When Back-to-School doesn’t go as planned…

While January marks the start of the “new year,” for  parents, back-to-school is the real beginning of the year.  A new year brings new classes, new teachers, the re-establishment of  home and classroom routines, new activities; new everything!  All of this change  leads us to  hope that maybe the attention and behavior issues experienced last year will work themselves out with a new start.  In some cases, they do!  Maturation over the summer may work in your child’s favor and perhaps your child’s behavioral difficulties are a thing of the past? On the other hand, maybe the new year has brought a new set of challenges.

Sensory processing disorder occurs when the brain has trouble appropriately  responding to sensory stimuli.  These sensory systems can include sight, hearing, feeling, taste, smell and movement.   Difficulties with sensory processing may affect one system on its own or multiple systems at the same time.   Sensory systems can be over-sensitive or under-sensitive.  While it’s typical for kids to experience some difficulties as a normal form of development, it’s not typical for these sensitivities to significantly affect aspects of everyday life.  How do you determine if it’s just a “quirk” or if it’s an actual sensory processing issue? When sensory difficulties interfere with a child’s ability to participate in typical peer activities or to complete daily tasks, it’s important to dig a little deeper.

Here are some real life examples of how some kids process sensory input:

  • My child will only wear sweatpants, never jeans. The seam on my child’s sock has the capacity to ruin the whole day if it’s not JUST SO.
  • My child will only eat three foods. Total. End of story.  New foods are a big deal and often result in major mealtime stress.
  • My child hates how the lunch room smells; he’ll gag at the smell of certain foods.
  • My child is distracted by noises that I can barely even hear, such as the buzz of fluorescent lights.  Other daily sounds, such as the toilet flushing, scare the heck out of him!
  • My child is clumsy; he’s always running into things and falling off his chair. My child plays so rough that other moms are telling their children to avoid my kid.
  • My child over-fills his mouth when he eats. He chokes often and is such a messy eater.
  • My child doesn’t seem to be able to “feel” when she has to go to the bathroom; this results in accidents and now she’s embarrassed and anxious about it.
  • My child is really routine-based.  A break from that routine is incredibly stressful and often results in a meltdown.
  • My child has a hard time following through with the morning sequence.  He requires constant reminders (no, seriously…CONSTANT REMINDERS)  to move on to the next thing.  It’s as if he doesn’t hear the direction until the 5th time.

While these sensitivities can cause some serious stress for the entire family, they can also have significant classroom implications. When a child has a disrupted sensory system, three key areas can be affected:

*Organization: It’s hard to stay organized when your sensory system is on overload. It becomes difficult to remember what you were doing or what you should be doing when you are constantly distracted by all the sensory information your coming your way.

*Attention: Attention is measured in many different ways, especially at school.  For kids with a sensory processing disorder, the ability to keep their “eyes on the board,” actively listen and participate, and follow multi-step directions all the while remaining in their seat can be a real challenge. The ability to filter out the distractions to concentrate on the  most important information may not come easily.

*Behavior: It’s hard to regulate your emotions, stay on task, do what’s expected, and respond appropriately when your environment makes your head spin. Regulating  your behavior ALL DAY LONG is a full time job!  It can be physically draining to keep it together.  Parents often bear the biggest brunt at the end of the day when kids finally succumb to that end of the day meltdown.  

If back-to-school has left you feeling concerned about  your child’s emotional, functional, academic and/or social success, or if there are parent-teacher conversations circulating around *attention *organization and/or *behavior, it might be time to take a closer look at their sensory functioning across different environments. If you’ve noticed these sensitivities, but thought your child was just being high maintenance or poorly behaved, we encourage you to seek out an occupational therapist with experience in sensory processing disorders. Lucky for you, we know some phenomenal ones!

By: Heather Arnt, M.S., CCC-SLP

As always, Red Door Pediatric Therapy offers a free, no-strings-attached screening. Learn all about us at our website:  www.reddoorpediatric.com

Benefits of Co-Treatment Sessions of Speech/Occupational Therapy

There are endless benefits to co-treatment therapy sessions with the pediatric population. Co-treatments are sessions conducted with 2 or more therapists/disciplines to maximize therapeutic collaboration. At Red Door Pediatric Therapy, co-treatments are performed when therapeutic goals are similar or complimentary. In this article, I will discuss what benefits therapists have seen at Red Door with regard to implementing meaningful and functional gains.

At Red Door, we typically conduct our co-treatment sessions with two therapists/disciplines. In pediatric therapy, there is often a hierarchy of skill acquisition. For example, in order to take a successful bite of food from a fork (OT), one must be able to complete lip closure (ST). This hierarchy lends itself nicely to co-treat sessions, as multiple goals can be targeted cohesively with the same functional activity. In order to best explain specific benefits for children, sessions will be described specifically according to treatment plan themes.

