Use of Interactive Metronome Interventions within the diverse population of pediatrics.

CONGRATULATIONS!

• You have completed the IM Certification process.

• You have gained an understanding of how IM can help a diverse population.

• Get ready to learn more advanced applications of IM.

Applying Interactive Metronome to the World of Pediatrics

diverse unpredictableunforgiving

energetic creative stubbornvariety novel defiantirrational aggressive ritualisticstimulating clumsy disorganized

Common Q&A Leading up to the Development of PBP

• At what age can I begin to implement IM with a child?

• What can I do to motivate a child to do IM?• How long should IM sessions be with a

child?• Can I use Listening Therapy at the same

time as IM?• What should I do if a child begins to cry as

he doesn’t like IM?

Common Q&A Leading up to the Development of PBP

• Will IM help my child get off ADHD medications?

• How can I get my child to sit still for long enough to do IM?

• Can a child with a cochlear implant use IM?• How can I use IM to improve ocular-motor

stability?• Can I use IM in a group setting?

And thus, the concept of getting IM training ‘IN SYNCH’ with the needs of

pediatric providers was born…

Brainstorm 1: Who, What & Where do you IM?

1. What is the youngest child you have ever used IM with?

2. Where do you typically treat your IM clients?3. What key problems do your clients present with?

Give 3 examples1. _________________________________2. _________________________________3. _________________________________

4. List any secondary problems that you have identified while using IM.

5. What clients have NOT benefited from IM? Why do you think this was the case?

Areas Commonly Identified for Treatment

PHYSICAL• Tone• Range of movement• Endurance• Gross motor coordination• Fine motor coordination• Reflex integration• Posture• Environmental limitations• Vision impaired• Hearing impaired• Sensory-motor impairments

Areas Commonly Identified for Treatment

COGNITIVE LINGUISTIC• Learning disabilities• Delayed processing• Auditory processing delays• Language processing delays• Memory impairments• Attention to task• Organizational skills• Poor insight/judgment• Decision-making skills• Following directions• Delayed working memory• Poor sequencing• Ability to comprehend technology

Areas Commonly Identified for Treatment

EMOTIONAL

• Anxiety• Self-esteem• Sense of self• Depression• Lability• Irrational fears• Attitude

Areas Commonly Identified for Treatment

BEHAVIORAL

• Passive• Defiant• Aggressive• Controlling• Agitation• Self-obsessed• Ritualistic• Self-stimulating• Inability to attain/sustain

eye contact

Areas Commonly Identified for Treatment

SENSORY• Sensory-seeking• Sensory-avoiding• Visual sensitivities• Tactile sensitivities• Auditory sensitivities• Olfactory sensitivities• Gustatory sensitivities• Vestibular sensitivities• Body-in-space awareness• Internal drive• Impaired modulation skills• Impaired behavioral regulation• Inability to attain/sustain a ‘ready alert state’

Areas Commonly Identified for Treatment

NEUROLOGICAL• Developmental delays

– genetic• Developmental delays

– environmental• Developmental delays

– acquired

Maximum Weightage with IM (child led!)

Use of an X-RayVest & Pinto Beans to Give Deep Pressure Input

IM Cave Providing Safe Environment

Blending Oral Motor Sequencing Task with Bilateral Upper Extremity Control

on a Hand Trigger

Head & Neck ROM to the Beat

Oral Motor - Tongue ROM

Chewing In Sync to the Trigger & Beat

Strategies to Modify IM

IM student squishing bugs to a consistent interactive beat.

• As your learning foundations develop - start thinking about modifications to IM that will facilitate activity application to specific patients.

Brainstorm 2 – How are you using your IM?

1. List 3 activities that you feel blend well with IM treatment activities.

2. What professional attributes do you bring to your IM sessions that help enhance activities?

3. List 3 items that are useful to have on hand when applying IM to the pediatric population.

4. What is your best advice to a co-worker when using IM with the pediatric population?

5. What areas do you find most challenging when using IM with the pediatric population?

Modifications – Environmental

As you set up your treatment area for each individual, consider :– Size of room/space– Seating options– Lighting options– Available wall space– Available floor space– Storage for small/large

items

Sample Pictures of IM Room with Desktop Computer (Clinic

Setting)

Desktop IM Set-up in aHome Setting

Portable IM Unit with Use of Rolling Carts

Portable IM Unit with Use of a Rolling Computer Bag

Modifications – Applying IM to Your Treatment

EnvironmentEmily• Emily is an 8 year old child with a diagnosis of

“handwriting difficulties.”• She comes in for her regularly scheduled one-hour

OT session. • She is working on

– proximal stability (trunk control) – bilateral coordination– fine motor skills– visual attention to task

Treatment Sessions May Include These Activities:

Treatment Minutes

Reach and place activities while sitting on a therapy ball 10

Rolling across the treatment mats holding a ball overhead 5

Jumping-jacks, superman, pretzel rolls, dance and freeze games 10

IM exercises (B hands, R hand, L hand with reference tone) 15

Eye-tracking activities in supine with suspended ball 10

Fine motor activity (puzzles/ker-plunk/jenga) 10

Modifications – Applying IM to Your treatment

EnvironmentJOHN• John is a 3 year old boy with a

diagnosis of developmental delays. • Scheduled PT session of 30 minutes

duration.• Fleeting attention, quick to quit.• Goals include being able to:

- climb a flight of 5 stairs - attain half-kneeling stance - being able to pick up items from the floor

with stand-to-squat stance- kick a ball with his right foot

Treatment Sessions May Include These Activities:

• *As proficiency and tolerance to IM improves, start to increase the minutes of IM used in each session.

