Intervention strategies

Intervention strategies aimed at improving independence for the client with impaired cognitive skills can include deficit-specific training of cognitive skills, meta-cognitive training, compensation, social skills training, and task-specific training. Deficit-specific training involves restoring or improving specific cognitive tasks such as attention, initiation, and problem-solving through remedial exercises, grading of tasks, and gradually increasing demands on cognitive performance components.³⁹ Meta-cognitive training works to improve the fundamentals needed to set realistic goals by enhancing self-awareness and skills such as time management, self-control, anticipation, and self-monitoring. Compensation teaches the client to use alternative methods or strategies to complete a given task. Individuals can use lists, memory notebooks, electronic cuing devices, diaries, wall charts, and picture schedules. Social skill training involves improving interpersonal skills such as nonverbal cues, verbal and nonverbal communication skills, and conflict negotiation skills. Task-specific training, also referred to as functional skill training, involves systematic training of specific tasks required to complete an activity. A combination of these techniques may be needed to achieve the most efficient and functional outcome for the client.

When working with cognitive functioning, the OT practitioner also conducts activity analysis to break each task down into parts and determine specific skill areas the client might be lacking. The OT practitioner may use forward or backward chaining to teach a task. Chaining involves breaking the task down into individual steps, teaching each step, and finally putting the steps together. Forward chaining involves teaching the task from beginning to end, while backward chaining involves teaching the task from the last step to the first step. For example, tying shoe laces may be taught using forward chaining, where the client is taught first to tie the initial knot, then to make a loop, wrap the other lace around the loop, push the lace through the hole to make another loop, and finally pull both loops. When using backward chaining, clients complete only the last step of pulling the loops to finish the task. Next, they would combine the last two steps of pushing the lace through the hole and pulling the loops to complete the task. They would continue adding the previous step of the task until the task can be performed completely by the client. Another way of adapting an activity is to provide faded assistance or grading. This involves providing assistance for all, or a portion, of the activity. As the client improves, assistance is “faded” to encourage the client to perform more of the activity independently. Faded assistance could occur in the form of physical assist or grading of the activity in the form of adaptations or accommodations to the size of objects, speed, frequency or duration of the activity, height and angle at which the activity is performed, number of steps, complexity, and sensory components of the activity.

Telephones

The telephone and the cell phone are the most commonly used communication devices. Children who have disabilities can use these devices to ensure safety and security. Cell phone features can be set up to benefit people with motor challenges. One key dialing, speaker phone, and more rugged phones may be helpful. A common cell phone adaption that is widely available is the large number pad.

Children who have disabilities may need training in the effective use of a cell phone. The child practices with the phone repeatedly to ensure that he or she will be able to access the phone when needed. Picture cards that demonstrate the steps of making a call may be helpful and can be attached to the phone by a key ring. Important phone numbers such as home and emergency numbers should be programmed for one key dialing. Other phone numbers or the key to the phone’s speed dial may also be included on the card attached to the phone. If the child is unable to use the phone to call multiple numbers, the phone can be programmed to call one number only. Families can consult with their cell phone providers for further information.

Currently, individuals who cannot speak but can use technology with dexterous fingers are also able to use cell phones. Text-to-speech applications are available for the iPhone^® and other devices.

Low-tech communication boards

Low-tech communication boards are simple and inexpensive pieces of equipment to augment communication. They are often the first support used to increase a child’s ability to communicate. Communication boards may contain pictures of items or activities a child may want or need. In the early stages, the child may use the board to make choices. This is especially effective for children with physical disabilities who are unable to access their environments independently due to motor limitations. Using a communication board, the child is able to indicate what toys or areas of the room s/he wishes to interact with.

More complex communication boards may be suitable for children who lack the motor control to speak and type quickly for communication but have the cognitive ability to communicate and spell. These boards may contain frequently used phrases and the letters of the alphabet. The children point to the letters or words with their hands or a mouth stick to indicate what they would like to communicate. Although these systems can be effective, they require an active and participating listener and can be laborious to use. However, they may also be an important first step in facilitating communication and can demonstrate the chidren’s ability to use their cognitive and motor skills to communicate.

