TRANSCRIPT - Sensory Needs of Students with Visual Impairments and Optic Nerve Hypoplasia Ð 3/27/23

>>Athena: My name is Athena Oden and I'm a pediatric physical therapist and I have worked in pediatrics with public schools and private schools and set up motor labs and residential facilities and just a lot of different places. ECI as well, helping design playgrounds. Just the gamut of things, just like you guys all do. And teaching and providing seminars and things. But we're going to look at some of these ideas about these concepts and how we can use these concepts as independent interventions. I always like to make the connection that my own grandfather graduated from TSBVI in 1915. My grandmother also attended TSBVI, and my uncle graduated from there in the '50s. It's just an amazing place with a wonderful connection for me. Beverly. 

>>Beverly: Hi. Thank you, Athena. So I'm Beverly Jackson and I am a certified orientation and mobility specialist and I'm currently working as a clinical instructor at Stephen F. Austin State University in Nacogdoches, Texas. I work in the visual and O&M prep department and teaching all of our new O&Ms and TSVIs coming in the world. This has been my passion for quite a long time. My former job I worked with school districts in the area and started consulting with the O&Ms and TSVIs and teams about students with optic nerve hypoplasia and we decided or discovered over a period of time that many of these students had some challenging -- what we called at the time behaviors that we were seeing that were really interfering with their ability to make progress in their O&M lessons, make progress with their work that they were doing with their TSVI, and also their classroom settings. Athena has always been in the back of my mind. I've been to some of her workshops, her ready bodies learning mind trainings. I actually have her very first book that she wrote, and now I have the third one. Is it the third?

>>Athena: Yes.

