for training to ensure the ongoing development, standards of excellence and effective implementation of this important work.
The following goals have been established by the international community, in keeping with things that would have mattered to Dr. Ayres, aimed at achieving this vision:
1) Promoting Scholarship in ASI®: Dr. Ayres was committed to the scientific method in building her theory and ensuring ongoing evolution of this important work.
Goal: 100 papers that further the understanding and evidence for ASI®, will be published in peer reviewed journals (start date January 2013) (must reference or be consistent with Ayres Sensory Integration®)
2) Ensuring Effective Intervention through Comprehensive Assessment in ASI®: Dr. Ayres developed highly valid and reliable methods for evaluating comprehensive sensory integrative functions that have stood the test of time. We value these tests and encourage ongoing training in their use, as well as in theory and practice in ASI®. However, there is a need for a valid and reliable set of tests of key sensory motor functions that is accessible to therapists all over the world so that they can identify, understand and treat sensory integrative dysfunction.
Goal: a set of tests with demonstrated reliability and validity will be developed and internationally normed in 100 countries and made available at low or no cost.
Update: We are very excited about the International Normative Data Collection for the Evaluation of Ayres Sensory Integration (EASI) that is currently taking place. South Africa has made a great contribution, testing over 300 children for establishment of norms and diagnostic patterns.
3) Facilitating ongoing development and implementation of ASI®: Dr. Ayres mentored a generation of therapists, educators and researchers who have followed the road map she left for implementation of ASI®. It is time to ensure that leadership and pathways to excellence in the ASI® approach are in place for future generations.
Goal: Sensory integration training that includes clearly defined pathways for demonstrating competency in ASI® will be developed and available in 100 countries.
As you can see, Ayres Sensory Integration® has a worldwide presence, and there are many therapists and scholars dedicated to the continued study and furtherance of her work, as well as protection of the integrity of the name of Ayres Sensory Integration®.
Please join SAISI on 20 July 2020 for our Ayres 100th Birthday Celebration Bash, as we look back on the development of ASI®, and look forward to the future! More information can be found on our Events page soon.
OT from the tent: A creative space for teletherapy
Today’s blog post is written by Lauri Adams. Lauri graduated from UCT in 2012, and completed her training in Ayres Sensory Integration in 2018. She opened her private practice focusing on paediatrics and is based at various schools in Durban. Today she shares her own experience of starting telehealth, and how necessity leads to wonderful creativity.
When lock down was announced we were lucky to have the opportunity to retreat to my fiance’s family farm. I was grateful for the comfort of open space, fresh air, the opportunity to exercise and we could truly enjoy special moments together as a family.
The move to the farm was not without complications, however. We now had to deal with diverse personalities under one roof and had to manage our different living habits. I had to juggle these trials with my other major challenge, which was taking the plunge into the world of telehealth. The concept of therapy using an online platform was completely alien and it took a lot of research and practice to get myself more comfortable with the idea.
Another major hurdle of life at the farm was the intrusion into each other’s work spaces. I needed to make an urgent yet resourceful plan. Ideas included: using bluetooth earphones, scheduling my online OT sessions at quieter times and escaping to the outside cottage. Sadly, through trial and error, these experiences did not work out, as I was not meeting the needs of the children and their families.
I put on my different OT hats to come up with a better solution. My key requirements for successful telehealth sessions were to have access to a stable internet connection, my own privacy and to provide a play space for the children where they felt safe and secure. Thus, the innovative idea of having a sensory tent in the garden was created.
My tent provided a great self-regulation tool for both me and children. As a therapist it helped to ensure confidentiality as well as reduce my exposure to external sensory input so that I could remain modulated, focused and “in tune” with the children’s needs. It also gave me with my own private space where I could dance, sing and be whole-heartedly connected to the children.
Subsequently, this enabled me to work successfully with the children so that I could guide and facilitate their functional performance and occupational engagement. More so, the children absolutely loved the idea of being provided a dedicated space that invoked a sense of peace and calm. This environment also enhanced their imagination and play experience. For some, it resembled the concept of a small, protective womb space, where they felt safe, contained and organized. This all nurtured their levels of comfort and willingness to participate in our sessions actively.
During this journey of telehealth, I began to explore more ways of providing calming sensory inputs. Firstly, I made sure that the lighting was low and that my voice was soft and reassuring within this space. I then advised the parents on ways of providing slow rocking motions to their child by tightly wrapping them up in a blanket and swinging them slowly from side to side (similar to the movement experience of a hammock). Within the tent I included yoga mats, soft cushions, large bean bags, sheets, cardboard boxes and small chairs to encourage the children to be involved in pushing, pulling, climbing and crawling actions in order to attain further deep pressure inputs. There were also oral based resources (bubbles, straws, whistles) and tactile items (a shoe box containing soft sponges, stress balls, play dough and different textured homemade knitted animals which were filled with rice to add additional weight and calming inputs) that the child could request to open in times of need. These sensory experiences all contributed to organizing their bodies.