Communication boards may contain words or pictures that are hand drawn, computer illustrated, or photographic. Several programs that provide a wide range of high quality illustrations and commonly used pictures are available. Communication boards often come with Velcro so that pictures can be held in place or moved as needed. Picture books organize pictures for communication. Books allow access to a greater number of pictures than do communication boards and may be organized by topic for quick and easy location of pictures. Velcro is often placed on the outer cover of the book so that the pictures currently in use can be displayed on the front of the book. Note: The use of pictures for a communication board should not be confused with the Picture Exchange Communication System, which will be explained in greater detail later in this section (Tables 19-2 and 19-3).

Using pictures to communicate to the client

Pictures can also be used as visual supports to assist an OT practitioner in communicating to the child.⁷ These pictures will be called visual supports in this text to avoid confusing them with communication boards that children use to communicate their thoughts. When pictures assist a child to function, it is important that the OT practitioner consult with teachers and parents so that the system can be used across various settings.

Visual supports are commonly used to communicate expectations, show how many activities are expected, and demonstrate the order of activities.⁷ Visual supports can increase on-task behaviors; be used to teach complex topics such as arousal or excitement level by presenting symbols that young people can understand and relate to; increase self-awareness of emotions and arousal/excitement level, and also be used to augment social stories to ensure children know how to respond and act safely in challenging situations.⁷

Picture exchange communication system

The Picture Exchange Communication System (PECS) was created to increase communication for individuals with autism spectrum disorders.³¹ PECS has also been found effective for other populations with cognitive, communication, and physical disabilities. The system is put in place by a speech and language pathologist and should only be used under the supervision and guidance of that specialist. Nevertheless, it is important for OTAs to have a cursory knowledge of the program, which is widely used.

PECS is a systematic method for teaching initiation of communication through the exchange of pictures.³¹ Through PECS, a child is taught to use communication to get his or her needs met. The goal is to teach the child to use communication independently. The system is not necessarily a replacement for speech; frequently young children who begin using the program also begin to use vocal language.³¹ An OTA can continue to use language with a client who uses PECS. However, basic use of the protocol will reinforce the work done in speech therapy and may improve OT sessions and outcomes (Table 19-5).

High-tech voice output communication AIDS

A wide range of high-tech devices and software is available to augment communication for people who have disabilities. These devices include small, handheld devices that contain a few messages; larger devices that are portable, are mountable on wheelchairs, and store large amounts of vocabulary; and complex systems that can be used with computers to export any message the individual can type.¹ The handheld and larger portable devices are usually the first high-tech devices used with children, who must learn to use the devices as they are learning to communicate and use vocabulary. It is important that their continued development is taken into account when selecting a VOCA.

VOCAs are the specific hardware that the child accesses for communication. These high-tech communication boards work in the same way as low-tech boards: the child accesses a picture or symbol to communicate with others. However, when a picture or symbol is accessed by the child on a VOCA, an audible message is given out by the device so that others can hear it when the child wishes to communicate.

Small devices present a limited number of pictures, sometimes as few as three or five.¹ When activated, the device plays a frequently used sentence or message such as “I want to play” or “I need to go to the bathroom.” Some of these devices are able to record specific messages and can therefore be useful for including children who have difficulties with typical occupations of childhood such as giving an oral report or acting in a school play.¹ More complex systems comprise several menus that present words or messages within a theme. The child is able to access many words or messages for each theme. The child first selects a topic from a main menu page and then is able to access a number of words or messages about that theme. For example, the child might access a food theme, in which several choices of favorite foods and snacks are presented. Common themes for young children include foods, bathroom, greetings, weather, songs, and toys. As communication and the use of the device develop, an ever-expanding array of themes may be programmed on complex VOCAs.¹

VOCAs can be accessed by a variety of means so that an individual can communicate using whichever part of the body he or she is best able to move. If the child has controlled movement of the upper extremity, he or she can access the symbols with fingers on a touch screen. If less volitional movement is available, the child may use a switch to select the appropriate symbol.²³ Switches can be accessed through paddles that are pushed by any part of the body where controlled movement exists. This might be the hand, elbow, or side of the head. Puff and sip configurations can be set up for the individual who is unable to move any of the limbs in a controlled manner.²³