>>Beverly: So it's the third one. And I always wanted to work closely with Athena. So I felt like she could help our population of students with visual impairments. And then we started looking at the optic nerve hypoplasia population. So we started this project about -- we did it for about five years. We worked with students with visual impairments and ONH in local school districts and along with teams. Each year we added a new group of students and we just kind of followed them and we started doing on-site visits to their campuses. We worked with the teams to identify what their concerns were and maybe some strategies that they had tried in the past. And then kind of went from there to develop some plans of implementation. We did see a lot of progress in some of our students -- we'll share one here in a little bit -- but it's been a really great success story in many ways. We felt like we wanted to share that with you today. I need to start out with just some history of optic nerve hypoplasia. Many of you probably already know -- sorry about that. Go back. Optic nerve hypoplasia, or ONH, is the third leading cause of visual impairments in children ages birth to 3. Cortical visual impairment is the first and premature retinopathy. It also is paired with possible brain and endocrine abnormalities. It is considered an optical visual impairment -- ocular visual impairment. It's also considered a spectrum disorder because of many other things that go along with a visual impairment. Then we also see hormonal impacts due to the hypothalamus. Some of you might also know this as Septo-Optic Dysplasia or de Morsier's syndrome. With the hypothalamus, that's where the autonomic nervous system and the pituitary functionings are coming from and that's why we're seeing some of this happen. So some of the general ONH characteristics that we see are varying degrees of visual impairments. So sometimes we have students with low vision all the way to total blindness. We might also see nystagmus go along with that and other impairments related to their vision. We also see problems with regulation of temperature. So a lot of times our students are very sensitive to cold or heat. We are seeing hunger and thirst. We see disrupted sleep cycles, lots of irregular sleep patterns during the day and at night. And mood regulations. So sometimes really high highs and really lows and not in between. Hormonal irregularities, abnormal appetite. Many of the students are overweight or underweight. We also see aversion to food textures, which in turn lead to poor diet and poor nutrition, which might affect all the other areas as well. Many of our students are diagnosed with diabetes insipidus and we are seeing pituitary gland dysfunction. With that we see a decrease in cortisol which leads to adrenal fatigue, we're seeing low blood sugar, the inability to fight stress and infection. We're also seeing the hormones being affected. Leptin is the most common one. That's necessary for metabolism and creating hunger. So we decided that -- we were looking at different students and Dominique was one of them on our list to go and check out. We wanted to be able to identify the root cause of these behaviors that we were seeing with Dominique and to try to understand why she was exhibiting some of these challenging behaviors and to develop a plan to help her move along in her progress. So this is Dominique and she's age 6 -- she was age 6 at the time of this project. And we found that she had no early childhood intervention services or no formal services prior to age 5.5. When she was 5.5, she started in a general ed Ed kindergarten class. She was walking, talking, doing some functional tasks. To many she might appear that she is typically developing. And then you start seeing those demands being placed on her. She has those longer school days. She's at school all day. She's not at home getting to kind of do what she wants, and we started seeing some of these behaviors. You will see in the very far left image, Dominique is standing with her adaptive mobility device and it's a rectangular device with rollers at the bottom and it's meant to push in front of her body so that when she's walking, the device would pick up and detect obstacles and help her learn to stop and not crash into them. And this was a normal position for Dominique. She stands with her head down, her feet are kind of wide apart, toes are pointed out. She didn't really have a good body and spatial awareness. Most of the time the AMD was positioned closer to her body. She had a really hard time pushing it forward. And then the picture in the middle is one of Dominique's favorite things to do is kind of lay -- I think this was a crash pad or a large bean bag. But she enjoyed falling into it and rolling around on it and it gave her so much pleasure. And then the third picture is a photo of Dominique reading one of her tactile symbols on her classroom door. But as you can see, she's pressing her head into the wall at the same time. So she's looking for some kind of information. So I have some photos here of Dominique. This was her typical day. This was what she kind of looked like on a daily basis when we first saw her. At the top right corner we have Dominique sitting at a table or a desk and her head is laying down, her hands are in front of her. You can't see in the photo but her hands are constantly moving. She's fidgeting, scratching, tapping, she's making noise. The bottom left photo you see Dominique, she's what we call the tutorling position so she's crouched down on her hands and knees or actually her knees and elbows and her head is into the floor. She's pushing it into the floor. She's kind of in that shut down mode. She's not wanting or ready to engage in any activities. And then the middle picture is another one of Dominique. She has her pre-cane in front of her and she's sitting on the floor kind of in the turtle position, but this time she's on her bottom and folded forward where her head is in her hands and her head is pressing into the floor. She's not participating in the activity, which would be walking down the hallway with her AMD. And then the picture on the bottom right is Dominique in classroom. This was during a classroom, like a storytime. And she's been asked to sit in her chair. And this is her preferred method of being in her chair. So she's facing the seat of the chair. She's bent over at the waist and her face is pushing into the squishy mat that's provided for her. These are very, very common things that we saw with Dominique. Most people might say that those are behaviors but what we found is these are results of other things. Mostly fatigue, mostly inability to sustain and to be able to keep up with the pace of the normal day. So we got some preliminary information from the team. We asked them what are your main concerns. What are some things that you're seeing that are contributing to her inability to participate and make it through the day. And so some of the things we saw, or the team reported on, was she dislikes those loud sudden noises. She covers her ears many times. Some of those noises might be the toilet flushing, the door slamming, a vehicle driving by from outside. A dog barking. Noises in the classroom from other peers. She also tends to move very slowly during those transitions and many people thought maybe she's being what they would call stubborn or non-compliant. But we were also curious was this related to fatigue or behavior. A hesitancy to touch new things. When you told her it was something new, of course, hey, Dominique, we're going to put our hands in shaving cream or rub some soap on our hands. If it was something unfamiliar to her, she was hesitant to touch. On the other hand, she had this urge to fidget and move constantly and touch and grasp and poke. So she would find anything that was within arm's reach, if it was on her own accord, and do some of those behaviors with it. One of her favorite things was to find the badge of the employee, the teacher's badge. And if it was elastic, she would pull on it, flap it, bang on her chin and flap it on her hand and poke it. And that was kind of a common thing for her that she felt like she needed to do all day. The next thing we saw was this need for movement. So many times, after five to ten seconds of sitting still, she would stand up immediately. She was really hard to get her to sit back down, so lots of moving, lots of desire to seek movement. And then again fixating on sounds. She was very echolalic. She would repeat things she had heard on a talking toy. We were told that she had a variety of toys at home that had a lot of buttons and voice output. That was our impression that she spent a lot of time engaging in those toys. So very echolalic from those devices. We also saw that she would drop on to the floor when walking at times. She would lie on her stomach and would not move. Again, she got into that turtle position where she was shutting down or seeking information. Then we saw a weak grasp on her AMD, adaptive mobility device. Not only that but she had a hard time with pulling out chairs, pushing in chairs, opening and closing doors. Then we saw overall low muscle tone. Mostly upper body but definitely lower body as well. Just kind of locked into her tone and chin down, arms kind of down. Not really a good arm swing when she walks. Wide gait of support. Slow and lethargic in her movements. We saw lots of instances of being nonresponsive and saying no to things. Dominique, it's time to go to lunch. No. Even if it was something that was her favorite thing to do. Lots and lots of noes. Excuse me. So then we decided, okay, let's get some formal information. So we looked at some sensory profiles and decided on one and we used it to gather information regarding different categories of the sensory system. And these were the two categories that we found that we were seeing the most of. Under responsive and seeking sensation behavior. We saw that she doesn't always notice when her hands and fingers are messy or her clothes are twisted. She was seeking movement that interferes with her daily routines. She really wasn't attending to what was going on around her. When she did get the movement, she would become very excited with the movement and be very, very exaggerated with it. So just mild forms of movement would not stimulate her. She had to have really hard, heavy movements, big exaggerated movements. She also would jump from one activity to another, which, again, was interfering with her play and interfering with her ability to participate. And then we saw bouncing and standing and pounding her hands and feet. I'll show you a video of the bouncing and standing. The pounding hands, she would just do a lot of hand compressions and clapping her hands together and stomping her feet. Lots of foot movements that we were seeing. And then on the low energy and weak areas we saw that she has weak muscles. She tires easily, has poor endurance. We see a weak grasp, inability to lift heavy objects. Again, really challenging to open and close doors, to pick up her backpack from the floor, to pick up anything over her head was a big challenge. And to stand, to go from sitting on the floor to standing was very, very challenging for her. It required a lot of energy. And then you'll see -- you can see in some of the photos I showed earlier, she does a lot of propping to support herself. So head on the table, head on the wall, leaning her whole body, upper body most of the time on whatever that surface is. Athena is going to talk about the why, why we're seeing all this. Here we go.

