Month: February 2021

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Learning to Read Body Signs: Help for Children with Functional Abdominal Pain (FAP)

pain

The newer kid to the more mainstream discussions in pediatric OT is interoception. The term cropped up I’d say about 2-3 years ago. It speaks to how we experience the internal signals of our body and the effects those have on regulation and awareness. I think it is definitely crucial to consider when working with children with Sensory Processing issues.

One thing the study authors emphasized in this study and approach is the idea of teaching children to be curious about what their bodies are telling them. I take this as the idea being to not stigmatize the feelings. I think this is very insightful and helpful from an acceptance based approach! I think that often children who have more sensitive sensory systems are often also anxious and/or struggle with more intense feelings. For these children they may compound their negative feelings when trying to please others if made to feel badly about their feelings. I think the authors are on a very good path by reframing the children’s sensory sensitivities in a positive light.

Journal Behaviour Research and Therapy (SNIP 2.086)

Article Title Acceptance-based interoceptive exposure for young children with functional abdominal pain

  • 1A Systematic review of homogeneous RCTs
  • 1B Well-designed individual RCT
  • 2A Systematic review of cohort studies
  • 2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 4 Case series (and low-quality cohort and case control study)
  • 5 Expert opinion without explicit critical appraisal

Methods Child were screened and recruited from a pediatrician’s office. Inclusion criteria included:

  • Age between 5 years and 9 years 11 months at time of screening
  • A guardian who was fluent in English
  • At home access to a device with video chat function
  • Positive Screen for FAP on the Questionnaire on Pediatric Gastrointestinal Symptoms Rome III Version (Meaning 2 or more stomachaches with impairment or 8 or more stomachaches with or without impairment over 2 months time (Zucker et al. 2017, p. 202)

Children who had an IQ of <70 or pervasive developmental delay were excluded.

Intervention

Parents completed a semi-structured interview, and both parents and child completed 2 weeks worth of a pain-diary. Both parents and child also completed multiple self-report questions. These provided information on the mental health of the parents and child, emotional regulation and pain symptoms. Parents completed ratings of their children’s pain before treatment and two weeks after treatment.

What was in the pain diary?

  • A parent and child rating on a pain thermometer that indicated the intensity of the child’s pain
  • A parent report with insight on their child’s distress about the pain
  • The child’s report of their affect

Treatment

Children participated in 10 weeks of therapy during which they participated in cognitive and physical activities to promote becoming, “Feeling and Body Investigators.” Both parents and children received positive reframing education on how their sensitivity can be beneficial and an advantage.

The children’s parents traced them on a piece of paper to create a body map that was then used throughout treatment. Researchers then introduced children to specific body sensations. They also completed exercises that illustrated interoceptive feelings (Zucker et al., p. 203).

See the infographic for more details on the treatment intervention.

Findings

Investigators found that parents’ ratings of their child’s pain were significantly reduced following intervention. Similarly, the children’s ratings of their own pain decreased significantly.

Parents’ ratings of the distress their child’s pain caused them were also significantly decreased following intervention. The authors suggest this supports the study’s aim of reducing a child’s fear of their own bodily sensations.

Parents also rated how their child’s pain interfered with their day pre and post treatment. After treatment, parents’ ratings improved significantly.

Both children and their parents reported decreased negative affect (such as sadness and nervousness) for children following treatment.

Things to Consider

The demographics of this study were mainly caucasian (75%) females (66%) (Zucker et al. 2017, p. 206). One may consider how easily the findings can generalize to the general public who presents with FAP. The study authors also mentioned that the sample size was small and there was no control group.

References

Zucker, N., et al. (2017). Acceptance-based interoceptive exposure for young children with functional abdominal pain. Behaviour Research and Therapy, 97, 200-212.

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Sensory Regulation through a DIR/Floortime Approach

Sensory processing is so central to what peds OT’s do these days, but there remains a lot of difference in opinions. From “whether it exists,” to what’s the most effective way to treat it. One often leaves OT school feeling like there’s still a lot of new learning to be done.

Learning curves for new grads can be steep. I will say that I personally have shifted my thinking dramatically as an OT since the time I graduated. I have gone from being very detail oriented, goal focused, everything must look like typical to much more practical, holistic and functional.