The tent has proved to be a very successful space for providing telehealth services. I have received positive feedback from the children and families as they truly saw the value of this form of therapy. Some parents even set up their own sensory tent for their child in the garden in order to model our safe space. It also allowed for parents to be more actively invested in their child’s development, growth and OT journey. This has empowered them to understand their child better and aided their relationship. It also helped to facilitate the functional carry-over of the child’s therapy goals within the home environment.
My online sessions have tended to follow a similar routine. This familiarity has allowed the children to feel more secure within our sessions. We often began with a check in activity, which included the zones of regulation. This was important so that the children could recognize and communicate their feelings in a safe and non-judgmental way. In turn, it aided their self-regulation and self-control. I then moved onto supporting their sensory systems in order to aid their modulation and motivation for the session. This often addressed vestibular, proprioceptive and tactile systems. These warm up activities also included brain exercises, movement breaks and sensory snacks, which helped to increase arousal levels, focus and organization. Thereafter, I targeted their underlying building blocks of development being postural control, visual tracking, bilateral integration and motor planning. After that, I worked on their key performance areas and occupational domains which where mostly in line with their school and home outcomes. This being: gross and fine motor skills, visual perceptual skills, activities of daily living, life skills, and performance in handwriting and reading.
The success of the telehealth has proven to be a surprise to many of the parents and even to me. Over half of my caseload is currently using this form of therapy with me. With the prospect of lock down persisting for the foreseeable future, I strongly advise any hesitant therapists and parents to give this a try. Telehealth has had a very positive impact in the lives of the children. It has helped to serve their sensory, behavioral, learning and emotional needs, especially during these uncertain times. I have really enjoyed this learning experience and look forward to connecting more with the children.
For those interested in my resources, below are the links and contacts:
- Pink Oatmeal: https://www.pinkoatmeal.com/freebie-library/
- Boom Learning: https://wow.boomlearning.com/
- The Learning Station: https://www.learningstationmusic.com/
- Jack Hartmann: https://jackhartmann.com/
- Reena Singh: https://www.youtube.com/channel/UCo39M1MZ7Z5hPBYrGMSSTeg/videos
- CoordiKids: https://www.coordikids.com/
- Your Therapy Source: https://www.yourtherapysource.com/freestuff.html
- TelehealthShare: https://telehealthshare.com/freebies
- Twinkl: https://www.twinkl.co.za/
- Eye Can Learn: http://eyecanlearn.com/
- Highlights Kids: https://www.highlightskids.com/games
- Tools to Grow: https://www.toolstogrowot.com/free-therapy-resources/sort/date-new or https://www.toolstogrowtherapy.com/family-resources/
- Goldie Hill (makes textured, weighted, material or knitted soft toys): Contact her on: goldiehill@gmail.com or lauri@otforkids.co.za
If you have a creative way of doing teletherapy, or have something helpful, encouraging or new that you think we could share on our blog, please send your suggestion to saisi@uitweb.co.za.
Starting a telehealth journey: one therapist takes the plunge
Today Jeane Kolbe shares her telehealth experience with us, how she started planning and processing, and some practical ideas to use over a screen.
Not unlike most other OT’s, I was completely thrown by the idea of doing tele-therapy. I am very hands on in my treatment and love the physical handling aspect of my job. To be honest, my employee seemed more eager and willing to tackle this new world of online therapy than me. It took me a full week of hard thinking, and enough hours spent on webinars to amount to a week’s worth of actual work, before I became more comfortable with the idea.
When I decided to start this journey, I had never before used a virtual platform. Not even for social calls. The idea of therapy using Zoom scared me immensely. Thanks to another colleague, who was at the forefront of kick starting tele-therapy in response to the national lockdown, I was talked into doing a session. His advice was simple: “Just do it.”
I decided to set up a trial session with my best friend’s daughter, and explained that it is primarily for my own benefit. I wanted to see whether I would be able to make tele-therapy work. This did not mean that it could not be beneficial for her daughter as well, so I asked her what she was concerned about. I prepared the consent form, and conducted an interview to establish what she had available and the aims she wanted to work on with her daughter. I wrote up the treatment plan and we scheduled a time for my first daunting session of tele-therapy.
My heart was beating out of my chest as I connected the Zoom call. How silly! This was my best friend and her daughter after all. Nonetheless,it felt like a 4th year final exam! It was the first time I had used Zoom as well. I started the session and pressed record. As the time passed, I felt more and more at ease, and after watching the recording I was proud of my first effort. The session did not come without hiccups. We ended up with massive kitchen scissors because the child-sized ones were for a left-hander and this child was right-handed. I wanted her to move between stations using different animal walks, but mommy ended up setting up the stations next to each other. Despite all of this, it was a great learning experience and most of my aims in the session were reached. Most importantly, the child had a lot of fun! From this, I developed more specific treatment plans and decided to do a walk-through with the mom before future sessions.
I sent a template to my employees, which they should use when doing tele-therapy, and we set some rules in place. The plan had to be sent the day before, and a quick call to the mom/dad to make sure they understood what was expected. Nothing was to be done without the consent form having been signed and sent back. The first treatment plan had to be signed off, and I was available to watch their sessions to give feedback. I am happy to say that they have been doing great jobs and are not in need of a lot of guidance. This is easier than it looks.