>>Athena: So one of the things we have to think about in the information we gather from this are why are we -- do students with visual impairments with optic nerve hypoplasia, why do they have sensorimotor challenges. You might notice we have been talking about a sensory profile and now we're talking about sensory-motor challenges. You cannot separate those two. According to the dynamic systems theory, which is our current medical model of development, all systems, whether it's our muscular system, our digestive system, hormonal, cognitive, auditory, all systems depend on and interact with each other. So all of those systems need massive amounts of rich experience for a child to develop ability and to develop function. Well, and we know that typically in the early childhood of a child with a visual impairment they may not have that huge amount of rich experiences. And so that is going to limit their ability and their ability to develop function as well. So that may be one of the reasons that Dominique is not very posturely secure. So start thinking about the things that Beverly talked about. And let's think about her postural security. She's leaning on things. She's not able to stand very long. She appears fatigued. A lot of times when we begin to look at sensory or sensory applications, one of the first things we look at for children with visual impairments is the tactile system. And it's often used as a go-to for more information about learning about your world. But if all of these systems depend on each other and all of these systems interact with each other, how much developmental experience has that tactile system had to be able to supply them with information about the world. It's not automatically able to give them all the information they may need or all the information that we understand from the tactile system. There are a couple of other systems that we really need to think about too. The tactile system is what I call an external system. The information is from the external world. The vestibular, which is your fluid in your inner ear and your proprioceptive systems are knowledge about yourself. They are internal information. And they help the child understand motion and that motion-defining orientation and space. Proprioception is understanding joint stress and that joint stress is what helps you recognize and define any movement you make of your own. Where your arm, leg, or foot placement is. David Brown coined the statement of the forgotten senses, and this is what he says about that. We do know from experience that difficulties with vestibular and proprioceptive functioning in particular always need to be addressed first if the children are to make the best possible progress in using touch and residual vision and hearing effectively. In other words, basically this is the foundational piece. Do you realize that the proprioceptive system, the vestibular system and visual system are a triad that help you understand postural security. They calibrate each other as you grow and develop. So if your visual system is not available to you and your proprioceptive and vestibular systems receive little stimulation, then you don't have a lot to calibrate your posture or your ability and security in space. And so it really makes it different for the children. So next one, Beverly. So we can kind of see now why some students might appear to be seeking more information. And we will often talk about sensory-seeking or sensory-avoiding. It's a lot of what we're actually talking about. If you see a child rocking or rotating their head or bouncing up and down, they are seeking vestibular information, because with the rocking and bouncing and movement of the head, they are trying to stimulate the fluid in that inner ear to get vestibular stimulation. Our typically-developing children roll, jump, and play. If they're jumping up and down and foot slapping and pounding and enjoying vibrating toys and flapping and fidgeting and chewing, all of those are proprioceptive stimulation. And so they're going to be seeking that information to learn more about themselves. They might look like they're avoiding certain things. They may be fearful for their feet to leave the ground. They may be turtling on the ground. Dominique is in adaptive PE and she's not participating. She has turtled on the ground and she is leaning over not participating at all. That could very possibly be a lack of vestibular information. I don't understand where I am in space but my security is the ground. Also the loose grip or refusing to hold things, that's proprioceptive information developed in the hand by the joint understanding of how firm a grip is. How much information has she had to develop that? So the world can really be very frightening. Visual information about your whole environment is limited and vestibular understanding of your own movement in space is limited and people are telling you to stand, so you really don't have a lot of tactile grounding except for maybe your feet. And your proprioceptive knowledge of how your own body is moving and your joint and limb control is limited. There's going to be a lot of different things going on. And a lot of them are fear and fatigue and frustration. Fearful of the environment they're in, because they don't know all about their environment. Fatigued because it takes a lot of energy to be able to coordinate that movement or coordinate involvement in that environment, or frustration because they just can't do it any longer and we sometimes see that as behavior. We really need to remember that all of these systems are connected and they're not independent from each other. And one of the things we could -- one of the ways we could think about it is like a bucket. A bucket of needing to be filled. So the vestibular bucket needs to be filled, the tactile bucket needs to be filled. The proprioceptive bucket needs to be filled. Our typically-developing children are going to bounce, run, jump, squeal, fill those buckets and then organize everything together with some finesse for a short moment to sit an engage and control themselves. And then they need to fill those buckets again because they drained them using the control to sit and be still. So a few moments later when their bucket gets drained, their performance deteriorates and they have to fill it again. How do they do that? By rocking in their seat, jumping up and down, or other types of movement. Or they're just going to quit. And lay back, turtle on the ground because they have nothing left for the next classroom performance. And when you look at a diagnosis, especially one of optic nerve hypoplasia that involves a lot of hormones and possibly adrenal fatigue, then we need to recognize that she may actually be very tired. So when we begin to recognize that -- and Dominique would turtle on the ground -- we would walk to Dominique and say, Dominique, we understand you may be very fatigued. You have five minutes to stay in this position. We want you to rest. But after five minutes then we want you to get up and continue to come with us. So we need to understand that besides the fear there might be true fatigue and there might be a lot of frustration in these students. So if we need to stimulate these systems, how can we stimulate these systems? Next slide, Beverly. So we can stimulate these systems in a lot of simple ways, and one of the things we need to think about is typical childhood. And enjoyable things and fun things. So the proprioceptive system is developed with what we call heavy work. That's pushing wagons and pulling and climbing and carrying heavy things. Anything that puts pressure through the joints. Walking on your hands and knees. The vestibular system learns from spinning, rocking, swinging, jumping, rolling, and anything that causes the movement of the head will stimulate that fluid in the vestibular system. So we need to remember that what we are trying to provide for Dominique is not just for bucket filling, we're also building, building, and mature these systems so she has a capacity for more ability. There are a couple of things you need to remember about stimulation. One of them is you need to provide variety, because that's what real life is like. Don't pick a particular stimulation and just do it over and over and over and over. We accommodate to a repeated stimulation. For example, if I get in my husband's old truck, which he loves dearly, and it doesn't have any good shocks and we're bouncing up and down for a period of time, in the beginning I can really feel that. But if I've been in the car for 10 or 15 minutes, I don't notice it as much. I have accommodated to it. So children can accommodate to something also if it's too repeated. So provide variety. Also, provide a little at a time, because children can become overloaded. Think about these children who may not have had a lot of proprioceptive or vestibular or movement very early in their childhood and now we are giving them a lot. We need to go slowly. We need to provide it and build it up slowly in short bursts, five minutes, three, four, five, maybe up to ten minutes, but multiple times a day. Not for long periods of time, not for 30 minutes at the time, but multiple periods during the day. We need to remember to change the method of stimulation, especially if you're looking at vestibular stimulation. You want to have a variety, you want to spin, roll, swing. And you can swing in swings outside. You can swing on hammocks. You can do all kinds of that. We need a lot of variety. But one of the big important concepts is to stop and start. Stopping and starting allows a stimulation and then a registration of that stimulation and a rest, which is important, and stimulation and a registration of that stimulation. So you want to check with your OP and PT or see the book we're going to talk about later. But what we're looking for are simple activities for Dominique. We want to fill her bucket. We want to feed these systems but we don't want what we're doing to become another task to be evaluated. Instead of being something to evaluate, we are looking for ways to develop her foundation. And so they will be simpler and they will not be something that is necessarily part of an IEP or part of a goal. And they're also not considered sensory breaks because we're not really using sensory breaks, as David Brown says, the whole world is sensory. Everything is sensory so we are just filling these particular systems to help provide postural security so she's going to be better off in almost all of her learning situations. Beverly