• Get in as many IM repetitions as you can while presenting the just-right challenge.

Treatment Minutes

Crawling up an inverted wedge and crashing onto mats 2

Supported half-kneeling while hitting suspended ball 2

Throwing beanbags at target and picking them up in supported squat-to-stand transitions

2

Kicking playground ball at bowling pins 2

IM in supported sitting with PT, hand-over-hand 2*

Repeat activity sequence up to 3 times.

Modifications – Sensory Considerations

• Lighting• Space• Sounds• Surfaces• Scents

Modification Kit

• Colored Tape• Self-adhesive Velcro strips• Non-slip matting• Various textured/sized

balls• Visual timer• Balloons• Bubbles• Stickers• Washable tattoos• Munchies• Chewables• Suckables

• Variety of switches/triggers• Cable splitters• Portable speakers• Variety of headphones• Soft squishy bug toys• Selection of small kids toys• Silk scarves• Ball on a string• Flashlights• Word/Letter/Picture flash

cards• Soft knit gloves• Sanitizing hand wipes!

Larger Items to Consider

• Hopper or rebounder trampoline• Bosu• Balance disc• Therapy ball• Aeromat or large foam cushions• Weighted balls (3-5#)• Mop handles• Weighted items (i.e., vest, blanket, bean bags)• Portable sports equipment (i.e., baseball bat,

hockey stick, etc.)• Portable floor mat

JAKE - Sample Goal Analysis

• “OT and Speech Therapy to address difficulties with handwriting and reading”

• Change to “Occupational Therapy evaluation and treat, Speech Therapy evaluation and treat, diagnoses: lack of coordination and developmental language delays.”

• 7 years of age, struggling with academics, an active child, below peer level developmentally.

Difference in Learning Style

• Attention to task• Reading / writing skills• Disruptive influence on classmates• Gross and fine motor skills• Balance• Visual motor skills• Reflex integration• Language delays• Sensory-motor integration skills

Treatment Plan: OT and ST two times per weekPT referralDevelopmental Optometry referral

Jake’s Goals

Within six months (5/08), Jake will:1. hold a pencil with a right-handed

modified tripod grasp (85% of written tasks).

2. trace infinity pattern independently with consecutive intersections for 20 reps.

3. throw overhand 5ʼ at target with right upper extremity 5/8 times.

4. demonstrate shoulder girdle strength sufficient to wheelbarrow walk 30 with support at lower legs.

5. read 10 basic site words fluently.6. follow 2-step verbal directions timely and accurately.

Brainstorm 3 – Consider Each of the Six goals

Brainstorm the following aspects of each goal:1. What skills are required for goal

attainment?2. What activities/exercises could you use to

work toward achieving these goals?3. List three modifications of the use of IM to

achieve goal attainment.4. How could you set up these activities to

mask the challenge of the activity?

Use of giant knitting needle to practice tripod grasp onto trigger.

Maneuvering colored ballsinside infinity loop to the rhythm of the metronome beat

Goal #1

• Attention to task• Bilateral integration (praxis)• Gross and fine motor skills• Body-in-space awareness (proprioception)• Kinesthesia (movement/motor planning) • Sensory-processing skills

(visual/auditory/vestibular/kinesthesia/proprioception)

• Phonological awareness• Expressive/receptive language

Suspended hand trigger placement working on grasp/ release and visual control

Use of office footrest as a slant board to increase anterior pelvic tilt and postural control

Goal #2

• Handwriting training• Postural alignment and

strengthening• Sensory integration training• Visual-motor training• Reflex integration training• Gross and fine motor skills

training

Tracing infinity loop with trigger placed at center to mark the beat

Use of hoop to define Motor plan for overhand throw

Goal #3

• Use of hoop to address boundary for movement with overhand reach

• Use of large/novel items to reinforce modified tripod grip• Visual motor applications during IM• Balance applications during IM

Overhead swing with bat to trigger, within the context of sport, to increase motivation to challenge

Turn taking to increase focused attention to task

Goal #4

• Use of child-specific interest (i.e., sports)• Use of turn-taking games to increase attention to

task• Allow child to set up components of the activity

Reference Point

• Now, for your own reference, jot down 3 sample goals that you may have for an individual using IM.

• Consider how IM can fit in with “the whole picture” when planning discipline specific treatment.