We soon sent out the consent forms to the children we felt could benefit and started tele-therapy for my practice. The response was definitely not overwhelming (about 10% of my case load), but I saw it as an opportunity to spend time developing activities which could be used for tele-health. I soon discovered the whiteboard feature on Zoom (see link at the bottom of this article), and that I could share my screen! Very exciting times for me!
Initially I used the whiteboard for very basic things, like getting the child to finish a symmetrical drawing, then later became braver and braver, to the point where I now use games I develop on Microsoft Publisher for the child to play with me. One of these games which was a great success, is to get the child to copy a shape/picture in a sensory medium and then reveal what is under the block. I have combined this with motor activities or pieces for a puzzle. The children love the surprise element and, depending on how quickly you reveal the picture, it could also work on visual closure.
To work on bilateral coordination and midline crossing, I made this printout (below) and asked parents to have 2 coins ready. The children are then asked to follow a path from a specific colour to another one, moving the coins with their fingers. You can swap fingers around, cross hands over, do one hand from the top and one from the bottom etc. It can address the aims of following of instructions, and discrimination between the left and right sides. You can upgrade it by starting with big coins and progressing to smaller ones.
Another activity which all kids seem to enjoy, big and small, is winding up a box to bring it closer to them. To work on the vestibular system, they spin and wind the rope (2m) around their waist to pull the box closer. Mom has to pull the box back in order to unwind again, allowing the child to spin in both directions. When I want to work on fine-motor skills, I get them to wind the rope around a toilet roll or pencil, for bilateral coordination. Each time the box gets to them, a new piece of a puzzle is presented. Just for clarity – the rope is tied to the box and the free end gets given to the child.
Playing any kind of lava monster game, where children need to use pillows or other equipment to move across the floor without touching the floor, has been a source of great fun for the little ones. I get completely out of my comfort zone and become very theatrical in the process, pretending to be asleep and then awake with big eyes to observe. They become very excited and everyone has a good giggle.
As part of my treatment plan, I send the worksheets or printouts I need the mommy to have available and ask her to print or copy them.The treatment plan also provides a list of things she has to have ready, and then the outline of the actual activities during the session. I also make provision for an extra activity should there be time left over and type the homework for the week.
When the session actually happens, I check the setup with the mommy, in order for me to have an understanding of where things are in the room/house. I then have a quick ‘check in’ with the child and explain the expectations of the session. After this, we follow the activity plan, and then end with saying goodbye. I often then spend an extra 5 minutes debriefing the parent and telling them what a great job they did.
What I have found to be amazing, is how empowered the parents feel after each session and how excited they are for the next one. All of the parents we have dealt with so far have been very supportive and positive about this new way of treating. It also seems as though the kids love the one-on-one time with the parent and flourish during the quality time spent together during tele-therapy.
Activities for tele-therapy are as broad as your imagination, and only limited by the resources at the parents’ disposal. In saying that, I find that most parents have a variety of items that you can use. Therapy balls, big blankets, pillows, swings or jungle gyms in the yard, trampolines/beds, soft toys and all sorts of other puzzles and toys etc.I found the supply list from Built to Bloom extremely helpful to gauge exactly what the parents have available. I also ask the parents for a video of the toys/puzzles they have, and sometimes a photo of the child next to a piece of equipment we might be able to use.
While I undoubtedly miss my practice and physical contact with my beautiful children; I am so glad that I decided to brave this new world to ensure continuation of therapy during a time where many of these children are feeling uncertain/insecure about the world around them. I hope this serves as inspiration to start or continue your tele-therapy journey. It is not as scary as it seems.
Thank you Jeane for sharing your experience with us. For those of you looking for telehealth resources, maybe some of the items below will help:
- How to use the whiteboard on zoom
- A social story for children to understand telehealth before you start, created by Child’s Play in Alabama
- An escape room activity where the child must decipher the code to get out of the toy room
- The teleshare.com site has wonderful lists of websites which are helpful for telehealth sessions, as well as samples of forms, lists and presentations. Some items are free, some for sale and you can even share your own designs and ideas with other therapists!
- The telehealth share Youtube channel has loads of videos advertising resources, but also demonstrating sessions and ideas.
It will take some time to work through these pages, but if this pandemic has taught us one thing, it’s that we are stronger and provide a better service when we share our ideas and help others along. If you have something you would like to contribute to our blog, please send an email to saisi@uitweb.co.za. And why not join one of the SAISI support Whatsapp groups for even more ideas and support?
Open letter to my son’s OT
Have you wondered how the parents of the children you see for therapy feel about the lock down, and how it is affecting their children? Have you actually asked them how they feel about the home programmes, suggested activities, broadcast groups, telehealth sessions or a pause in the therapy process? Some colleagues have managed to provide a wonderful supportive service to their clients and feedback is so important in guiding our clinical reasoning, as well as motivation for therapy services. One mom was happy to share her insights with us. We thank her for her generous contribution to the blog today, and applaud the OT who is working with her boy.