>>Beverly: Okay. Thank you. So we developed a plan for Dominique and we were able to move her, with some interventions and with some amazing teams that we worked with, we were able to progress her from those lethargic patterns and fitful bouncing into secure ambulation. I'm going to show you three video clips that kind of discuss that. The first video clip is -- I'm going to play it. They're like ten seconds long so I'm going to talk through it really fast and I might talk a little bit after the video. The first one to start out with is Dominique is sitting with her TSVI. There's a small table and she's standing. She has her chair. Obviously she has pushed it back behind her and she's folded over in half and laying her torso and her head and arms on the table. The teacher is doing her best to get her involved in a routine. She's already thrown a few of her items on the floor, as you can see. I think this is a grooming routine she's working with. And Dominique has become a little frustrated. She's thrown them on the floor. She's pushed her chair out. I'm going to talk to you about what she's doing in this video. So the TSVI is prompting her. Dominique is kind of standing. She's tapping on the bag that's in front of her, the bag that holds all the items. The TSVI is tapping. They're kind of doing a tapping back and forth. Dominique was pounding her hand first and then she started pounding her foot. Instead of doing the task that's being asked of her, Dominique has resorted to movement. She's pounding. She's asking for information through her body. And, again, she's having to hold herself up with that table. This is an easier position for her to be in than sitting in that chair, believe it or not. The next video -- I'm not great at doing these videos. Here we go. Dominique -- it's loading slowly. So in this -- before I show the video, Dominique, the class was sitting in a circle. This is a paraprofessional that's working with her and everyone's asked to sit in their chairs. Dominique tends to do the opposite of what's asked of her. So she decides to stand. As the teacher's prompting her to sit down, you'll see that the movements that Dominique is exhibiting increase. So Dominique is standing. She has the chair against the back of her legs. Her arms are kind of out to the side and you'll see that the teacher starts leaning in to talk to her. I'm going to play the video. So she's jerking her arms. Her hands are flapping. Her knees are jerking. She's doing that bouncing in her knees. Her right foot is coming up and down, her left foot is coming up and down. She has this random jerking. She found the teacher's name tag and now she's going to start pulling on that. We had a two-minute video of it. We're not going to show the whole thing but what we saw in this video the more demands were placed on her, the more the teacher prompted her, these movements increased. I'll show the video one more time so you can see it. She's jerking, hands are flapping. She's making some facial grimaces. Do you want to describe any of those movements, Athena?