The first set of benefits includes the Speech/Occupational Therapy “Feeding” Session. During a feeding session, there are many oral motor sequences that take place in order for a child to be successful from the start to the finish of a meal. A meal involves several sequences of fine motor and oral motor control, strength, and coordination. There are also several language components present which are not limited to vocabulary, following directions, understanding and implementing sequences, making requests, understanding and use of directional concepts, etc. Positive outcomes include:

1) Teaching a child to formulate a meaningful expressive request for desired meal items. Whether a child is verbal or non-verbal, the ability to make a choice is key. Since eating is a functional activity that occurs 3+times per day, there are multiple opportunities to integrate the skill of eating and the skill of meaningful requesting. All children have food preferences and dislikes. Co-treatment allows the opportunity to help a child convey these preferred and non-preferred selections. While the occupational therapist focuses on teaching functional use of spoons, forks, knives, plates, napkins, etc, the speech therapists reinforces the language component by helping the child use communication through answering yes/no questions, pointing to preferred items through gesture, making verbal requests for desired items, teaching vocabulary labels, demonstrating the function of meal utensils etc.

2) Exposing the child to different types of oral stimulation can increase their oral motor control for feeding and increase ability to produce sounds and language. A variety of oral motor therapy tools can be used to stimulate different parts of the oral cavity (tongue, lips, cheeks, teeth). Such tools include, blow toys, whistles, straws, chew tubes, tongue depressors, etc. These tools, when used correctly can increase breath support and control, lip strength and control, and tongue coordination…all of which support expressive language and articulation as well as mealtime activities.

3) A well-trained Occupational Therapist can provide meaningful strategies for children who have sensory (of the 5 senses) difficulties. These strategies can help to address sensory information the child requires to understand their environment. Children may exhibit behaviors that interfere with goal implementation because they are not clearly understanding/interpreting their environment (sounds, smells, touch). An OT can help other therapists to provide means of “calm” so that other goals can be addressed in the therapy session. Some of the tools used at Red Door include: therapy balls, tactile brushes, squishy fidget balls, vibrating toys, swings, etc. When used correctly, these sensory tools can increase attention to task, increase focus and accuracy, increased success in understanding/following directions. Consideration of these sensory differences and providing an adapting therapy session has the added benefit of gaining more “trials” on goal items (which means more reliable and measurable progress).

The second set of benefits is derived from the ST/OT dressing sessions. Dressing and undressing are additional forms of daily living activities that occur 2+ times per day and can provide an opportunity to target skills across disciplines.

1) Sequencing! Dressing involves a complicated set of sequenced movements and manipulation of clothing to orient onto the body. This order insures that the child “understands” the language involved in following directions to complete dressing steps “in order.” This understanding of “order” carries over to “following through” with a dressing sequence.

2) Dressing involves a great deal of vocabulary specific to concept/description words. Some of these vocabulary words include: open, top, around, through, up, down, forward, backward, front, back, bottom. Where language is impaired or delayed, these vocabulary words are difficult for children primarily because they are not tangible like nouns, or don’t involve an observable action like verbs. Co-treatment with dressing skills allows the child to both hear and use the concept vocabulary while engaging in a hands-on experience with the clothing items.

3) Fine Motor and FUN! The possibilities with speech/language and fine motor experiences are practically limitless. Art projects and crafts are excellent ways to utilize and encourage tripod grasp, strength, muscle coordination and control. Language can be integrated with the use of vocabulary, descriptions, following directions, sequencing, sound practice, and much much more!

There are many benefits that result from sessions conducted with Physical Therapy and Speech Therapy. These sessions involve more physical activity, awareness to the body in space, and loads of fun.
1) Physical activity increases brain function! Research has shown that when children become more physically active, their expressive output increases. Physical activity can involve passing the ball back and forth, swinging, climbing ladders and stairs, and many physical and social games that encourage heightened activity level.
2) Motivation! Motivating physical activities can be used as a tool to elicit a variety of language skills. Children can make requests for desired activities, use breath support to manipulate volume and control, and produce more oral motor control while the other muscles of the body operate. Language is easily incorporated into physical therapy goals that assist with body tone, posturing, and coordination.

Intangible benefits of cotreatment sessions:
1) Two heads better than one, four hands better than two! Children can have minds of their own. As they explore behavioral boundaries, an extra set of hands (and bodies) can help to guide and demonstrate skills. These “hands-on” collaborative sessions can help therapists to better understand the needs and function level of kids as well as help to build professional skills.
2) Cohesive flow of expectations When children have the same expectations across people/therapists and environments, they are more calm and productive. This cohesive flow of expectations involves using the same demeanor, the same facial expression, and the same language structure.
3) In-the-moment problem-solving. Having 2 therapists allows for problem-solving to take place as the child is receiving direct treatment. This can be as simple and an extra set of hands to teach or demonstrate a skill to utilizing a strategy to address a negative behavior.