“Our OT is a NINJA of the highest order and we love her, not only for her skills and compassion but for her willingness to help, and her dedication to our little man. Thankfully, we have a wonderful relationship. We think so at least, but she may well cringe when she sees my number pop up on her phone!
Lock down has been an interesting experience for us and has definitely come with its challenges. Routine is something our little guy thrives on, and I suddenly realized I had better get one going or I was going to find myself at the mercy of a small gang of unpredictable little mutineers. We have two boys, both of whom have weekly OT sessions, although only one has Sensory Processing Disorder (SPD). To be honest, he is perhaps easier to help as I have received so much help along the way to gain a greater understanding of his needs. Over time, and with our OT’s help, I have learned to read him and see the signs of a potential overload. He too has learned to identify when he needs time or space on his own, and so removes himself. This has been challenging to manage in lock down as our boys are so close in age and generally play very well together but for an SPD child having your older brother in your space 24/7 gets a bit much.
Being able to Skype our OT has been an absolute life saver. Being able to discuss our ideas and see her describe exercises has made all the difference. Honestly, without this mechanism to clarify and communicate, I’d be in serious trouble! We have been 100% on board with helping our boys with their OT at home. We even did the pre-lock down plundering of the local stationery, arts and crafts store, (art is one of our son’s greatest regulators) but there is just no way you can be successful without the input and interaction of your OT. The assistance we received from her in
a) setting up a schedule,
b) trying it and,
c) feeding back for her to tweak it to get the best out of our boys has been invaluable.
Teletherapy is an absolute must if you can. It looks like lock down is going to be around for a while and I don’t have enough wine to ensure everyone in my family makes it out alive on my own! Honestly, as a parent, just seeing the familiar face of the one other person (other than my husband) who understands our son the most is such a sense of relief. OT’s have to stress the importance of consistency, fun within the activities as well as a structured approach. We as parents really do need an awful lot of hand-holding. We tend to turn things into serious work when they should be more fun. Possibly looking at a way of integrating the child’s schoolwork that is being sent home (not sure what kind of watch my son’s teacher has but time definitely goes slower on hers!) with OT activities so as to reduce the amount of time spent working, might be an idea.
At the end of the day, as a parent I appreciate the support more than anything, knowing that I can call and be reassured that what I am doing, although nowhere near as effective as an actual OT session, is a step in the right direction.
Just a note from a mom who loves her boys.”
Have you asked parents for constructive feedback about telehealth yet? If you have something to contribute to our blog that would give us insight so that we can provide the best service possible under the circumstances, please send an email to saisi@uitweb.co.za.
Coping with Corona: Finding balance, getting organised and evolving into the new
Today’s post is written by Stefanie Kruger, longstanding member of the SAISI board, lecturer and private practitioner. She contemplates the current phase we all find ourselves in and how we’re adjusting to it.
“Why, sometimes I’ve believed as many as six impossible things before breakfast” – Alice in Wonderland
Who would have thought… it might be possible to bring the world to a standstill: from work, school, and sport, to restaurants, movies, flights, conferences and many more unthinkable events? That lions would be resting on a golf course, that penguins would walk down the street, and that a kudu could calmly roam a suburb. It was also noted that the pollution levels have dropped so significantly, that the Himalayas can be seen from 200km away.
Adapting to the COVID-19 lockdown
An adaptive response is defined as an “appropriate action in which the individual responds successfully to some environmental demand” (Ayres 1979).
The nationwide lock down due to the COVID-19 (Coronavirus disease 2019) pandemic has brought about various challenges, not only in our capacity as occupational therapists, but also as individuals who form part of different families and communities. This is highlighted by the fact that we are all participating in different occupations and have many roles to fulfill, in our profession as well as in our personal lives (Occupational Therapy Practice Framework 3rd edition, AJOT 2017). Everyone was faced with a sudden and unpredicted situation where the “normal” routine made a radical shift and, in some instances, came to a complete halt.
The situation forced everyone out of their comfort zones of familiarity where things had a certain flow, to a place where we all had to find a new daily rhythm and routine, and find a new way of doing familiar things. In one way or another, we felt some pressure.
Our adaptive behaviours have been challenged on many levels, including autonomic nervous system responses such as heart-rate, sleep-wake cycles and digestion, to emotional stability, finding a calm-alert sensory midline, and on a praxis level, becoming more organised in a new social-distancing and stay-at-home routine with implications for time and space. (Smith Roley, Blanch and Schaaf 2001).
As occupational therapists working in the field of Ayres Sensory Integration (ASI)®, we are familiar with concepts such as sensory and emotional regulation, adapting to demands from the environment, and being able to develop ideas and problem solve in novel situations or deal with unpredictable changes that challenge our praxis. And yet, the past couple of weeks have brought about many different challenges and scenarios, which resulted in various responses; to cope, make sense and possibly to merely just survive by taking one day at a time. Various support groups got formed, and platforms were created where people could connect, and where we could share ideas, resources and even frustrations. Despite being physically distant, we were not alone. This level of connectivity (although a bit overwhelming initially) is empowering us to have courage and to face the coming weeks with confidence. Some might be able to relate to the words of Bruce Lee: “Courage is not the absence of fear, it is the ability to act in the presence of fear”. Others might be able to relate to the gentler words of Mary Anne Radmacher: “Courage does not always roar. Sometimes courage is the little voice at the end of the day that whispers I’ll try again tomorrow.”
