Outpatient Certifications

Below I included some of the most common certifications therapists had obtained and talked with me about while spending time at outpatient pediatric clinics.

Sensory Integration (SI) Training/Courses -
- A couple outpatient therapists at the clinics I visited had completed further sensory integration training.  One course in particular was an intense 3 month course in California through Jean Ayres.  From speaking with them, they shared that after attending the SI class, they felt it further shaped the way they provided occupational therapy services.  Sensory integration further evaluates the way a child is able to process and adapt to the sensory interactions that are going on in a child's environment and within themselves.
For further information on the SI course offered in California I have provided a link:
http://chan.usc.edu/academics/continuing-education/sensory-integration

NDT training -
-Many therapists shared they had also attended a multiple day course on Neuro-Developmental Treatment (NDT).  They shared that this course had given them greater confidence when handling patients and a greater knowledge base to draw from for interventions during treatment sessions.  

Alert Program - "How fast is your engine running?"
-The Alert Program was a program I learned about that focuses primarily on self regulation and emotional regulation.  This program a therapist can attend a course on or get mentored by another therapist who has received proper training.  This program enables the child to identify when their "engine" is running too slow, too fast, or just right.  Therapists explained that this program is a great way to raise awareness for the child and is a positive home program for families.  Many therapists have seen great success when utilizing this program.
To read further about the Alert Program:
http://www.alertprogram.com/

Handwriting without tears courses
-While spending time in an outpatient setting, I realized how common it is for an OT to work with children on handwriting.  Whether it be letter formation, fine motor strengthening, proper pencil grasp, attention, etc.  There are many aspects that can impede a child's ability to learn handwriting in a school setting. A curriculum that I specifically learned about was Handwriting Without Tears.  This program was designed by an OT specifically and is utilized in many schools as well.  From my experience and after talking with therapists, children tend to have success with this multi-sensory way of learning handwriting.  Therapists shared that the Handwriting Without Tears materials are easy to understand and children enjoy working through it.
Handwriting without tears link:
https://www.hwtears.com/hwt

There are many more certifications therapists can obtain when working in an outpatient pediatric setting.  The therapists I spoke with shared that the continuing education courses they attended and the certifications they had strongly impacted the way they delivered OT services and planned treatment sessions.  Seeking out continuing education courses is a way to provide evidence based interventions and stay up to date on what is working for children outside of the clinic you work at.

Images found on Google.

Assessments and Interventions within the NICU

As my rotation comes to an end, I cannot believe everything I have learned and how thankful I am for the time I was able to spend in the NICU.  Below I am including some information regarding helpful assessments and interventions I used during those four months.

Assessments - Within the NICU I was at, a huge component used for assessment is clinical observation.  With the babies being so fragile and sick, we are constantly observing their vitals, stress cues, and reaction to our presence.  We are continually assessing their movements, head shape, tolerance, etc. and documenting on those observations.  We can then reflect on change over time within our documentation and continue to facilitate their progress during their hospitalization.  
Another assessment which was occasionally utilized was the HELP (Hawaii Early Learning Profile) assessment.  This assessment was commonly used for the long term babies who required prolonged hospitalization.  This assessment consists of six domains which include: cognitive, language, gross motor, fine motor, social-emotional, and self-help.  These enable therapists to better understand where the baby is developmentally and specific skills to continue addressing during treatment sessions.  

Interventions - There are a number of interventions utilized within the NICU.  Below I have included some common ones I became familiar with over the past four months. 
The focus of the treatment session and the response from the baby dictates greatly what our interventions will include.
If we are focusing on tactile/proprioceptive system development we may include positive touch, infant massage, proprioceptive joint input, ROM, or containment holds for example. 
As we continue to progress the sensory system we may introduce bouncy swings for short periods of time to stimulate the vestibular system.  As the babe is developmentally progressing we may also incorporate auditory stimulation such as music therapy as an intervention.  Visually, when is a babe is age appropriate to begin visually tracking, we may encourage the babe to follow the therapist's face or a motivating toy.  
As an infant grows and develops we may also progress to incorporating multiple sensory interventions to allow the babe to explore their environment and develop a greater capacity to take in their surroundings.  
Additional interventions provided include: head shaping techniques and positioning devices, environmental modifications, parent education, boundary support within isolette to promote a womb like position.

These interventions and many more enable therapists to provide positive developmental care within the NICU and be a key member of the interdisciplinary team in the hospital!

