TherExtras

Lifelong Learning

2010-09-06T17:21:57-05:00

The words in the title were emphasized to students in the physical therapy (PT) graduate program. Meant to emphasize – you do not learn everything in PT school.

Back when I was the age of the students-I-used-to-teach the pop-culture book Passages came-out. (About) 30 years ago the idea of ‘adult development’ was novel. The idea of consistent developmental stages in adult life became a common understanding through this non-fiction book.

*Sigh*

I have learned so much since then.

I have no problem oversimplifying here in order to get to what I really want - to beat-up put-down mock anal-ytically discuss: developmental evaluations.

I remember this particular child because of the ‘aha’ I had while preparing her required in-depth triennial evaluation. At the time she was 12-years-old and her special education folder was size-able. In every document from a PT her gross motor developmental level was listed as in the range of ‘6 months’.

How helpful was this redundant and demeaning form of description?

Did ‘gross motor level 6 months’ help to form goals for her individual education plan (IEP)?

Beyond the time when a child is determined to be eligible for Early Intervention (EI) services by means of a developmental evaluation I seriously question the continued use of the evaluation as a marker for progress made over time and supposedly as a result of said intervention.

I am especially sympathetic to the parents who year-after-year are summarily provided the same negative information (as required) at the beginning of an IEP meeting under the auspices of ‘current level of functioning’.

From that triennial report -on I committed to put meaning back into the functioning part of 'current level of functioning'. [Leaving behind the anal-lytical discussion of questionable developmental evaluations now.]

The photos of this student in different positions were leftover saved from an instructional ‘book’ made for the teacher of her life skills class. The positions I recommended for this child were meant to help stretch and strengthen her during her school day. To get her out of lying on a bean bag or a mat.

I might not recommend exactly the same positions if I met a child just like her today.

I have learned so much since then.

The child in these photos had significant orthopedic problems – contractures in her shoulders, elbows, hips and knees and weakness and over-lengthening of the muscles that oppose those contractures. Her orthopedic problems were the result of years of inactivity in positions that did not challenge or promote activity in all her muscles.

Something like 10 years of inactivity, of believing that intermittent and discreet time with a PT is sufficient to reverse a delay in motor skills. Two times per week of multiple passive perturbations, no matter how much laughter elicited, is ineffective treatment for developing either rolling or crawling. Think about it, near-100 PT treatments per year, for how many years? – had been provided to this girl only to repeatedly tell her parents that her developmental level is similar to a six-month-old child – which it was not.

The learning I have done since these photos were taken (yes, that is me 25 years ago) has reinforced what I learned with this particular student. Developmental motor milestones are an insufficient guide for treatment of children with development-altering diagnoses.

(I’ve said it before) A child who learns to sit and stand will have a substantially different (better, I think) and potentially healthier life than a child who cannot sustain these two positions.

Sitting and standing are positions of function.
A child need not learn to roll or crawl first
in order to benefit
from supported sitting and standing.

Since meeting and serving the girl in these photos 25 years ago I have also learned that the attitudes of my colleagues are not easily changed.

I still see therapists bouncing 3-year-olds on inflated orbs. The children who learn to move do not learn to move because of this kind of treatment. The children would have learned to move anyway without 2x/week of professional bouncing.

I have challenged myself to make my case for positioning as part of the lifestyle of a child in just 50 minutes when I present at the World Congress on Disabilities in November.

Here is the abstract I submitted and was approved for me to speak:

Therapeutic Positioning:
Movement begins with a position.

This session will address the effectiveness of positioning children with delayed development to promote movement and learning. The presenter will give practical suggestions to help adults make lifestyle changes that promote physical development despite delayed skill acquisition. All suggestions are based on human physiology and currently accepted science. The presenter has over 30 years of experience during which she has observed the reluctance to lifestyle change for developmental benefit. The presentation will include information to dispel the myth that children learn to move only during discreet limited time periods and by the hands of therapists.

I have also learned more about the parents of children currently in the care of therapists. Many of you are the most important influence on the therapists and teachers of your children.

Your mindful and engaging requests to target functional goals could make a difference in lifelong learning for your child.

Turn-around Space

2010-09-02T10:31:12-05:00

If you are an experienced driver you can probably estimate whether the road ahead is wide enough to easily reverse the direction of the car.

If your experience has been that you never estimate road width correctly you might choose to drive around the block instead.