>>Athena: Sure. A lot of times you will see a kind of jumping and vibrating of themselves or jumping up and down so fast it looks like a vibration. And really what they're doing is filling that proprioceptive system, that joint system to help them understand where I am in space. Because sitting in a chair is kind of like dog paddling in a swimming pool. There's no information there for them. So she's trying, in her own way, to participate in that circle time by doing that bouncing and jumping up and down. But once you remove her to the seat you're probably going to have what we call behavior problems because she feels so lost.

>>Beverly: Yes, thank you. Athena just does that so beautifully. So these are the early things that we were seeing. After maybe six months of intervention -- you might have seen earlier in the videos that she was walking with an adaptive mobility device, AMD made out of PVC. She transferred to another campus and that new team took on this responsibility and the challenge with continuing this with Dominique, you will see her walking in the hallway. She's using a cane and she's trailing the wall, kind of in a diagonal training position. She reaches out to touch the wall here in a moment. So she's using a combination of some hand trailing and some walking. She's still kind of slow. She's still kind of pokey but she's doing a lot better. She stops in response or moves her cane in response to an obstacle. Again, she's trailing the wall some. She still enjoys the heavy foot, the walking with the heavy foot. I'm going to show it in big screen. Sorry about that. So she's here crossing an alcove along a hallway. Her shirt says perfect princess, because she is a perfect princess. Her posture looks pretty good. Go ahead, Athena.

