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Clinician
Kelly Beins, OTR/L, Occupational Therapy Consulting, LLC.

Background
Client Name: “J”

Gender/Age: female/seven years of age; adopted at seven months from an orphanage in China

Diagnosis: Emotional Regulation Disorder

Details: Milestones from seven months forward were unremarkable with the exception that J is reported to have self-fed early and at age seven still prefers finger feeding vs. using utensils. Additionally, J’s mother noted that J was a climber and seemed to lack depth perception. Medical history is insignificant for problems with the exception that she gets headaches at school and has current high-frequency hearing loss.

Presenting Problems
J was referred to occupational therapy (OT) because of ongoing difficulties with paying attention, following verbal directions, sitting still/always “on the move”, high anxiety, low frustration tolerance, frequent temper tantrums and “melt-downs”/screaming/crying. Social challenges include being mean, inability to tolerate groups of children she doesn’t know. These challenges were significantly impacting:

  • sleep patterns (parents’ sleep included)
  • participation in meals and other family activities
  • ability to complete the morning routine and get ready for school
  • social interaction on playground or at play dates with other children
  • self-esteem and confidence

Summary of Changes
Upon completion of her therapy, J met or surpassed all treatment objectives. At time of discharge, J’s mom reported, “Our lives are 180 degrees different than prior to starting therapy. J is a different kid. If someone had told me our lives could be like this, I would not have believed them.”

Follow-up two months post-discharge indicates ongoing carryover of functional gains. With regard to specific treatment objectives, changes observed are as follows:

  1. Mealtime behavior: Prior to therapy, meals were typically a time for emotional outbursts and melt-downs. J’s mom reports that her becoming upset at mealtime is now “a rare occurrence.”
  2. Attention to home and school tasks: Pre-therapy, J’s attention to relevant home and school tasks was limited to five minutes at a time and she needed ongoing repetition of directions. J would not play independently and relied continually on adult direction and intervention to complete activities and/or remain engaged. Post-therapy, J will attend to tasks for at least a half-hour, and requires minimal verbal repetition of directions.  J’s mom reports J “plays on her own in her room with her Barbie’s for an hour now.”
  3. Morning routine: Pre-therapy, J. typically needed over an hour to get ready for school in the morning, and required ongoing step-by-step verbal directions from parent(s). At time of discharge, when asked about the morning routine, J’s mom stated “she does it all on her own without an issue, and within 15 minutes.”
  4. Social interaction: Pre-therapy, J was able to play with other children she knew; however, if children unknown to her arrived she escalated into emotional upset in 5-10 minutes or she refused to continue playing. Post-therapy, J will remain actively playing, without incident of emotional upset or aggression, on the playground at school or at a public park. J’s mom reported, “My friend who watched J for me the other day couldn’t believe the change in her. She said, ‘She is not the same J.’”
  5. Sleep-related behavior: Pre-therapy, J would typically take more than 40 minutes to fall asleep most nights of the week, with ongoing assistance and involvement from her parent(s) and with much difficulty calming down right up until the time she went to bed. Post-therapy, J falls asleep after her bedtime routine within 20 minutes.

Therapeutic Goals
The process of Goal Attainment Scaling (GAS) was used to establish therapeutic goals and measure progress throughout the course of J’s treatment.

Functional Goal: Improve sensory processing, so that J can participate successfully in family, school and social activities with family members and peers.

Treatment Objectives: the following objectives are recorded on parent/teacher reports:

1)    J will remain seated at the dinner table for the duration of the meal without incident

2)    J will attend to tasks with no more than one verbal repetition of directions

3)    J will complete morning routine including above activities within 30-44 minutes

4)    J will be able to play on playground or in public without incident of argument

5)    J will fall asleep after bedtime routine

iLs Program Used
Overall course of treatment was 20 weeks. iLs Concentration & Attention Program 3x per week x 16 weeks (with two breaks of a week each because of family vacation); iLs Calming/Prep Program was used at home, as needed (for organizing and stress management), throughout the course of treatment.

Other Interventions Used
J participated in OT and iLs once per week in-clinic, combined with the iLs Concentration & Attention Program at home 2-3 times per week. In total, she completed the 40-session iLs Concentration & Attention Program over a three-month period.

Additionally, J enrolled in hippotherapy once a week toward the end of the program. When school began again, we saw some regressive behavior, possibly due to the stress of returning to school. We reduced her therapy sessions at that time and added deep pressure and proprioceptive activities for a week. This shift in therapy was made to reestablish functional gains that had been achieved previously, prior to regression. Immediately (within one week), a return to higher level of function was noted.

Conclusions and Recommendations
The combination of iLs, OT and therapeutic riding was an effective means of helping this 7-year old girl learn to self-regulate her arousal level and decrease her anxiety. She accomplished all of her therapeutic goals, and her family and teacher are duly impressed with the changes.

The therapist and parents believe that iLs significantly enhanced the therapeutic outcomes and likely decreased the overall duration of treatment. The results of this case echo this therapist’s experience combining iLs with OT in multiple cases: iLs consistently plays a significant role in improving arousal, regulation and behavior, and is a valuable complement to OT. The challenge is in finding a way to fit iLs into the family’s lifestyle and busy schedule.

Comments from Ron Minson, MD, iLs Clinical Director
This youngster is totally uncomfortable in her skin. Thus, she is totally uncomfortable with the world in which she lives. Everything in it feels like an assault so she is naturally at war with what feels to her like a hostile environment. Her nervous system is stuck in a fight/flight mode of sympathetic overload. This is an important case study because it represents a very common clinical presentation seen by many iLs practitioners who tell me they spend an inordinate amount of time trying to help children settle down, attend and focus so that they can do their therapy.

The contribution of iLs to the skills OTs use for organization and calming is twofold. One, the bone conduction delivery of the music is known to bring about a marked increase in feeling grounded and calm through its effect on the vestibular system; the child begins to feel comfortable in their body, a necessary first step to being comfortable with the world. The other contribution is that iLs stimulates a branch of the vagus nerve in the outer ear and ear drum, increasing parasympathetic tone and down regulating the fight/flight sympathetic system. This increased vagal effect has been documented to promote calm, decrease over arousal and to increase social engagement.

Once the child can feel safe in her body, feel calm and grounded, and thus able to sleep better, she is then able to regulate her emotions, put the brakes on her impulses and engage socially with appropriate communication. Finally, the skill of this therapist is evidenced by her use of multiple, complementary therapies, such as the simple-yet-effective technique of deep pressure to restore homeostasis as her client struggled with the anxiety of returning to school.

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