If your child uses a wheelchair or adapted stroller you get why restroom stalls are larger – turn-around space.

Designing spaces to accommodate persons using wheelchairs is just one component of a concept called universal design.

[ Image of an accessible floorplan linked into this blog. ]

[The idea for this post topic came to me as I was turning-around the mower yesterday.]

Space.

I bet many of you do not even remember when there were no large restroom stalls. Or public sinks that always had cabinet doors directly underneath. After a time, people have started to accept these design differences that accommodate the needs of a few in order to give access to all.

As difficult as it may seem at the time a new idea comes to the fore something that was uncommon frequently becomes common within one generation.

I can’t help but wonder if we can make the whole of (our) society accessible for every possible impairment (like the inability to walk). Not to mention older and less developed parts of the world. Even websites are judged for accessibility.

Then there’s the metaphorical interpretation of the title of this post. How much ‘space’ do you need to do an emotional ‘turn-around’?

How fast are you at turning-around your attitude or a negative feeling?

Our ability to adapt takes cognition which is dependent on brain power. Young children learn to think and adapt through experience. More mature children adapt more easily. Adaptation is a cognitive developmental process.

However, I also think that the common perception that older folk are more rigid adapt less fast than younger folk has merit. Way back when I was a member of a university faculty the department secretary administrator was having a discussion with the dean’s administrator regarding the exposed pipes under the sink in the faculty workroom.

“It’s ugly.
Why did they build it this way”
she said.

This comment came as we were oohing and aahing at our new out-of-the-basement digs. I was able to explain that requirements due to the American with Disabilities Act (ADA) dictated access to sinks by persons in wheelchairs. Upon inspection for meeting ADA requirements, storing boxes in the area under a sink is a violation. I recommended she make a curtain if the drain pipe was so offensive to her.

Even longer ago, at a different university, I gave an ADA-related assignment to my students in a Professional Behavior course. I required the would-be-physical-therapists to measure and document whether the restroom in a local restaurant met ADA requirements. Despite the unpopularity of the whole course this assignment, I am confident they learned about the space needed to maneuver a wheelchair.

For you, I offer a link to a video that shows an adult’s large capacity for adapting to her physical impairments.

among the giants – 23 minutes

This time last year at TherExtras:
On the co$t of wheelchairs – Weighty Issues

Tonight’s tweets – in case you are not on twitter.

2010-08-30T22:30:00-05:00

I am not a ‘news’ source & I caution you to be careful who you believe. http://bit.ly/9JQtKW

Last week ‘news’ of a study purporting ‘evidence’ of sensory integration dysfunction in the brain ping’d thru the internet.

I had difficulty finding the original sensoryintegrationautism research article. Not 1 tweet gave the location of the original article.

The only real way to tell if the work was newsworthy is to look at the original publication – in an online journal.
http://bit.ly/9WhZNx

The ‘real’ news is that a method to study this relationship has been developed, using 17 persons w/ #autism & matched controls. That.is.all.

Here’s a research article w/ good design & data to support a conclusion on what are typically fuzzy ideas.
http://bit.ly/bqLJak

#Parenting Children w/ Developmental Delays:
The Role of Positive Beliefs http://bit.ly/bqLJak

The conclusion is not overstated. “increasing mothers' positive beliefs during early childhood could aid in reducing their stress”.

That.is.all.

Other posts related to research at TherExtras:

Is there a spectrum for neuroscientists?

The Burden of Proof

What should be researched?

Anticipation

2010-08-26T20:13:05-05:00

Are you planning to see the movie Flipped in a theater this weekend? We look forward to seeing the screen version of one of our Teen’s favorite books.

The ability to anticipate (pleasure) is a cognitive skill/task. Heavily dependent on memory, the ability to ‘look’ ahead in time, to ‘envision’ (in your mind) a future that is tied to an emotion (also a thought) of excited pleasure: anticipation. (Image from here.)

Somehow the brain has to be able to make the connections between the current information and a memory with the understanding of both occurring again in the future.

Similarly, a child’s ability to understand humor is a thought-combination of memories that don’t seem to quite go together – as when a bowl on a parent’s head causes a baby to laugh. Danette’s post nicely depicts steps of developing humor with recommendations for how to foster those steps.

But what if the expectation of the future does not trigger an emotion of pleasure but feelings of fear and anger?