Ladder Approach

The ladder Approach was developed by an occupational therapist specifically for treating patients in the NICU.  Lisa Bader developed this tool to assist therapists in the NICU to have more direction and confidence when treating babies.  I personally found this tool helpful because it enabled me to think through my intervention sessions more clearly.

The ladder approach breaks down sensory development and describes it as steps of the ladder. A baby first begins developing their tactile system within the womb, and this system is the first to fully develop.  When treating premature infants, this system is the first to be addressed during interventions before progressing to other sensory systems in case an infant's brain, developmentally, is not ready to progress.  As stated in the manual, the tactile/proprioceptive system develops first, followed by vestibular, olfactory/gustatory, auditory and finally the visual system.

My therapy sessions always began addressing the tactile system to give me an opportunity to read the infant's cues and better understand what they could tolerate during the session.  If appropriate, I would then progress up the ladder to continue working on other sensory systems.  Within each sensory system there are various interventions and techniques which can be applied.

I was thankful to have found the ladder approach and have the opportunity to use it as a supplement to this rotation.  It further developed my understanding and knowledge when working with my mentor in the NICU.  This approach allowed me to better organize treatment sessions and better treat my patients.

For more information visit: http://www.otptinthenicu.com/

Infant Massage Sessions

Since attending my infant massage course, I have been working towards becoming certified by completing two sessions with four families.  This has been beneficial in continuing my learning and ability to teach infant massage to parents.  I have learned a lot through this hands on experience!


Parents have been very eager to learn and incorporate this technique into their routines.  A key point to make sure parents understand is that the massage is not meant to be forced or become an activity they have to complete even when their child is not receptive to it.  This should be a positive interaction between them and if a babe is showing cues that they are not tolerating the massage or need a break, those requests are important to acknowledge.

Parents have provided positive feedback following the sessions.  The massage strokes can be a lot of information to introduce to parents.  The instructor of the course stated that infant massage is best learned when it is divided into four separate sessions to allow parents to practice various massage strokes on sections of the body and return with questions the next week.  This breaks down the material taught and allows  the instructor to go through the strokes more slowly.

Parents have stated that they enjoy doing the massage as part of their bedtime routine or right when their child wakes up from a nap.  Parents have also stated how it has surprised them how well the babies have tolerated the massage and seem to enjoy the strokes.  I had one parent state the handouts were very helpful for a reference and reminder on how to perform the strokes correctly and cover each part of the body.


Since working in the NICU, I have seen various massage strokes used in a modified way for the needs of the infants.  If a baby is gassy or seems to be restless and uncomfortable, I have had the opportunity to perform some strokes focused on the stomach and bicycling of the legs to assist in relieving some of their discomfort.  I have seen great success with incorporating massage into some of my treatment sessions when appropriate.  The positive touch provided by massage is a great supplement in treatment sessions with premature infants when therapists commonly are providing positive touch techniques to promote healthy neurodevelopment.

Infant massage can be beneficial for babies of all ages and is a great bonding experience for them and their parents.  I have really enjoyed developing my skills in this techniques and becoming a certified instructor.

Infant Massage

This past weekend I attended an Infant Massage Instructor course through the International Loving Touch Foundation.  This course equips individuals to organize and lead a parent-infant massage program.

Infant massage is a positive interaction between a parent and infant using manual manipulation of soft tissues of the body.

There are many benefits of infant massage and they can be categorized into 4 categories:

1. Stimulation

• All senses are stimulated
• Weight Gain
• Communication, interaction with caregiver or parent
• Growth hormone production
• Immune system
• Increased myelination in brain
• Increased oxygenation to skin, all parts of the body

2. Relaxation

• Muscles
• Reduces stress levels
• Stress/relaxation cycle
• Release tension
• Pain management, comfort
• Development of Condition Relaxation Response (CRR)
• Teaches relaxation at a young age

3. Relief

• Colic, constipation, teething pain
• Move trapped gas and stool out of bowels
• Helps sleep disorders
• Regulates stress levels
• Release of pain from medical intervention/trauma
• Verbally reinforce pain release with use of visualization and positive affirmation

4. Bonding/Interactions

• Eye-to-eye contact
• Skin Contact
• Entrainment
• Promotes attachment and bonding between parent/caregiver and child
• Builds better relationships with parents and as adults with others
• Develops security and confidence in child, trusting/knowing they can be loved
• Quality one-on-one time between parents and child/infant

The list could continue on!

Why is infant massage something an OT would be interested in??