>>Athena: Yeah, during that six months when we were working, we were able to help fill that proprioceptive system and vestibular system. We have filled that bucket for her so she took that stimulation and information and translated that as a foundation to more ability. So she's walking in a stronger more upright gait. She's still a little bit slow because of that insecurity of understanding where she is. But as we build more understanding into her lower extremities, into her foot placement, then she'll be able to speed that up as well.

>>Beverly: I think she looks really good here.

>>Athena: She does.

>>Beverly: This is very exciting to see. Okay. How do we get all this in place? How did we make sure that she had what she needed on a daily basis? So we kind of developed -- based on the sensory profile and the feedback we were getting from the team and kind of understanding her daily schedule, because that was a big deal. We decided or kind of came to the conclusion that she really needed more of that vestibular and proprioceptive activities to support her O&M and VI time in the classroom. This was created for multiple members of the team. I'm showing you a chart here -- it's actually a table. At the top left corner there is an activity and we have a note to choose five activities a day. And then we have another curriculum for the time and minutes. And then we have five more curriculums for Monday through Friday. We have an a.m. schedule and a p.m. schedule so they're able to check that off. Down the column of the activities, we have bouncing on the ball and sitting for five to seven minutes. We have laying on stomach on the ball. We also have that she can move forward, backwards, side to side on that ball. Five so seven minutes at a time. Pushing a heavy cart for seven to ten minutes. If you don't have a heavy cart it can be a basket loaded down with something. A lot of times we use like the water bottles, the cases of water bottles, a heavy chair, a heavy basket, anything that's pushable, having her push that. Crawling through tunnels, going under chairs and tables. Crawling around on the floor. The tunnels are great because it's kind of really appropriate activity for kiddos to do. You see those in a lot of motor labs. Crawling through those tunnels five to seven minutes. Floor activities, while on her knees with her arms over her head. That's challenging. She's bearing weight in her knees. She's having to bring her trunk and torso up, keep those arms elevated. The idea of having them over her head is so she is having to reach above and work on that balance. Also we have walking on uneven surfaces. Not just smooth tile floors all day, let's have her walk on the gravel, the grass, the dirt. Have her go over, under, through, around, and between things. Bouncing on the trampoline and jumping. Trampoline balance and bouncing. So trying to balance on one foot. Jumping and bouncing on that trampoline for five to seven minutes. Jumping off the trampoline and stepping with both hands held. I'll let Athena talk about that one. And bunny hopping while walking. She's doing bunny hops and she stands to walk and does bunny hops. Do you want to talk about how the importance of jumping off of that trampoline and what that does to the vestibular system?

>>Athena: Sure, absolutely. Actually, when you look at all of these, they are vestibular proprioceptive and you can kind of split them out a little bit but they are working together all the time. Even the bouncing the ball and sitting. They're getting that weight transfer in those legs but they're also getting the head movement for the vestibular system, stomach on the ball, pushing a heavy cart, moving forward through space. Most of these things are designed to be that way but, again, they are typical at-play activities for children. And that's the other thing we want to make sure that we focus on. As far as like -- as Beverly mentioned -- jumping off the trampoline or stepping off the trampoline. Sometimes a child can learn to jump up and down on a trampoline because they have enough rebound, but that is a simpler skill than stepping off the trampoline. In order to step off the trampoline they have to be able to step through space and step down, and that takes a lot of balance and proprioceptive information in the leg that is left supporting them up on the trampoline. And how to move that leg once the extended leg reaches the floor. It's really a very complicated thing stepping down off of a step, when you think about it. So it is something that needs to be practiced again. It helps her learn to be able to lower her own body weight through one knee, and that's going to help her learn to go up and down the stairs. Just learning to manage stairs by knowing where they are and where the step is is not the only skill that's necessary. We actually have to have the proprioceptive understanding to be able to manage those steps as well