Anxiety

I see anxiety in many posts about the beginning of the school year. No doubt parents have anxiety based on previous experience where they felt denied or that their child was poorly served in school in the past.
(Image from here.)

I don’t believe that every.single.child transitioning into special education is mis-served or that their parents are angry advocates. Sometimes I wonder if people haven’t replaced the meaning of advocacy with the word fight. And I have sometimes wondered if parents haven’t been taught to expect mistreatment in the public school system.

If the person or literature or blog post teaching you how to interact with school personnel regarding your child’s special education uses the word fight, consider that a red flag. I don’t doubt that participating in your child’s special education is work. Hard work. But I advocate for diplomacy over battle when dealing with your child’s IEP committee.

If you expect a certain outcome from the school and arm yourself for battle you may just walk into a peaceful pow-wow wearing the wrong 'costume' - leading to another emotion, disappointment.

Be careful what you anticipate.

More A-words

This time last year at TherExtras:
The Big Equipment Decision - Are you hesitant to order a wheelchair for your child?

The Science of Cooking

2010-08-21T22:12:50-05:00

The change in food when heat is applied for cooking is the stuff of science.

The biological and chemical changes are consequences of natural law – for our use since discovered millennia ago. Image from here.

My Studly Hubby-teacher often reminds me of the scientific basis of cooking. He has a whole set of Alton Brown dvds (purchased for his classroom with a grant).

Back to the natural stuff – if you remove a fertilized egg from the warmth (heat) of the nest it dies. But if you keep it cold in a refrigerator, its physical status is preserved or deterioration is slowed significantly. And then, to improve the taste of the egg, high heat is used to cook it or change the physical properties from liquid (yoke) and gel-like (white) to solid (solidity determined by how long and high the heat was applied).

I encourage you to teach your child some science in the kitchen. [The kind of science that is not on her IEP.] This post includes a few more adaptations to cooking eggs.

What child would not want to watch this?

Admittedly, cooking egg is pretty advanced stuff. But if learned over time, albeit slowly or step-by-step, this simple skill can expand to greater independence in the years ahead.

If your child requires support to stand, consider setting-up to have her stand while watching you cook on the stove.

If your child is learning to eat (and egg is in her diet) consider feeding her immediately after showing her how the egg was cooked.

Include your child in the parts of the cooking process that will help him practice hand (fine motor) skills.

If your child is cognitively and physically ready to cook with heat, be sure the pan is hot enough to fry the eggs.

If the egg is cracked over a hot-enough surface, it immediately turns white. Not like this.

Very capable people have difficulty turning eggs – me included. I was taught to cook ‘an egg in a basket’ when I was young. This adaptive method not only makes the egg easier to flip but adds the nutritional value of a grain (if that is in your child’s diet). Start with a piece of bread on a plate and a small container or cup.

Press the cup/container into the bread to cut
a hole in the middle of the slice.

I usually place the bread in the pan after the butter melts and before the pan is hot. This allows the bread to soak-in some of the butter for better toasting.

Selection of which fat/oil to use is a very personal decision. Fats burn at varying degrees and have different tastes. Modern science has taught us that some fats benefit our bodies (are healthier) while some fats actually hurt us (are unhealthy). Teach your child your family's fat preferences and the reasons some are used to fry while others are used as spreads (i.e. margarine and mayonnaise).

Ah! the transparent 'white' instantly turned white - the temperature of the pan must have been hot enough!

It.is.so.much.easier to flip a jiggly slippery egg
when it is surrounded by bread!

This time last year at TherExtras:
The first post in my series on wheelchairs: Firm and Flat

Effects of Case Law on Healthcare Insurance Rights

2010-08-16T21:29:38-05:00

The Attorney presenting on (Texas) Medicaid spent a large portion of the time referencing a settlement between Alberto N. (et al) vs. A.H. (Executive Commissioner of the Texas Health and Human Services) and J.H. (Commissioner of the Texas Department of Aging and disability Services). The case is referred to as ‘Alberto N.’ for short.

Interpreting my data, the first two posts on the presentation by this attorney are not very popular among my readers, so I will promise this one is the last. At the same time, if you support the concept of universal care, understanding Medicaid and all other precursor programs, well, makes sense to me.