Our tactile system is the first to develop in in the womb.  As a baby, touch is one of the main ways we learn and explore the world.  As an OT student working in the NICU each week, positive tolerance and interaction with touch is a major component of our therapy sessions.  When a premature infant is used to the input of the womb and quickly has to adjust to the outside world before their systems are ready to do so, positive touch and interaction with their parents is a crucial component to healthy brain development. As listed below, touch can influence many aspect of early development all of which will affect the way in which a developing child will complete their daily activities and routines and interact with their environment as they grow older.  These are all things occupational therapists assess and evaluate throughout treatment.  Infant massage is just another "tool in our toolbox" to use to empower and educate parents when trying to help their children.

As outlined in our course last weekend, there are five aspects of early development influenced by touch:

1. Communication - Engaged pre-speech components and emerging speech (direct eye gaze, listening, turn-taking, etc.)

2. Motor - Improves muscle tone coordination and increases body awareness

3. Socialization - Infant and caregiver engage one another, infant usually in the quiet alert state

4. Self-Help - May stimulate oral motor musculature awareness, lip closure, relaxation of tension needed for swallowing, etc.

5. Cognition - Overall awareness of self and body boundaries, cause and effect, and increase attention span

I am so excited to see how infant massage can be incorporated into my professional career and how parents can benefit from this daily 15-20 min activity with their child.

There are multiple companies who offer infant massage information and resources.  They can be accessed through an easy google search.  For more information from the Loving Touch website, please visit:

http://www.lovingtouch.com/

Documentation: Outpatient vs Inpatient

One major difference I have noticed from spending time in both inpatient and outpatient pediatric settings this fall is the various methods of documentation that exist in the world of therapy.

At our hospital, we use a system called EPIC for online documentation.  Within this system, there are templates created for occupational therapy.  Each template is geared towards a population we may be treating.  For example, there is a pediatric template along with a NICU template.  These have been created to increase efficiency and ease of documentation.  The information within each template is relevant to the population you are treating.
I have been learning how different it is to document for the pediatric population, especially within the NICU.  I have been learning a whole new language to communicate through it seems! We are documenting what we gather from evaluations/assessments along with what treatments we provide and the rationale for our services.  Within the acute setting, another role we have is to determine the next level of care we feel is needed.  This may include going to an inpatient rehab facility to continue building strength and independence in ADLs, receiving outpatient services or even OT within the home.  We may also be suggesting adaptive equipment for the child and family to utilize at home to increase independence and safety, such as a commode or shower chair.  These are all pieces of information we include within our online documentation system.

The outpatient documentation that I have observed during this rotation has tended to be much more narrative form. It had been based off of a SOAP note format.  This means that there is a subject, objective, assessment, and plan portion of the note.  Goals are frequently revisited to document progress made.  Both settings take into account ADLs that are being addressed (if age appropriate) or developmental aspects that are requiring therapy.  In the outpatient setting, parents are typically very involved with the goals and home programs are crucial for progress to be evident.  As one therapist explained to me, there is only so much you can do in a 30-45 min session each week.  So much depends on the work that is done at home and involvement of the parents.  This is another reason why education is huge for parents so they truly understand what we are doing and how this can benefit their child.  If we explain ourselves and parents understand the strategies they use, they will often times feel more confident carrying through with home programs.

Being able to expand my skills set and broaden my documentation skills throughout this rotation has been great so far and I look forward to continuing to develop my skills!!

OT NICU Evaluation Form

The beginning of week 6 is upon us!  Time is flying and I am loving every bit of information I am learning in the NICU.

At the hospital I am completing my rotation at, when OT gets a consult from the medical team to evaluate and treat an infant in the NICU, we first complete a thorough chart review to gain as much information as we can before seeing the baby.  This is a way to be more prepared upon entering and determine what further information we need to gather throughout our session.

I have created a document that allows us to put all of our information in one place throughout the infant's hospital stay.  This evaluation form allows us to stay organized and best treat each baby and their families.  We also document all of our treatment sessions electronically.  This form is a way to keep up to date on our caseload and easily look for a baby's information within our clipboard or binder.