>>Beverly: Beautifully said, Athena. Thank you. So this was the sensory motor schedule we created for Dominique. You can see in the photo on the right she's sitting with her O&M and she's always on one of Athena's wooden spinning boards. This is something we had to build up for Dominique to be able to learn to tolerate. She was doing a couple of rotations at a time and stopping and going the opposite direction. She eventually got to where she could go 10 to 15 times in one rotation and she was doing it by herself as well. The point of this is to understand that we didn't say, okay, this is going to take five hours a day for Dominique to do. We were very specific in seeing, okay, let's do an a.m. time and a p.m. time. But the idea of having the chart is so that she's getting the variety. She's not doing the same thing all day. So on Monday she's going to push the heavy cart, jump on the trampoline and maybe bounce the ball and two other things. She's going to do that in the morning. Maybe in the afternoon we might do something different. It's a way to keep those activities separate. We also found that it didn't take a lot of time. You can see five to seven minutes, maybe even ten minutes. But you can put some other activities into that while it's happening. What we also found is that because we were feeding that system before the task, if she was doing these activities right before she was asked to sit down or walk down the hall or do something that requires some cognitive load, that we were actually seeing better results and we were having to prompt her less and redirect her less. So we spent a lot of time building up that system to do the task and then the task was much more efficient and we got better results. We saw better results and better performance out of her. So, remember, feeding that system before the task is really going to help. We also found that these activities were a lot of fun. The people that were doing them with her, they were enjoying it. It was fun. It was a good way to connect with Dominique. And when we really sat down and thought about it, we found that these activities were also addressing not just her sensorimotor system but her concept development and body and spatial awareness. She was -- by having an IEP that she's going to walk down the hall holding a cane for 25 feet, we're addressing it through these sensory motor activities and addressing that body and spatial awareness and the stamina as well. So, again, these are just some photos of the sensory motor activities that we were doing with Dominique. Different people were doing these activities throughout the day. One of them was walking on a balance board holding on to the O&M and to the wall. We were eventually able to move that balance board away from the wall. So she got her balance improved and she was able to just do -- she's holding on with two hands here. I did see her holding on one with hand and holding the pinkie of the O&M. Another one is on the mat bearing weight on her hands and knees and the pattern of sitting on the floor and standing. The third one is Athena working with her along the wall. There's a peg board hanging on the wall and she's on her knees on a mat and she's working on activities that are over her head. This would be attaching things on that peg board so that they're above her head and she has to work a little bit harder to build herself up. It really improved her concepts, her strength, her stamina, body and spatial awareness. All right, Athena.

>>Athena: So because we saw so many children that were demonstrating behaviors that were leading to problems in the classroom and leading even to other diagnoses. We put together this checklist. This is six pages of observations. What you see here is a scoring page that is the smaller page to your right. And it has a list of vestibular, proprioceptive, tactile, auditory, olfactory, key movements, and oral activities with a scoring sheet. The larger screen or picture of the page that you see to the left is half of a page of the part of the vestibular sensorimotor checklist. We have several different questions. Three are exampled here. Let me take you through one of them to help you understand how this works. You would have the first question is desires or seeks out linear movement activities. Some of those options, which you can check off, might be rocking, swinging, bouncing up and down, jumping on a trampoline, nodding their head up and down. If you're seeing those activities in the child you would then move on to choose one category. So you would check is it 90% of the time always. 60% of the time often. 40% of the time some. 10% of the time never. Or they refuse to do those activities. Some of those are in red. 40% is not but the others are. Some of those are in red. And if you are checking something in red then it needs to be addressed. Directly below that, you will see, under the areas that need to be addressed, you will see that there are links to V1, V2, V 4, et cetera. Those are links to specific activities that will pop up, that come from the ready bodies book. And because they are showing linear movement activities most of the day, what can I do to help halt that so-called behavior and help build that vestibular system for them. So this is -- and these link directly to the activity. This allows you to tally up how many of those did you see in vestibular, how many of those did you see in tactile so that you know which area needs immediate attention first. Now, this is actually part of a -- if you'll go to the next one, Bev. This is actually part of the course that I have on ready bodies learning minds.com or RBLM.teachable.com. It's a six and a half-hour course that takes you through infant development, the development of even some reflexes. The development of postural security. The development of all of these systems and how children with visual impairments can be assisted in maturing these systems. It's also applicable for Deaf and Hard of Hearing, for children with autism, for children with multiple impairments, for children with multiple disabilities because all of our children have all the same systems. And so stimulating those systems is going to benefit all of those children. So the sensorimotor checklist that you saw is a part of this course. Once you attend this course there's a PDF on there that is fillable and allows you to score your students. The front page you have to tally and score yourself. So you can score your students and you will have direct links to the activities in the book. The book is also provided for you as a part of this course. And it helps to find what specific area in our children really needs a lot of attention so that we can help them build the foundation for more ability. Do we need to continue teaching tasks? Yes. We need to teach tasks. But at some point they only have a certain level of ability or foundation to reach a task. So if we're having trouble with these tasks, let's back up and look at how developed is that foundation. And the more developed we can create a foundation for them, the more they'll be able to organize into those tasks that we're trying to teach them. And you'll see more and more success. We also are working on having that checklist in a couple of months as part of a website, so that you can do online evaluation, update and tracking progress. That will be an e-mail that we can send out from our course or whatever. But hopefully in a couple of months that will be that way. But if you're looking at the course now, you still have access to that checklist. And the course is up and running now.