It should be noted that cotreatment is not always the best option. Cotreatment should be used to improve therapy and not to provide less service to a child. You can consult directly with your therapists to verify the benefits of therapy implemented in this format.

Kelli Ellenbaum, MS CCC-SLP

The Importance of Gesture in Learning to Communicate

The Importance of Gesture in Learning to Communicate

By: Kelli Ellenbaum, MS CCC-SLP

                The importance of gesture development in infants and children has been long underestimated.  In the field of speech language pathology and communication, there are few formal assessments that provide therapists and developmental specialists with developmental age comparisons.  Therefore, much of the work we do as therapists during the evaluation process relies  heavily on experience.  This article will talk about the importance of gesture as a form of communication and provide a general guideline for gesture development up to 24 months.

                Gestures are defined by Iverson and Thal (1998) as “actions produced with the intent to communicate and are typically expressed using fingers, hands, and arms, but can also include facial features (e.g. lip smacking for “eating”) and body motions (e.g. bouncing for “horsie”).“   Gestures appear very early in infancy.  The jury is out on exactly when these gestures reliably show themselves.  However, one study that was conducted by Meltzoff & Moore, 1983, evaluated infants 0.7 to 71 hours after birth and found that infants were able to imitate facial expressions specific to open/closing mouth, and sticking their tongue out. Researchers hypothesize that this form of imitative gesture means that language will later be built (http://minnesota.publicradio.org/display/web/2009/08/21/midday2/). Early developing gestures have themselves deeply rooted into imitative learning. Human children learn communication through example.  Communication, by definition, is the process of transferring information from one entity to another. Communication processes are sign-mediated interactions between at least two agents which share a repertoire of signs and semiotic rules (Wikipedia, 2010).  Children observe activities around them and process large quantities of information through their senses.  They track, gaze, see, and watch their environment and the interactions people have within that environment.  Children use visual information to imitate what has been stored in their brains.  More reliable communicative gestures are documented around 7-9 months (Carpenter et al., 1998).  Some examples include open-handed reaching, reaching up to indicate they want to be held, pushing objects away in protest, and arm flailing.

                As I stated earlier, infants and toddlers learn gesture through observational and imitative learning.  There is an important social interaction component to this imitative learning that is required.  Communication must be developed from human interaction.  In other words, radio or TV will not develop communication that can be interpreted and used in natural context. Many children who are diagnosed with an autism spectrum disorder will use scripts derived from TV programs, movies, commercials, etc.   While I do consider this a form of language learning, it is not initially functional for 2-way communication.  In my clinical experience, I have found that the development of gesture in children with autism spectrum disorders is consistently absent if not significantly delayed.  Many children that enter my office initially seek services for a delay in verbal communication (either not talking, or talking very little compared to their peers).  During my evaluation process, I often ask parents if their child uses alternative forms of communication to convey messages (i.e. gesture, sign, pointing, hand leading, eye gaze, grunting).  If their answer is yes, I derive that they have a good foundation for 2-way communication, and therapy will focus more heavily on increasing verbal communication (words, sounds, and the like).  However, if the answer is no, this could indicate deficits possibly related to imitative learning, gesture, eye contact, social interaction, etc.  Children who lack understanding and/or use of “gestural” communication often use behavior as a form of communication (represented by screaming, tantrums, crying, etc).  If gesture is absent or delayed, I make observational notes and attempt to determine if an evaluation for an autism spectrum disorder, sensory processing disorder, or developmental disability is warranted.  It is important to note that gestural communication and body language can taught, and just because gesture is absent or delayed does NOT mean that meaningful communication cannot be developed with the right strategies and treatment plan.

                The frequency and variety of gestural use can be used as a factor in identifying deficits.  In the presence of responsive adults, 12-month-olds typically communicate intentionally about one time per minute, 18-month-olds about two times per minute, and 24-month-olds about five times per minute (Wetherby, et al., 1988).  Specific gestures (especially pointing) have also proven to be a strong indicator of later language skills in children with typical development (Morrissette, et al., 1995), children with Down syndrome (Franco & Butter, 1996), and children with autism (Baron-Cohen, 1989).  An analysis of videotapes of 9-12-month-old infants who were later diagnosed with autism revealed that a limited variety of social interaction gestures was what differentiated them from the typically developing infants, not the frequency of social interaction gestures (Colgan, et al., 2006).  Thus, a limited variety of communicative gestures may indicate risk for communicative disorders as early as 12 months of age (Crais, et al., 2009).