Dr Jean Ayres, the pioneer in the year 2020
The year 2020 marks what would have been the 100th birthday of Dr. A. Jean Ayres. We are grateful for Dr Ayres’s wisdom, and being more of a visionary and pioneer in the 1970’s than we might have realised, without the luxury of the technology we have at our disposal today. The ASI® approach is an evolving and adaptable theory with terminology and strategies that can be applied to different diagnostic groups, ages, and therapeutic settings. We came to realise that digital therapeutic support would be possible over an electronic platform. As ASI® practitioners, we have the neuroscience to fall back onto in terms of identifying to some degree what was happening, to ourselves, to our partners, and possibly even our own children. We are also able to identify some strategies (some might be more effective than others) to assist our households to adapt to the new routine and getting stuff done.
However, we also find ourselves in a situation where our own sensory midline is being challenged to the point of feeling unbalanced and probably concerned about finances, work commitments, catching up with household chores and keeping up with school work, where desperate times could easily lead to desperate measures.
Ethical considerations for providing electronic therapeutic support
For many ASI® practitioners, providing digital therapeutic support over an electronic platform might have seemed impossible, an unthinkable thought. However, 45 years ago Dr Ayres already offered to provide long distance assistance by mail, to her nephew Philip “providing that he would like to do so” (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
The ASI® approach is child directed, implying that clients have a say in their intervention whether it is face-to-face or on an electronic platform. ASI® advocates for empathy, implying that we should try and understand the position of the client and the family in their unique context. It is imperative that we keep their best interests at heart and only give what they have capacity for: whether it implies the time and energy to implement those strategies, or the money to pay for the services provided. We therefore have to keep in mind that they too are possibly experiencing pressure to manage the emotional well-being of everyone at home, are trying to stay on top of household chores, and possibly feeling financial pressure of losing income. We should therefore be sensitive in terms of what their need is, and what they request. It is true that it takes time to prepare and set the stage for online intervention. However, we should take heed not to overstep the fine line between assisting parents/clients who are asking for help, and over-servicing clients who are already feeling like they are not coping, and over-charging for a service that was not asked for. The parents and caretakers play a vital role in presenting long distance support. We should value their and respect their feedback, and keep in mind that they too are probably taking one day at a time, and proceed at a pace that is comfortable to them.
Growth and evolving into the new
The one thing that is certain, is that life as we knew it, will be different after the COVID-19 lockdown is over.
“It’s no use going back to yesterday, because I was a different person then” – Alice in Wonderland
The butterfly has to make peace with the process of metamorphosis, and endure the pupa phase to become a butterfly, spread its wings and enjoy the freedom of flying. There shall be a shift in us too during this uncomfortable period of lock down.
They say hindsight is 2020 vision. We too shall obtain new perspectives looking back at the year 2020. We learnt knew technical skills, showed our children how to appreciate the small things and learnt not to take life and our loved ones for granted. With our evolved 2020 vision, we might have new ideas that can possibly influence the way we work and prioritise our work-life balance in a positive way. Once we emerge from this proverbial pupa phase, we will all have grown into a new person, found new direction, developed a new way of being, and doing old things in a new way. May God bless everyone.
“Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” Reinhold Niebuhr
References:
- Ayres AJ. Sensory integration and learning disorders: Western Psychological Services; 1972.
- Ayres AJ, Robbins J. Sensory integration and the child: Understanding hidden sensory challenges: Western Psychological Services; 2005.
- Mailloux, Z., & Miller-Kuhaneck, H. (2014). From the Desk of the Guest Editors—Evolution of a theory: How measurement has shaped Ayres Sensory Integration®. American Journal of Occupational Therapy, 68, 495–499. http://dx.doi.org/10.5014/ajot.2014.013656
- Occupational therapy practice framework: Domain and process (3rd edition). American Journal of Occupational Therapy. 2017; 68(Supplement_1):S1-S48.
- Parham, L. Diane, Roley, S. S., May-Benson, T. A., Koomar, J., Brett-Green, B., Burke, J. P., Cohn, E. S., Mailloux, Z., Miller, L. J. and Schaaf, R. C. (2011) Development of a Fidelity Measure for Research on the Effectiveness of the Ayres Sensory Integration Intervention American Journal of Occupational Therapy, 65, 134 – 142
- Schaaf RC, Mailloux Z. Clinician’s guide for implementing Ayres sensory integration: Promoting participation for children with autism. Bethesda: American occupational therapy association. linda. linneanet. fi/F. 2015.
- Schaaf, R. SmithRoley, S. (2006) Sensory Integration: Applying clinical reasoning to practice with diverse population. Psychorp
- Smith Roley, E. Blanche, & R. Schaaf (2001), Understanding the Nature of Sensory Integration in Diverse Populations. USA: Therapy Skill Builders.