Name: Bay/Room # Date of Evaluation: GA: Reflexes: Palmar Grasp _______R   _______L Plantar Grasp _______R  _______L Scarf Sign __________	Mother’s Name: Age: Father’s Name: Age: Sibling______________Age__________ Sibling______________Age__________ Sibling______________Age__________ Sibling______________Age__________ Family Availability:
Infant Birth History DOB: GA at Birth: Mod of Delivery: Apgars________1min __________5min Birthweight _________g Diagnosis Complications of birth:	Maternal History Grava________ Para_______ Prenatal care/complications: Labor & Delivery: Medications:
Respiratory Assistance:	Social History:
Current Medications: Sedatives:  Diuretics: Anticonvulsants: Steroids: Antibiotics:  Other:  Caffeine      Theophylline	Interventions Provided: Stress Cues Observed:
Current Feeding/Nutrition: Time____________ Type__________	Coping Skills:   Observed      Facilitated Tone:
Head Shape Observations: Positioning devices provided/used:         Isolette    or    Crib

Outpatient Pediatric Therapy

Along with my time spent in the hospital, I am also fortunate enough to get some experience in a pediatric outpatient setting as well.  Each week I have been spending a day at a pediatric clinic.  I have really enjoyed this opportunity.  I definitely have to think in a whole different way!  The documentation is very different, along with the focus for the children.

In the outpatient world, an occupational therapist may be helping a child increase their fine motor strength and coordination so they can hold their pencil properly at school all day.  A child may be having a hard time dressing themselves or completing other age appropriate self care tasks and that may be one of our goals.  We may work on strengthening various muscles through play and exercises.  They may be struggling with processing all of the sensory input they are receiving and react in frustration and negative behaviors.  As therapists, we could help kids and their parents develop appropriate coping mechanisms and increase their tolerance to various sensory stimuli that their brain previously could not handle.  A child may be having a hard time planning the actions they want to perform or being attentive to a task at hand.  

We may treat children with a diagnosis such as cerebral palsy, down syndrome, autism, developmental delay, anxiety, and so many more.

A lot of kids I have seen have been working on handwriting.  Many of the therapists are either trained in handwriting without tears or use some of their techniques within their treatment sessions.  This is a well known curriculum many teachers use when teaching children to write.

For more information on handwriting without tears and their handwriting strategies visit:

https://www.hwtears.com/hwt

Another important aspect of outpatient pediatric therapy is the occupation of play.  If the child is motivated and excited to participate in therapy, they will not view what they are doing as work but rather a time to play and have fun.  This depends on the age of the child of course, but if a child feels they are simply playing with some of their favorite toys, they can improve desired skills without realizing they are working for it.  Children learn so well through exploration during play and appropriate supports in place. 

                                                                        Retrieved From: http://www.spotstx.com/about/

An additional component of any outpatient therapy is what is done outside of therapy.  As therapists, we cannot fully help a child if they are only working on their goals during one session each week.  It is important to educate parents and children (as appropriate) on what they need to continue working on at home.  We want to make sure parents feel comfortable completing their home program.  We all understand that life gets busy and some weeks are better than others, but with continued work at home, the child can best succeed at meeting their goals.

I look forward to gaining more outpatient experience and will continue to share them with you! 

Premature Infant Occupations

What occupations are important for a premature infant?

I am already in the 4^th week of my rotation!  Time is flying and I am learning so much.  I feel like I am a sponge trying to soak as much up as I can.  As a future occupational therapist spending time in the NICU, it is only natural to think about our role within this setting and what occupations are important and meaningful for the infants we are treating.

Just as we would not expect each adult or child to value the same occupations, the same holds true for a premature infant and their family.  Each baby and their family must be treated individually and holistically. 

An occupation within the NICU that therapists are commonly addressing is an infant’s ability to explore.  Even though premature infants spend much of their time sleeping (which is very important for development and growth) the small amount of time spent awake is crucial for the wiring of their brain.  During that time, infants have the opportunity to explore their environment.  Exploration, specifically sensory exploration, is an occupation that will shape the infants cognitive development.  The way an infant experiences touch, movement, oral sensations, sound, and visual stimuli are all shaping the way their brain develops.

Within this post, I want to focus on the important of touch. Our tactile system is the  most developed at birth.  It is the foundation of all experiences and contributes greatly to future emotional and intellectual development.  Within the womb, the infant is continuously receiving tactile input that is comforting and soothing.  When that child is born early, the input quickly changes.  Medically, the baby is experiencing unpleasurable events related to their necessary medical cares.  These events can have lasting effects on their sensory development and the way they perceive their environment.  For example, when a baby is receiving painful heel sticks or an IV placement, the brain is learning that touch is negative and something they want to avoid.  An infant who has developed an aversion or hypersensitivity to touch may:

•           Demonstrate developmental delays
•           Experience difficulty bonding with parents
•           Develop issues with feeding later in life

This is why it is so important for families to understand the importance of positive touch and provide these opportunities so when they go home and continue to grow, they do not develop an adverse reaction to the tactile stimulation they will encounter during their daily activities. 