This journey has led me to be interested in developmental approaches like the DIR/Floortime model. From what I’ve read, it is a collaborative approach between parents and professionals, in which parents are key players. It also emphasizes emotional development and engagement. These are also two elements that have become largely more important to me as I’ve learned to see the forest instead of focusing only on the trees.

I plan to research more into DIR and similar approaches, but this was a basic starting point on an article that reviewed DIR’s impact on communication and self-regulation.

Journal Journal of Occupational Therapy, Schools, & Early Intervention (SNIP 0.535)

Article Title Intervention effects on communication skills and sensory regulation on children with ASD

  • 1A Systematic review of homogeneous RCTs
  • 1B Well-designed individual RCT
  • 2A Systematic review of cohort studies
  • 2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 4 Case series (and low-quality cohort and case control study)
  • 5 Expert opinion without explicit critical appraisal

Methods Professionals recruited 25 children aged 3-6 years old with ASD and their families to participate in this study.

Intervention

A multi-disciplinary team developed focused individualized intervention plans for each child that were completed for a 10 month period. The programs included 1-2 elements that were included in the approach: Floortime, sensory integration and speech therapy (Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida p. 349, 2018). Important aspects of the intervention process included:

  • A team of multi-disciplinary professionals who worked as a team with families
  • Identifying children’s strengths, preferences and interests
  • Focusing on developmental areas that emphasis connection, engagement and social skills to promote learning in a child’s natural environments

Every member of the team of professionals was trained in DIR/Floortime and OT’s additionally were trained in Ayres Sensory Integration (Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida p. 350, 2018). All team members had also worked for more than 5 years in the Early Intervention System with children with ASD.

Sessions were as follows…

Floortime A psychologist led parents in 30 minute Floortime sessions, in which psychologists coached parents in promoting joint attention from their child. The psychologist also observed and provided feedback to the parent utilizing these skills following the time spent working together.

Sensory Integration OT’s led sessions for 30 minutes if the child participated in multiple therapies from the three options (SI, Floortime and Speech therapy). The children who only participated in SI therapy participated in 45 minute sessions. OT sessions aimed to promote joint attention, social skills, perceptual skills and motor planning through eliciting increased integration of sensory input.

OT’s also provided education to parents as to the connection between sensory integration abilities and difficult behaviors children sometimes display. In this education, OT’s included information on how to adapt the child’s every day routine with modifications to promote regulation.

Speech Therapy Speech therapists used augmentative and alternative communication systems in sessions to promote natural gestures and symbolic communicative forms during their 30 minute sessions (Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida p. 352, 2018).

Measures Parents completed the Assessment Scale of Children with ASD, which gathers information on Social Communication, Repetitive Behaviors and Restricted Interests, and Sensory Processing.

Findings

Children demonstrated statistically significant improved scores for the areas of Social Communication and Sensory Processing. The area of Repetitive Behaviors and Restricted Interests did not yield a statistically significant in the change in parents’ ratings.

Things to Consider

The authors note that the study had no control group, so the results cannot be compared to a lack of treatment, alternative treatment, nor control for development by maturation alone. They also noted that they did not compare or categorize children based upon the severity of their symptoms of each area included.

A limiting element in applying this study to a wide array of OT’s is that the OT’s in this study were trained in both Ayres Sensory Integration and Floortime. I definitely believe I do Sensory Integration Therapy based on the principles in the infographic above, but I’m not officially trained. What I do take away from this article is evidence that developmental models such as DIR/Floortime are a valuable tool to enhance the occupational therapy one is already providing.

References

Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida (2018). Intervention effects on communication skills and sensory regulation on children with ASD, Journal of Occupational Therapy, Schools, & Early Intervention, 11:3, 346-359, DOI: 10.1080/19411243.2018.1455552

Watling, R., & Hauer, S. (2015). Effectiveness of Ayres Sensory Integration® and sensory-based interventions for people with autism spectrum disorder: A systematic review. American Journal of Occupational Therapy, 69, 6905180030.

http://dx.doi.org/10.5014/ajot.2015.018051