Telehealth and Ayres Sensory Integration® – Is it possible?
Today’s blog post by SAISI vice chair, Elize Janse van Rensburg, is a summary of her webinar developed for the Telehealth-SA Facebook group in light of the COVID-19 lock down in South Africa. It is a long read but provided here as a resource for therapists trying to settle into a new way of thinking. Enjoy!
The global COVID-19 pandemic has brought about a very sudden change in the way the vast majority of occupational therapists are able to work. In South Africa, as in many other countries around the world, a nationwide lock-down with movement restricted to only essential services has caused many occupational therapists to cease delivery of face-to-face intervention services.
Shortly after the announcement of the nation-wide lock-down in South Africa, the Health Professions Council of South Africa (HPCSA) announced that they would allow the delivery of telehealth services, something that has largely been prohibited by the HPCSA in the past. Initially, services could only be delivered to existing clients; however, this limitation has also since been lifted. The HPCSA now states that:
Telehealth should preferably be practiced in circumstances where there is an already established practitioner-patient relationship. Where such a relationship does not exist, practitioners may still consult using Telehealth provided that such consultations are done in the best clinical interest of patients.(HPCSA Notice to amend Telemedicine Guidelines during COVID-19 – dated 3 April 2020)
These changes have caused many occupational therapists trained in Ayres Sensory Integration® (ASI®) to ask whether it is at all possible to deliver therapy from an ASI® frame of reference via telehealth. It sounds so strange to think that such a hands-on intervention could be delivered over a computer screen. Being confronted with these questions in my own mind as well as from many colleagues, and after being asked to present a webinar for the Telehealth-SA Facebook Page on this topic, I wondered whether there was something in the history of sensory integration that could help us – and oh boy was I surprised and excited to see that no one other than Ayres herself showed us decades ago exactly how we could do it!
Forty-five years ago, in 1975, Jean Ayres’ nephew, Philip Erwin, at that stage in his early teens, struggled immensely with difficulties that Ayres linked to sensory integrative dysfunction. In the absence of someone trained in sensory integration where Philip lived, Ayres proceeded to ‘treat’ Philip via hand-written letters! That’s right – not Zoom, not MS Teams, not WhatsApp or e-mail, hand-written letters sent by mail, every second week. Ayres’ letters, as well as reflections from Philip and one of Ayres’ scholars, Zoe Mailloux, are collated in the book “Love, Jean”, which was published in 2004 (Ayres, Erwin & Mailloux, 2004). I had read the book before as I believe many of you have, but when I re-read it with “telehealth glasses” I was astonished by how much there was to learn from the book 45 years later.
Join me on a journey through twelve lessons about ASI® and telehealth that I found (and if you read the book, you may find even more)…
- GENERAL PRINCIPLES FOR TELEHEALTH WHEN USING AN ASI® FRAME OF REFERENCE
Lession #1: Desperate times call for desperate measures
If I knew somebody in Connecticut whom I felt could do a good job of treating Philip I would refer you to that person. Since I don’t, I am offering to treat Philip by mail, providing he would like to do so (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
We read in the letters that Ayres herself acknowledged that treating Philip by mail was not her first choice, but in the absence of other options, she was willing to do so because it would be in Philip’s best interest. For us as therapists, acting in the best interest of our clients should be our first priority. Telehealth may not be suitable for everybody, and as in face-to-face therapy, we need to tailor our approach to each individual child and family’s situation. The last part of the quote is also very telling – “…provided he would like to do so…” – we obviously need informed consent from clients (both children and parents), but more than that, we need their buy-in if we are to succeed in delivering telehealth occupational therapy services using an ASI frame of reference.
Lesson #2: Telehealth takes TIME and PREPARATION – it is neither quick nor easy…
Not too much was said at the time. Nancy [Philip’s mother] believes that Jean wanted to think about the ramifications – the big investment of her time and energy – of the offer she would make soon thereafter to treat Philip from a distance. (Erwin in Ayres, Erwin & Mailloux, 2004)
The big investment of her time and energy…indeed, telehealth is neither quick nor easy. It requires extensive preparation on the part of the therapist, thorough communication with the family, assisting the parent or caregiver to prepare and working within essentially unfamiliar territory. A good friend of mine sent me this quote:
I would argue that in telehealth, we should not just be offering a service. Willingness to serve, giving generously in the best interests of our clients, will be the only way that we can deliver telehealth in an ethical manner.
Lesson#3: Telehealth is never the ideal in ASI…
The hardest part of being treated under these circumstances is the lack of structure which keeps a person at the task and reminds him that the whole thing is worthwhile. (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004)
In telehealth, the presence of the therapist to provide physical and emotional support and co-create playful, just-right challenges is missing. Telehealth, therefore, does not adhere to criteria for Fidelity in ASI® directly, and will in most instances require a proxy (such as a parent or caregiver) to be present with the younger child to, for example, ensure physical safety, assist with regulation of arousal, tailor the activity to present a just-right challenge and ensuring success (Parham et al. 2011).
