Over a year has passed since our last occupational therapy (OT) update. Shortly after our last post about what we were working on with her, Amara went on maternity leave and another therapist was covering as our little man’s OT provider for a few short months. We are grateful Amara was able to resume working with our family, but as any provider who has worked with Tony knows, if you take an extended period of time off for any reason, he usually needs a period of readjustment. Especially if he likes a person, he may be both grateful for the return and simultaneously less cooperative. I think sometimes it’s his way of providing a consequence for behavior/circumstances he doesn’t approve of. Usually we can be assured he’s gotten over his hard feelings about these types of absences by the time he’s either returned to giving hugs or asking for tickles and/or chase.
Most of this post will be dedicated to pictures and descriptions of what we are currently doing and accurately reflect our real world circumstances. I cannot be the full-time clutter police right now, I have a very lengthy list of things to accomplish and nowhere enough time in which to do it. A few of the pictures used are for things we are working on to support occupational therapy goals in our own time, because there are enough activities rotated through in OT we weren’t able to picture all of them with Amara.
Amara arrives at the end of Emily’s Thursday shift, and he often has to be prompted to say “hi.” Social niceties really aren’t something he sees the need for, though he is getting better at initiating salutations. Sometimes, because he’s such a middle of the night party animal, he may start to fall asleep while we are waiting for her. If that happens, I open up one of his preferred educational apps, because those will usually perk him up enough to participate when she arrives.
Tony continues to have a lot of sensory problems related to tactile defensiveness with his clothes, but we are continuing to work on having him wear his clothes for therapists or guests. Sometimes he will decide this means we need to go somewhere, and he will get his car safety harness and start making requests. If Tony is already dysregulated, I may choose to allow him to stay in his underwear, and often he still takes off his shirt and pants/shorts before the end of a session. One of the biggest improvements we are seeing in all of his therapy types though, is an ability to remain calm without self-harming when told that we will be staying home and doing therapy instead of going wherever he requested.
Usually when Amara arrives, Tony isn’t enthusiastic about engaging in any of the activities she wants to do. She will then invite him to participate in a task he’s usually more willing to do, like color sorting. This toy is designed for duplicating patterns, but Tony has a strong preference for color sorting and pattern repetition is still a work in progress.
Emily & Tony
We’re working on fine motor skills for tripod grasp and we’re working on Tony imitating a drawing both vertical and horizontal lines on a white board. Sometimes he stops with the line, sometimes he does more of a scribbling motion in the appropriate direction. We also continue to have him trace a variety of lines and shapes on his iPad mini.
Yes, I still purchase a whole lot of toys to help support our goals. This one I got because I thought he’d be more more motivated by the color sorting aspect to maintain a sustained tripod grasp while moving in multiple directions, which will help build up those hand muscles to improve his fine motor skills.
Here, we’re working on the Lite-Brite to improve fine motor skills. He’s not interested in making pictures, we’re just putting in the pegs.
Ariana telling Tony to spit the pegs 
Amara & Tony 
Often he gets frustrated, and tries to chew on things he shouldn’t (such as the Lite-Brite pegs) or needs comforting. He sometimes requests a couple minutes of a TV break independently, other times we will need to remind him that he can do that if he needs a few minutes away from a task to calm himself.
We’re working on a lot of functional play. The train puzzle assembles more like a jigsaw puzzle, but has pegs to hold. I bought these as part of a strategy to help build him up to working jigsaw puzzles with more than a few pieces. We also assemble different toys for hand strength.
We are working on four piece jigsaw puzzles.
We’re also working on some eight piece jigsaw puzzles I purchased from Discount School Supply that we also use for labeling emotions. For jigsaw puzzles more than four pieces, he can struggle with how to start the assembly and I may need to place one piece to start him off. He may also need guidance for at least two other pieces as to where they might go, and then he is able to independently finish the rest of it.
This toy I purchased a long time ago because I thought the tongs would be great for building tripod grasp, but the included tongs are still too big for him to hold comfortably. This is a design flaw that I still feel the manufacturer needs to address given the age of the target user (preschoolers and kindergartners who are much smaller than my nearly 4′ 6″ kiddo), but we have been using it for functional play by allowing him to sort it with his hands alone. Amara has been working with him to use small kitchen tongs, and he usually needs some hand-over-hand support. He is able to get a few beads in on his own, and he often tries to find creative ways to simplify the task. Here for example, he is picking up the bead and trying to put it by hand into the tips of the tongs, so Amara will redirect him to put the ball down and retry.
We’re also working on self-care skills (activities of daily living) such as hand washing, hand drying, and brushing hair. Up until recently, he couldn’t get his hands behind his head well, we are seeing an improvement in his range of motion there, but he still often doesn’t have the patience to brush his full head of hair himself.
When we talk about some of the sleep difficulties Tony has been having with his ADHD medication, I want to make it clear that there is another side to this situation. What we are able to accomplish in some of his other therapies is more than it was before. The interactions between Tony’s different diagnoses are complex. We, as his parents, with his medical providers continually have to weight the pros and cons to things, and when it comes to his joint attention, there have been some huge pros. The current medication has certainly led to improvements in his participation during occupational therapy, and we will continue to work with his developmental pediatrician to try and find ways to address his sleeping needs, because that also is important to everyone involved.
Amara has noted and seen the improvements, both in joint attention from the Guanfacine, and from Tony’s own efforts to react safely when he’s upset. A few months have passed since Tony last tried any self-harming in OT. We are grateful to both Amara and Tony for all of the work they do as he continues to move forward.
