Toys, swings and dogs? Oh my! Tales of pediatric occupational therapy skills

Posted on 5/4/2018 by Shannon K. Holman, OTR/L, BCP

There are many amazing children and families that will shape your growth and development as a pediatric occupational therapist. As a pediatric therapist you will not go a day without learning something new, that you will learn just as much from your patient as you expect them to learn from you and that play is the hardest thing you will ever do.

Julian and I met in January 2011. He was about 7 years old and had a shy smile that would melt your heart. He was the “typical” child with autism, presenting with some motor skill challenges, social difficulties and underlying sensory processing struggles. Intervention initially incorporated sensory integration to address organizational skills, regulation and modulation of self, tolerance to transitions and changes in routine, fine motor skills, leisure skills and social interactions. As an additional intervention bonus, Julian’s mother was very organized and dedicated to ensuring her son was engaged in activities that facilitated his optimal potential and functional independence. With this energy behind our intervention strategies, Julian continued to demonstrate growth and gains in all areas, most noted in social and self-confidence. Standard and textbook, Julian was making progress.

In October 2012, Julian, his brother and his mother participated in a hiking activity at Red Rock that went unusually and unexpectedly well. Julian had such a good time that he was eager to share the experience with his father. The family decided they would return to the national park on the weekend, and Julian was looking forward to the outing. Unfortunately, they had forgotten to account for the popularity of the park on the weekends. What had been a quiet day on their original mid-week outing was met with a significant increase in the number of people… and their dogs.

It was in this manner that I learned of Julian’s fear of dogs. A fear that had never been discussed in therapy, as tolerance to animals was not something I thought of as affecting developmental skills or level of independence. I was in for a lesson on occupational profile and performance.

The story unfolds as such: a very excited Julian eager to show his dad his success, a family participating in an ordinary outing, an off-leash dog racing past Julian on the trail, Julian frozen in fear and screaming inconsolably. This led to a mother attempting to console her son, a frustrated father, a sad younger brother and a devastated Julian.

Julian had had dogs in his life as a toddler with no concerns or issues. A recent move had the family now living next door to two very large, loud and out-of-control dogs. Julian was terrified. He no longer played outside, would only exit the house to go to the car while it was in the garage with the door closed and would not go to visit friends if they had dogs. Conflict, anxiety, fear and sensory struggles. Julian had worked so hard and was doing so well and now we were losing ground.

My brain scrambled, remembering lessons on activity analysis, occupational profile and performance and what has value to the patient and family. And then, inspiration hit. Without knowing how or having experience, out from my mouth came the words, “Let’s bring a dog into the therapy sessions.” Mom agreed. Now in all honesty, I had no idea what this would look like, how to make it happen and, most of all, how to get Julian to buy into it. I had some basic knowledge of therapy dogs and had experience with a service dog, but this is the type of moment occupational therapy is made for! Inspiration, creativity, foundation of activity analysis, thinking outside the box and relying on our gut; that is the art and science of occupational therapy. Sometimes the best interventions come from the support of families, trusting your therapy instincts and sheer luck. Our luck just so happened to come with four paws and a wet nose.

Love Dog Adventures is an organization that inspires physical and emotional healing by creating custom protocols for therapeutic and educational animal-assisted interactions. They came to us in late November in the form of Kirby, the dog, and owner, Sue. Both Sue and I had no idea what was going to happen. She trusted I knew the therapy part, I trusted she knew the dog part and mom trusted we knew what we were doing. The all-amazing part, Julian trusted all of us.

Sue and Kirby, a Pet Partners-certified therapy dog, became a part of our weekly therapy sessions. On Julian’s time, we worked toward proximity of the dog, activities next to the dog and touching the dog. With time and patience, Julian progressed from Kirby always having to have his tail end toward Julian to Julian touching and holding Kirby. Sadly, Kirby passed unexpectedly. Together, as a team, we carefully explained to Julian what had happened and, true to childhood understanding, he accepted, grieved and picked up with Kirby’s brother, Benny.

Benny and Julian built a strong bond. Kirby was the introduction, Benny became the story. Julian soared through touch and holding with Benny. He began to walk with Benny, dressed and undressed Benny in his service vest and holiday costumes and could tolerate unexpected movements from Benny. We addressed sensory integration, handwriting, reading, fastener manipulations, spatial awareness and all other typical skills that were a part of Julian’s plan of care. With each passing session, Julian’s self-confidence and skill improved. Verbal skills, self-initiation and empowerment grew. With Sue’s knowledge of her volunteers and their dogs, she continued to match us up to amazing volunteers. In the end, Julian would successfully interact with more than 30 dogs of all sizes, breeds and energy levels, as well as a cat.

Julian engaged in play (ball, toy, treat), brushing, dressing, massaging and walking the dogs, as well as tolerating unexpected movement toward or past him, jumping and barking. He could now engage in community outings, walk with his mother around the neighborhood, socialize with friends in their homes regardless of dog, engage in family outings and entertain the thought of a dog joining the family. Tears filled his mother’s eyes on the day Julian let Benny “kiss” him and the day he fed Benny a small treat.

Eighteen months later, Julian participated in an autism walk with dogs present and on-leash with no concerns. The family again hiked at Red Rock. Mother reported she knew that success had been reached and all was going to be fine when an off-leash dog ran past Julian and Julian’s response was that “they aren’t following the rules,” as dogs are supposed to be on-leash in the park. No screams, no tears, no fear.

The inspiration, art and science that takes play to occupation for a child, the ability to take occupational performance and profile and create a treatment plan and intervention strategies, and the ability to learn what a child really needs is both the challenge and most rewarding aspects of pediatric therapy. But what Julian would forever change in my occupational therapy tool box is knowing that you don’t always know immediately what is important to a child and that you should start with the basics. Activity analysis will apply in all scenarios, so you must trust your skills and knowledge. Sometimes in our quest to facilitate optimal level of independence for a child, we learn what truly has value and importance to a family and their child. I am no longer the therapist who just facilitates developmental, executive function or sensory processing skills. I am a therapist who facilitates the skills for living life to its fullest as defined by child and family.

I leave you with this simple quote from Fred Devito that serves as advice for therapists, pediatric patients and their families… “If it doesn’t challenge you, it won’t change you.”

By: Shannon K. Holman, OTR/L, BCP, center manager of Select Kids Pediatric Therapy in Las Vegas, NV. She has treating experience in cerebral palsy, autism, Asperger’s, attention-deficit/hyperactivity disorder, sensory processing disorder and much more, in children birth to 23 years of age. Shannon is board certified in pediatrics by the American Occupational Therapy Association.