- ASSESSMENT IN TELEHEALTH WHEN USING AN ASI FRAME OF REFERENCE
Lesson #4: Comprehensive assessment needs to take place face to face
In response to your request for information on having Philip tested for sensory integration dysfunction, I suggest that you write an O.T.R. [a registered Occupational Therapist] who was sent to me last year for three weeks of in-service training, and has quite a bit of experience at the Churchill School in New York City in evaluating children with learning difficulties (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
Initially, HPCSA regulations provided only for telehealth services to existing clients. Although this has been amended, it does attest to the fact that conducting comprehensive assessment over telehealth is not ideal and, in many instances, not feasible. Ayres herself referred Philip to another therapist to conduct the assessment in person, where after she provided the ‘remote therapy services’ by mail.
The coding structure proposed by OTASA for the delivery of telehealth services in South Africa does include some assessment codes (codes 66201 through 66205), but does not include codes for comprehensive assessment.
Lesson #5: Parents can make valuable observations to AID in the assessment process
If your observations on post-rotary nystagmus are accurate (and I know how hard it is to be accurate) they are quite significant. No wonder Philip is having a rough time! The fact that he disliked the rotation is also significant… (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
Parents/caregivers who buy into telehealth, are able to contribute to observations that can aid in the assessment process. We can use written communication (e.g. emails), telecommunication (e.g. phone calls or video calls), checklists, and standardized questionnaires (such as the Sensory Profile 2 and the SPM that are both available for remote on-screen administration by the parent) to obtain information from parents to aid in the assessment process. For many of us, the reality is that we have not seen our existing clients for an extended period of time by the time we embark on telehealth services, and a measure of re-assessment may be necessary before continuing the therapeutic process.
Lesson # 6: Be creative in selecting data sources
Phil, sometime send me a piece of your math work, with errors, and also tell me just how you see the problem with math. Is it memory? Not knowing where to put the numbers? (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
Ayres was really creative in the way she continuously assessed Philip’s occupational performance and participation. She asked him to report back to her on specific things, asked for work samples, and interestingly also inferred about his progress from his actual letters (such as commenting on that his handwriting seems tidier later on in the therapeutic process). In our era of technology, we are even more fortunate and are able to use live video feed, recorded videos of activities or behaviours sent to us by parents (using secure platforms), pictures, the child/parent’s own interpretations of the problem and even online assessment tools such as mentioned under Lesson 5. When we collect this data and transpose it to a data-driven decision-making process throughout, we have a very good chance of ‘getting it right’ (Schaaf & Mailloux, 2015).
- SETTING THE STAGE FOR INTERVENTION IN TELEHEALTH WHEN USING AN ASI® FRAME OF REFERENCE
Lesson #7: Consider the context, environment and available resources and use them
This is what the procedure would involve: I would explain by mail the basic principles and the kind of equipment needed to engage in a series of sensorimotor activities. Most of the equipment I have put together myself, and there isn’t anything that I have made that couldn’t be made easier and better by at least four members of the Erwin family (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
There are many instances in the book where Ayres would tailor her recommendations to the space and equipment that Philip had available. We can do that too; it will require that you find out from the parent/caregiver what they have available for use during telehealth therapy sessions (you can find a helpful checklist as a free download here), and that you tailor your planning for therapy and home programs accordingly. Amidst the nation-wide lock-down we are unable to procure new equipment or toys, but luckily occupational therapists are notoriously creative beings! Ayres also reminds us that we don’t even need fancy equipment:
Remember that when you can’t do anything else by way of therapy, you can always roll on the floor. That’s one of the best things to do, anyway(Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
Lesson #8: Clients (children and parents) need to be EVEN MORE IN THE LOOP with the reason
behind what you do…
I’ll try to help you understand what I do know so that the activities will be more meaningful (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
One of the things that struck me most about Ayres’ letters to Philip was the amount of time she spent on explaining her reasoning behind her recommendations. She explained the neuro-anatomy, neuro-physiology, sensory integrative processes, everything. And her rationale for that is clear in the quote above – “…so that the activities will be more meaningful.” Parents (and children) need to be fully in the loop about what they are doing and why they are doing it. This will not only help them to derive more meaning from the recommendations, but will also empower them to be able to problem-solve when they need to make adaptations in-the-moment either during a telehealth session or when you are not there with them through a screen. Ayres also set clear guidelines for safe participation to Philip and his parents – this is vital to ensure greater adherence to fidelity where safety is the number one priority.
- SELECTING AND CONDUCTING APPROPRIATE INTERVENTION IN TELEHEALTH WHEN USING AN ASI® FRAME OF REFERENCE
Lesson #9: Anticipate responses to recommendationsand monitor responses and progress regularly
If Philip chooses to follow this suggestion, I would like him to write me every two weeks and tell me how he felt about that activity…
Sometimes during the 2nd to 4th month of treatment most individuals go through an upsetting period during which they feel less well organized and rebel at the treatment, but once past that stage treatment can be enjoyable. Academic improvement does not appear, usually, until around the fifth month…
(Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
Luckily with smartphones and the internet, we don’t have to wait two weeks to get feedback from our clients and their parents/caregivers! But just like Ayres, we need to follow up regularly to monitor responses to treatment, as we are not always there in person to make adaptations. It will help if we give guidance to parents on what to look out for in terms of adverse responses, dysregulation, and so forth in order to equip them to make adaptations timeously. We also need to build grading into recommendations; this will assist parents/caregivers with adapting activities to be successful.