Positive touch helps parents connect and bond with their baby and enables the infant to learn all touch is not bad.  The purpose of positive touch is to:

•           “Buffer” the necessary but sometimes unpleasant experiences in the NICU
•          Empower parents to take control over caring for their baby in this setting
•           Increase the baby’s positive sensory experiences
•          Limit the negative effects that stress of the NICU has on development
•           Prevent your baby from being sensitive to certain touch experiences

There are multiple ways positive touch can be administered:

•           Providing skin-to-skin or Kangaroo Care
•           Providing gentle, firm pressure to areas of the body that have experienced any negative touch (commonly feet, mouth and face area)
•           Watch your baby’s cues to help you know if he/she is tolerating the positive touch
•           Perform appropriate infant massage techniques taught to the parents

It is important to provide positive touch experiences 1-2 times per day or anytime there is interaction with the baby to support their growth and development.

What is Occupational Therapy?

As this rotation begins to take off, I wanted to make sure that I provided a further description as to what occupational therapy is and more specifically how occupational therapists work with children. 

When I began my OT program at Creighton, I was often asked, “What exactly is occupational therapy?”  Learning how to explain the profession without confusing people took some practice.  The beauty of our profession is that it can wear many hats.  That can also make it hard to explain to someone.

An occupational therapist is someone who specializes in working with individuals who are experiencing a condition that is limiting their ability to independently complete the tasks of everyday living.  For example, after an individual has a stroke, they may have a hard time using their body the same way they did prior.  Their brain may also think differently than it had before the stroke.  Things such as getting dressed, bathing, or eating a meal may be very hard for them to complete.  Part of our profession, is to help retrain the brain and regain as much function as possible.  We may also modify their environment to ensure they can safely participate in their daily activities.

In pediatrics, occupational therapists use their expertise to help children gain the functional skills they need for independence in play, learning, motor skill development, self-care, and socialization in their home, school, and community environments.  Environmental modification and adaptation is another key component we may use to assist the child in successfully participating in valued occupations.  Occupational therapy strives to ensure treatments and goals are client-centered to meet the needs of the child and their family.

An occupational therapist is able to use their knowledge and creativity to assist each patient reach the goals they find meaningful.  Being able to become part of a profession that values the needs of others so greatly is something I cannot wait to be a part of!

Introduction

It's finally here!  The Creighton OTD class of 2015 is beginning their final rotation.  A rotation that at the beginning of the program was an unknown, intimidating four months to think about for me.  Each time someone would mention "professional rotation" I would quickly begin feeling anxious, wondering how am I ever going to figure out what to do during that rotation?!  I should've known that God would have the perfect plan for me.

Ever since I was a little girl, I always said I wanted to work with kids one way or another.  I have continually been drawn to the pediatric population.  I worked at day cares in high school and college and was also a nanny during college.  So is it surprising that now this four month rotation is revolving around children and exploring occupational therapy's (OT's) scope of practice with pediatrics further?  Probably not!  

Retrieved From: https://www.uichildrens.org/

This self-directed final rotation of our curriculum allows us to formulate our own learning objectives and create activities to complete along the way that will help us accomplish those objectives by the end of our 16 weeks.  Within the pediatric population alone, there are many roles an occupational therapists can have.  I have specifically chosen to further develop my skills within the NICU.  This will take place at The University of Iowa Children's Hospital.  UI Children's Hospital has a Level IV 80+ bed NICU.  I will be learning to evaluate and treat premature infants, along with educating and supporting their families throughout their stay.  An intervention commonly used within the NICU, when appropriate, is infant massage.  During these 16 weeks, I plan to obtain my Certified Educator of Infant Massage certificate.  As I was formulating my plan for this rotation, I also thought it would be very important to learn more related to after hospitalization and what that continuum of care looks like.  I will be spending approximately one day per week at an outpatient clinic to further understand what specific assessments, interventions, and further certifications and training therapists are using in practice.  Are there things that inpatient therapists can better prepare parents for prior to discharge that would assist in the transition to home and/or outpatient services?  My hope is to gain a better understanding of that continuum of care from inpatient to outpatient in the pediatric population.  

OT within the NICU is a specialized area to work in and many people are not aware that therapists can play a vital role on these units with the collaboration of the entire interdisciplinary team.  I hope to assist in further advocating for our profession within these units to foster a nurturing environment for these infants to thrive and grow in the NICU and following discharge.

That is a quick breakdown of what this rotation will consist of.  I can't wait to see what further opportunities arise and where these next few months take me!  Further information and resources to follow!

I am so excited to embark on this journey and share it with you as I further my skills and knowledge in pediatrics prior to graduation!  Being able to complete this rotation is such a blessing!