                There are few formal assessments available to assess gestural function.  Those tools available have not historically focused primarily on gestural development, but are rather included as a component of overall development.  Gestural communication can be difficult to observe in an unfamiliar/new clinic setting, therefore, more informal assessments (such as parent interview and observation of parent/child interaction) are extremely helpful.  Informal assessments are subjective and provide the most information when the evaluator is skilled and knowledgeable in the areas of interaction, nonverbal communication/gesture, and play.  Documented observation of communicative components will positively contribute to the information obtained by formal tests.  A complete communication evaluation helps therapists determine etiology and plans of treatment that specifically address those deficits most impacting a child.

                Based on the research that has been conducted, here are some general guidelines for gesture development ages 9-24 months.  This information is provided by Crais, E., Douglas, D. & Campbell (2004) in their article titled:  The intersection of the development of gestures and intentionality. 

Gestural communication 9-12 months

A child between 9-12 months is able to protest by using a body signal (e.g. back arching) and push objects away with their hand.  They are able to request objects by pointing with their hand, reaching, making physical contact with an adult to get attention.  Children at this age are able to request actions by reaching to be picked up and performing an action indicating they want something to reoccur.  Socially, a child 9-12 months can seek attention by banging objects together, use consistent body movement to get attention (e.g. hand flapping, kicking legs), and grab an adult’s hand.  Interest in social games emerges at this age.  A child can demonstrate anticipation of social games (such as peek-a-boo, and song/finger plays).  Examples of anticipation include moving their bodies or holding hands up for the adult to manipulate.  Children also initiate social games by covering their face with a blanket indicating they want to play “peek-a-boo.”  Representational gestures such as waving goodbye and imitating clapping emerge between 9-12 months.  Children demonstrate shared attention by showing and giving objects.

Gesture communication 12-15 months

A child between 12-15 months is able to request by looking at the object, then the adult, and then the object.  They are able to request actions by giving an object to an adult for help (e.g. to have something opened or fixed).  Social interaction gestures at this age include demonstrating the functions of objects such as brushing hair with a brush, putting on a hat, or stirring with a spoon.  At this age, children begin to hug stuffed animals, clap in excitement/accomplishment, and dance to music.  Children ages 12-15 months point to objects or events.

Gesture communication 15-18 months

A child between 15-18 months protests by shaking their head for “no.”  Requesting gestures include reaching while opening and closing their hands to obtain an object, pointing to get someone to do something (e.g. open a door, carry them to another room), and taking the hand of an adult and guiding a hand or body to do something (e.g. take adult hand and putting it on their stomach to get tickled).  Socially, children begin demonstrating actions such as smacking their lips to indicate they want something to eat.  Children ages 15-18 months share attention by pointing to objects upon request (e.g. “show me the ball” or “Where’s the doggie?”).  They request information by pointing at pictures or objects with the expectation that an adult will name it for them.

Gesture communication 18-24 months

A child between 18-24 months seeks attention through “showing off” (e.g. sticking out tongue, making funny faces, making sounds to get a laugh, and performing fingerplays such as patty cake).  Representational gestures include shrugging shoulders or putting hands up to indicate “all done” or “where did it go?”  A child of this age blows kisses, signals “shhh” with fingers to lips, nod with a “yes,” pretends to sleep, and uses conventional gestures of excitement (e.g. high five).  Children 18-24 months will share attention by clarifying verbal messages with gesture (e.g. point to an object they have attempted to verbally label).

Children who have not developed gestural communication on time should be evaluated by a speech language pathologist.  While some children develop verbal language without gesture, it is important to consider the importance of gestural development for the further comprehension and use of nonverbal communication.


Baron-Cohen, S. (1989). Perceptual role-taking and protodeclarative pointing in autism.  British Journal of Developmental Psychology, 7, 113-127.

Carpenter M., Nagell, K., & Tomasello, M. (1998).  Social cognition, joint attention, and communicative competence from 9 to 15 months of age.  Monographs of the Society of Research in Child Development, 63,(4 Serial No. 255).

 Colgan, S., Lanter, E., McComish, C., Watson, L., Craise, E., & Baranek, G. (2006).  Analysis of social interaction gestures in infants with autism.  Child Neuropsychology, 12, 307-319.

Crais, E., Douglas, D. & Campbell, C. (2004).  The intersection of the development of gesture and intentionality. Journal of Speech, Language, and Hearing Research, 47, 678-694.

Crais, E., & Robert, J. (2004).  Assessing communication skills.  In M. McLean, M. Wolery, & D. Bailey (Eds.), Assessing infants and preschoolers with special needs (3rd ed., pp. 345-411).  Upper Saddle River, NJ: Pearson/Merrill/Prentice Hall.

Crais, E., Watson, L.,  Baranek, G. (2009).  Use of Gesture Development in Profiling Children’s Prelinguistic Communication Skills.  American Journal of Speech-Language Pathology, 18, 95-108.