>>Beverly: Thank you so much. And I took the course. It's beautifully done. Very good. So main ideas for today. We felt like we needed to kind of give you some things to walk away with today that you could start thinking about. Poor proprioception plus poor vestibular equals poor body awareness. And we know that's where everything begins is body awareness. Poor body awareness equals poor orientation and poor mobility. So by providing that vestibular and proprioceptive information we're going to improve body awareness and mobility and/or orientation. Also it's super important to consult with your OTs and PTs. Collaboration is key. With many students we had OT/PT adaptive speech, paraprofessionals, parents, DHH, everybody involved on the team so that they could implement these activities as well. Starting as early as possible we want to get in there. With Dominique we didn't get to start until 6 but she did come a long way. Had we been able to start with her even earlier we might not have had these challenges to begin with. Provide multiple experiences throughout the day. This is not a one and done thing. They have to have these activities all day. Their day should be kind of around these activities. And then that last one is provide variety. We need to provide variety so they don't accommodate, so they don't become accommodated to those activities and they're not meaningful for them anymore.

>>Athena: We need to remember two that none of us have just one problem. All of our systems are interconnected and crucial for development. So students with visual impairments or multiple impairments or multiple disabilities or autism, typically they can lack opportunity for sensorimotor experience early in that life. And so they need to build a larger foundation. And we need to look twice at behavior because behavior can be a representation of a sensorimotor need. You need to always ask are they afraid, are they fatigued, are they frustrated before we begin to talk about it being really a behavior. Are they showing a need for vestibular/proprioceptive stimulation while constantly rocking back and forth while we're telling them to stop? So simple activities, fun activities can provide them with a wealth of knowledge of self. And that knowledge of self is what leads them to the multifaceted abilities that we are trying to lead them into. I hope that's helpful for you guys, for sure.

>>Beverly: There's a few references at the back you guys can look at on your own. So I think that's a rap. We're going to stop sharing and hand it over to Kate. Thank you, guys very much.

>>Kate: We have just a couple of minutes and we had several questions come in, which I think you have answered most of them. But two questions that came in had to do with filling the bucket. So the first one, so how do you fill the bucket for older youth who never got it and still struggle with significant proprioceptive and vestibular issues? And the other one said what about children who don't seem like their bucket is ever full, even when it feels like we're providing so much.

>>Athena: I'll take the first one very quickly because I know our time is very short. But if you are working on these systems, I will just tell you that prepuberty the children make quick progress. The younger they are the quicker the progress. Post-puberty, they will continue to make progress. At my age I could continue to make progress. It just takes a little bit more stimulation and a little bit more direct stimulation. So absolutely do not give up on trying to stimulate these children and build that foundation. You can still change some of the things they're doing. We did this with some middle school students and had great success. I have done it with high school students. Don't give up on that. As far as the child I bet you're third quarter, which is the one who is constantly running and moving and is not going to be still and doesn't look like we can fill him up, apparently let's think about it this way: He's not doing a very good job of being able to fill himself up so he needs your help to fill him more. And if you go ahead and fill that bucket a little bit more and more intentionally, like the exercises we mentioned, you're more than likely going to be able to fill it in a stronger and more complete way than he's trying to do with the only thing he knows, which is running in circles. I have had students that have been jumping on a trampoline all day long. They have accommodated to that one movement. It means nothing more to them and their body doesn't need that stimulation anymore. But he does need moving in circles. He does need rolling on the floor. He does need other things. So, yes, expand that variety and continue to fill that bucket for them because apparently they can't fill it on their own.

>>Kate: Thank you so much. It's kind of fun to be creative and think about how can tasks still be accomplished even while we're in the middle of filling buckets.

>>Athena: That's right.

>>Kate: You can Braille while you're standing on one foot.

>>Athena: That's absolutely right. And standing is easier for children than sitting.