Alberto N. was (apparently) a landmark settlement in 2005. She gave us a copy of the ruling, but you can read it online. (Case No. 6:99CV459)

Quoted from her slide presentation handout:

Physical, Occupational and Speech-Language Therapy

-Children are entitled to all medically necessary therapy services.
-No diagnosis based decision making
-Children do not have to demonstrate that their condition will improve in order to receive medically necessary therapy services.
[On my copy of the handout I drew little representations of fireworks around these words.]

Interpreting the above words – which are an interpretation from the settlement – which is an interpretation of the original 45-year-old law – therapy (need) is decided by the professionals serving children. A clear fee-for-service kind-of-insurance and in fact the kind that was singularly available prior to managed care. I am old enough to remember when ‘coverage’ did not have (very many) limits and correctly submitted bills were reimbursed to qualified professionals.

[My fireworks spawned from years of claims-denial-mindset in every employment since the 1980’s.]

Re-phrasing as much for my benefit as yours ….the original law was written with the norm of the business at the time. Then, as all healthcare insurance entities experienced, the claims became financially unsustainable. Companies and the government sought to limit compensated medical care through regulation. This effectively moved the decisions for care away from the professionals to the people who implemented the regulation. I don’t think I am oversimplifying.

While the Medicaid program was originally implemented for those who qualified on the basis of income, the program has been expanded to include other groups and specifically those with significant disability and certain children. Repeating myself [again] your child might qualify for a Medicaid program in your state. Seeking information from the morass of complicated government regulation will not be easy. But as was said in comments on a previous post, Medicaid insurance can be life-saving.

This time last year at TherExtras:
The Many Meanings of Dance

Meet me at the World Congress on Disabilities!

2010-08-14T12:00:00-05:00

My presentation to speak at the next
World Congress on Disabilities
has been accepted!

If you have any means or reason to visit Dallas, Texas [giving yourself a pre-Thanksgiving break from shoveling your driveway] – come on down!

My presentation is titled:
Therapeutic Positioning: Movement begins with a position

And I could use your help.

My presentation will be a quick 50 minutes of me talking near-non-stop extolling the benefits of using equipment to help children learn to sit and stand. Would you allow me to use a photo of your child to help another parent or professional understand [what you have been reading here for the last 3 years]?

To volunteer a photo or photos of your child to be included in my presentation at the World Congress on Disabilities leave a comment on the permission page.

Appealing Denials from Medicaid

2010-08-13T12:18:19-05:00

The attorney presenting on (Texas) Medicaid gave clear information on appealing a denial for therapy services and equipment for children with diagnoses.

However, she had no nada zero zip answer for me for how to appeal denials outright lack of response to billing Medicaid for my services.

(Again, from my notes…)

However, all states are required to have protection and advocacy agencies (protection and advocacy for Medicaid recipients). She referred to this comprehensive site for information. [Or was it this site for comprehensive information?]

The attorney spent a large portion of the meeting making the case providing a history of (Texas) Medicaid appeals procedures. She used the history to show how procedural rules have been managed to deny services. Abounding conflict of interest.

Appealing a denial to (Texas) Medicaid leads to a hearing. Many hearings have been or are held by phone. Not surprisingly, at those hearings where an attorney was present a greater percentage of denials were reversed.

An important distinction came from another therapist in the audience – in her employment there were virtually no denials from the state’s intermediary for fee-for-service Medicaid. However, denials were/are routine from each of the (optional) (Texas) Medicaid health maintenance organizations (HMOs). Some discussion ensued regarding how to steer Medicaid families (back) toward the fee-for-service program.

Despite my recommendation to apply for Medicaid for your child with a diagnosis and on the possibility that I have not made this clear, the right for public money healthcare insurance does not come any more easily than that which is earned by you or your spouse through employment. Depending on your circumstance, however, Medicaid may be a more secure option. The attorney said she thinks Medicaid is secure due to the program being funded 67% by the federal government. (Her opinion; stat reference not given.) Which leads me to remind you that Medicaid funded services vary state-to-state.

And that her particular advocacy services are not available to appeal denial of eligibility. Circling back to the top of the previous paragraph – your role job as a parent of a child with a development-altering-diagnosis is complicated by earning the financing of medical care and therapy services for your child no matter who is in charge of the insurance system.
These are words from my notes (what I heard) –

insurance presumes authority
over someone’s health and well-being.

Last year at this time on TherExtras:
A Pioneering Life - a post about you.