This week’s post is all about tying up a few therapy notes loose ends. I strive to be comprehensive enough in each post to adequately address an issue and be useful to those who may need to try similar strategies or techniques. However, some of this past month’s topics were already long enough on words to risk out-Rapunzeling my average post length. So in the interest of respecting the time each of you has to read my ramblings each week, I made a few snips and saved a bit of length for another day. Because none of these extra notes was substantial enough to merit full posts by themselves, I am tying these loose ends together while we are still time-wise near to the original posts.
On Head Banging
There are some additional approaches towards safeguarding precious noggins for kiddos experiencing a similar drive to self-harm that can be beneficial depending on the individual’s circumstances. If a child will tolerate helmets or other items designed to minimize the trauma caused by impact, that can be a great option. Unfortunately for everyone involved in our house, these types of items currently provoke fits of panic and hysterics from Tony- and he removes them in seconds. He does not, however, calm down in seconds and we have found that even trying to use them increases his risk of a prolonged episode of attempted self-harming. Therefore, with our little man it is more useful to rely on methods focused more on teaching appropriate replacement behaviors and consequences.
There are times when I have had to follow him around the house with a pillow to slip directly under his head while he’s on his way down in an attempt to crack his head into the floor. We were so successful at preventing significant impacts doing this that Tony started using his open hands to hit the top of his head for most of his self-harming efforts. Certainly this won’t result in as serious of an injury, but it is still a coping mechanism that could cause harm and is therefore undesirable.
What we have done for this is work on teaching appropriate replacement behaviors such as stomping, clapping his hands, or striking a safe item like a drum to release some of that angry energy when he becomes upset. We also use this technique when he decides he wants to hit an inappropriate replacement item (like the TV) as a replacement behavior. Tony’s various symptoms have led to a great deal of damage and household items coming to a very early and untimely demise over the years, so while this behavioral adaptation may be safer for the head, it certainly is not for the budget when he does it on things he shouldn’t.
Drums purchased for neurologic music therapy program supports at home, also used as a safe activity for releasing angry energy, Photos by Ariana 
These drums can be purchased many places on-line if you need them…
Even Silver Linings Take Work
You may be tempted to think that something which made Tony happy, like Casandra (described as Ms. C in prior posts) returning to our therapy team would be pretty uneventful. However, Tony has high levels of rigidity about his schedule and any change requires work to ease him into it. Casandra, who is an ABA therapist, spent the first couple sessions after she came back just re-pairing with Tony.
Pairing is the process of being in his space, trying to engage him in activities he’s interested in but not making any requests towards therapeutic goals. The initial pairing process needed to be longer when she first started working with our little man because he didn’t know her. However, he still needed some adjustment time with fewer functional expectations to ensure a successful transition. That being said, he still has a slightly lower level of cooperation and history tells me this will remain so for a couple of months until he accepts that her return is really a solidified part of his schedule. I also need to provide extra practice on some tasks and skills we want Casandra to help him generalize to cooperating with others on so that he is comfortable enough with the items to engage with her.
Some things we are working on during Casandra’s sessions are tacting (correctly describing items using his AAC speech device), tracing circles and lines with a stylus, two-step imitation, appropriately responding to requests such as “come,” “stop,’ or “wait,” and functional play over two minute intervals.
One Approach to Developing Hand Strength Using Functional Play
This is a topic that could potentially be expanded, but at this time I only want to delve into a technique referenced (but not explained) in the caption for a picture that was used in a recent post. Our son, like many children, is more cooperative with activities he finds enjoyable. Because he has deficits in both hand and finger strength, I often try to find developmental toys that will engage him and can be used for both strength progression and functional play.
The Number Bugs shown here (and pictured in my post “The Snail”) are a Learning Resources toy that gets pulled apart into three sections that need to be reassembled. This is a great toy that can be used for counting, number recognition, and hand strength. What I set up for Tony was a slow progression. Initially, all I had him doing was pushing the heads back on after I removed them. Next I had him pushing together the two halves of the bodies. Our blue bug came with a ridge on the peg that holds the two pieces of the body together, so the extra difficulty required by that one often frustrated him and he initially needed hand-over-hand help pushing those halves together. Once he was doing that comfortably, we worked towards assembling all parts of the bug.
When he was doing that with confidence, we moved towards generalizing his cooperation with that for other therapy providers, such as Emily and Casandra. I moved on towards helping progress the skill of pulling the bugs apart, and the first step was to loosen the head a little bit for him so it was partially out of the body and a bit easier to pull off. Once he was doing that well, I would hold the body so he could try and pull the head off from start to finish by himself. This moved onto him holding the bug, and then working on pulling apart the body pieces in the same manner. And now, after nearly a year of working in this manner, Tony is able to pull apart and assemble all six bugs independently and can generalize this when playing with others.
This is an approach that could be used with other toys available on the market. I think the key to success with this technique is finding something that the child you are working with enjoys. Our son really likes toys with repetitive actions that can be lined up when he’s done. Your kiddo may enjoy different things, but this process can be adapted to other toys that require assembling or disassembling.
Tying Things Together
There are many moving pieces to the therapy approaches and programs required for any individual with significant deficits. As always, it really isn’t possible for me to fully address every aspect of a particular situation in a single post- though I certainly do my best to touch on the most pertinent aspects. Tying it all together in real life and on a blog can be pretty tricky. In real life, I don’t get to cut things out without limiting our son’s ability to progress, though certainly sometimes I have to make decisions about timing that will optimize his ability to acquire a desired skill. Truthfully, there are no perfect answers to some of these challenges because individual needs will vary, and I can’t always write posts that perfectly address everything that even we are dealing with…and I am grateful for your patience with that.