Lesson #10: Encourage and support INITIATIVE from child/parents
The equipment that you and your family made using two inner tubes is excellent and I commend all of you. I have used one inner tube as you illustrated, but it is hard to balance on only one. Using two makes it easy. That is what is good about it: it gives you the opportunity of not only swinging back and forth but also going around (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
Our clients and their parents are wonderfully creative (and they know exactly what they have at their disposal). Encouraging and supporting that initiative will undoubtedly make a positive contribution to clients’ buy-in to telehealth. What also struck me in this excerpt is how Ayres not only commended and supported them in their initiative, but also helped them to unlock the affordances of the equipment that they had. This way, they could apply the principles that she was sharing with them even more precisely.
Lesson #11: This is NEW to all – test recommendations out yourself …
But if your basement is small, don’t bother; get the accelerated motion by pushing against the wall with your feet. (That’s the way I ride my scooter board, which I do several times a week and feel the good effects for several hours.) (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
Perhaps the one thing that makes us most uncomfortable with providing telehealth services (especially in South Africa where we have never before been allowed to do it), is the thought of not having our trusted pieces of equipment available to us. Whatever we were to recommend to our clients now, will be things that we have not had the opportunity to experience first-hand. I do think it is important to try out things that we suggest to our clients ourselves, so that we can be sure that it is safe and that it works. The same goes for the technology that we plan to use – it is important to have a trial run to make sure both you and the family you are providing telehealth services too, are comfortable with the platform and know how it works.
- MEASURING OUTCOMES IN TELEHEALTH WHEN USING AN ASI® FRAME OF REFERENCE
Lesson #12: Always link recommendations to functional outcomes – and MEASURE OUTCOMES
Academic improvement cannot be guaranteed, of course, but it is almost certain that physical coordination and feeling of well-being would improve (Ayres, 1975 in Ayres, Erwin & Mailloux, 2004).
Ayres spent a significant amount of time in her letters to Philip to explain to him the outcomes that she anticipates from the treatment. She also asked him to report to her on specific aspects of these outcomes in his letters back to her – one of the ways in which she measured the outcomes of her intervention. Outcome measurement is crucial – even more so when we are in unchartered territory where funders are hesitant to pay for telehealth services and where we have little documented evidence of efficacy. Thorough record-keeping, obtaining and documenting feedback from clients and parents/caregivers regularly, and using outcome measures relevant to the functional outcomes targeted in your intervention can all potentially contribute to the body of knowledge and evidence.
SOME FINAL THOUGHTS
Can Telehealth make a positive difference in the lives of children with SI difficulties and dysfunctions?
Ayres herself, unknowingly, provided us with the answer to this question. While not our first line of defense, telehealth services have great potential in the delivery of occupational therapy services to children with sensory integration difficulties and dysfunctions. It will require an open mind, flexibility, creativity and indeed bravery, but I have no doubt in my mind that it is possible.
HELPFUL RESOURCES
ASI WISE free webinar on technology and SI: https://sensoryproject.org/technology-and-ayres-sensory-integration/
Telehealth SA webinar by Marelé Venter on Telehealth and Child and Adolescent Mental
Health: https://m.youtube.com/watch?v=PBo4E0ZW7jU&t=1886s
Telehealth SA webinar panel discussion by OTASA members touching on ethics and
coding: https://www.facebook.com/tiaan.moolman/videos/10159571750491632/ (you will have to be a member of the Telehealth SA Facebook page to access this video)
REFERENCES
Ayres, A.J., Erwin, P.R., Mailloux, Z. (2004). Love, Jean: Inspiration for families living with dysfunction of sensory integration. Crestport Press, California.
HPCSA Guidance on the application of Telemedicine Guidelines during the COVID19 Pandemic. https://www.hpcsa.co.za/Uploads/Events/Announcements/APPLICATION_OF_TELEMEDICINE_GUIDELINES.pdf
OTASA Occupational Therapy Guidelines for Telehealth Services during the COVID19 Pandemic. https://mcusercontent.com/81381981e9472692c1e82b2a1/files/4fc875ac-b8b0-426e-a028-8de37912f9dc/OT_guidelines_for_Telehealth_01.04.2020.pdf
OTASA Occupational Therapy Guidelines for Telehealth Services during the COVID19 Pandemic Update 7 April 2020.
Parham et al. (2011). Development of a fidelity measure for research on the effectiveness of the Ayres Sensory integration intervention. AJOT, 65, 133–142.
Schaaf, R.C., & Mailloux, Z. (2015). Clinician’s Guide for Implementing Ayres Sensory Integration ® Promoting Participation for Children with Autism. Bethesda: AOTA.
ACKNOWLEDGEMENTS
Members of SAISI Exco for support, encouragement and valuable contributions to the content of the original presentation.
Previous webinars as listed.