OT practitioners play a vital role in teaching children to use switches.²³ First, the OT practitioner provides experiences to help the child learn that the switch causes something to happen. This is most easily achieved with a cause-and-effect toy that moves, lights up, and/or makes sound when the switch it activated. Once the child understands the concept thoroughly, the switch can be used to operate a highly motivating phrase. In the case of some children, this might be “I want a snack,” “Tickle me!” or simply “Hello.” Next, the child works with more than one switch to produce more than one communication. In later stages, the OT practitioner works with the child to use the switch to select a picture from the screen of a high-tech VOCA. A common set-up includes a cursor on a screen that moves among various pictures. The child works to press the switch as it lands on a specific picture. In this way, the OT practitioner prepares the child to use technology to select whole words and phrases in a complex communication system.²³

Other alternative methods for accessing VOCAs include pointers and eye-tracking devices. Pointers may utilize light beam or infrared technology to select symbols.¹¹ Eye-tracking devices follow the movement and gazing of the eyes to select symbols and messages.⁵ These adaptations require a significant level of head and eye control as well as high-level cognitive skills.¹¹

Computer systems for communication

Computers allow individuals to communicate via email, blogs, and programs that convert text to audible speech.⁵ Many modifications are available so that individuals can access keyboards and mouse pointers.⁵

Alternative keyboards have been created to increase the ease with which a person who has a disability can type.⁵ Keyboards may be enlarged or constricted to allow for more success with the keys. The order of the letters may also be customized, so that the most frequently used keys are situated in the home row, or the most important keys clustered in the center for one finger typing. Keyboards can be designed for use with one or two hands. Further, keyboards may be programmed to produce words or phrases when a combination of keys is pressed. Other adaptations include moisture guards, overlays to increase visual contrast or tactile feedback, and rigid overlays to prevent pressing the wrong buttons.⁵

Computers may be accessed through non-traditional mouse arrangements if the user is unable to effectively use a mouse.⁵ A track ball may be helpful for people who have limited movement of the upper extremity, but accurate movement at the fingers. The track ball may also be appropriate for the individual who has full range of motion, but lacks the motor control or stability to move the whole hand or arm to move a standard mouse. Alternatively, a computer screen can be accessed through the use of a switch. Again, a cursor moves between different areas of the screen and the child presses the switch when the cursor pauses on the appropriate area. An individual may also use a stick or pointer as a mouse; software is available to interpret head movement as movement of the pointer across the screen.⁵ In addition, eye gaze and infrared programs are available for the individual with the ability to gaze into a camera in a controlled manner.^5,11 See Chapter 26. Assistive Technology for additional information.

Developmental stages of mobility

The OT practitioner takes into consideration the developmental stages of mobility while planning intervention. The infant and toddler typically take on the role of a passenger. The young child begins to explore mobility by creeping and walking. Transportation to and from school on a school bus or on public transportation becomes a focus for the school-aged child. At this time, the child is often exploring his or her community when riding a bicycle or scooter as well. As the child grows, increased importance is placed on safety and judgment as the child begins to explore the environment more independently. Crossing the street, reading and understanding street signs and signals, and negotiating curbs and obstacles within the environment become important to independence and safe community mobility. The adolescent and young adult incorporate all of the above developed skills as they find independence and autonomy preparing to drive or navigate public transportation.³ Ultimately, mobility is a necessary life component that leads to better quality of life, fulfillment of roles, access to leisure activities, and engagement in meaningful activities. In order to provide effective intervention, it is necessary to assess on an ongoing basis the child’s strengths and needs in performance areas specific to the mode of mobility that the child is seeking. Visual perception, motor coordination, muscle strength, sensory regulation, and executive functioning can impact the successful and independent participation of an individual’s mobility within the community. Adaptations in the form of mobility devices, supplemental aids, or modifications to the environment may be necessary to attain optimal independence. The child or the caregiver and the OT practitioner work together to develop individualized treatment goals, objectives, and a specific treatment plan to address the child’s mobility needs.