Calming down after IM session

Infinity Loop with IM

The Ultimate Balance Challenge

Going Backward to Come Forwards

Assessing the Right Pace

• Strategies to customize your approach with the pacing of IM activities include:

- Adjusting the tempo- Adjusting the duration of IM tasks- Adjusting the frequency of IM tasks- Supplementing IM tasks with age-

appropriate incentives- Monitoring IM participant for signs of

distress or fatigue

Signs of Distress/Fatigue/Overload

• Oral motor overflow• Sweating• Changes in skin color • Marked increases/decreases in postural control • Aversion to sensory input • Increases in motoric output • Changes in respiratory rates • Increased fidgeting behaviors • Increased vocal distress • Increased verbal distress • Decreased attention/engagement

IM Activity with Comfort Accommodations

IM Activities with Graded Force Pressure Accommodations

Riley Completing Step-up with IM

Riley Completing Upper Body Visual Challenge During Step IM Routine

Child Led challenge with IM-HOME

Motivational Strategies

Challenges• FACT: Most children do not

inherently want to work.• FACT: Most children do not

like to be told what to do.• FACT: Most children have

short attention spans.• FACT: Most children do not

like to engage in “non-preferred” activities.

Motivational Strategies

Assets• FACT: Most children want to have fun.• FACT: Most children enjoy novel activities.• FACT: Most children seek approval and success.• FACT: Most children enjoy variety as well as

routine.

Treatment Planning

• What are their likes/dislikes?• What are their “quirks”? • What is their “speed”?• What are their parameters to

sensory/motor/behavioral triggers?• How well do they respond to change?

Strategies to Motivate Children During IM

• Ask them!• Outline/structure • Pre/post IM activities

to arouse/calm• “Guesstimating”

scores• Reward incentives.• Parent/caregiver

involvement

Pre-IM Activities

Vestibular: Facilitate a ‘ready-alert-state’ through movement.

• Access• Specific training re vestibular input to cns output• Reward incentive• CAUTION you need to be

in control/set parameters

Pre-IM Activities

Balance activities: to increase focus

• Smaller base of support

• Unstable surface • Alert CNS • Activate major

muscle groups

Pre-IM Activities

Visual-motor: Alert balance, muscle energy and hand-eye coordination skills.

• Rolling a ball in sequence on a tray• Tapping a suspended ball with index

finger• Hitting a suspended ball with a bat• Tapping a suspended balloon• Rolling marbles into targets

Popcorn & IM in the Great Outdoors After Dark…

Increased Focus & Attention with Novel Play

Combined Preferred Activities with IM

Hitting Foot Trigger with Baseball Bat

Bribery & Distraction

Equipment to Enhance Pediatric Performance

Useful Equipment to Have ‘In Your Box’

• Velcro• Multiple Triggers• Specialized Triggers• Colored Tape• Weighted tape• Fidget items• ‘Quick fix’ items• Reinforcement items• Age-appropriate toys

and games

On the Stool & On the Beat

Busy Fingers

Animated Speakers

Age Considerations

“At what age can I effectively introduce Interactive Metronome activities into my treatment programs?”

My inspiration…Emma….

A presentation at the IM Professional Conference 2007 My thanks to Lucy Barlow, MED. SLP-CCC

From The Language Learning Center, Kingsland, Georgia.

Why IM for Emma?

• This provider’s prior observations of the success of IM with cross-hemisphere difficulties

• Neuro-rehabilitative aspects of IM• Prospect of stimulating hemispheric

communications• Motivation to achieve best possible

outcome for patient

IM Modifications with Emma & Lucy Barlow (SLP)

Emma…A Mother’s Story

Reyna

• 18 month year old• Feeding disorder in infancy• Sensory integration issues• Taste – texture –

temperature variances• Spitting up – gagging -

vomiting during meals• Extensor posturing• Breath holding• Decreased oral exploration

and play skills• Speech delays

Clapping to Music

Using Video Feedback

Wonderful Reyna

Lab 1 - Addressing Use of IM with Low Level Clients, Infants & Young Children

• Demonstrate 3 whole body movement techniques suitable for this client group.1. ____________________________________2. ____________________________________3. ____________________________________

• Consider environmental barriers that may hinder IM success with this client group.1. ____________________________________2. ____________________________________3. ____________________________________

• Practice 3 modifications in positioning for this client group.1. ____________________________________2. ____________________________________3. ____________________________________

Lab 1 - Addressing Use of IM with Low Level Clients, Infants & Young Children

• Practice using 3 modifications to switches for this client group.1. _____________________________________________2. _____________________________________________3. _____________________________________________

• Incorporate 3 motivational activities to engage attention for this client group.1. _____________________________________________2. _____________________________________________3. _____________________________________________

Lab 2 – Addressing the Use of IM in a Group Setting

• Practice turn-taking with IM involving 3 or more group members.• Set up an activity circuit using IM as a component task.• List 3 benefits of using a group IM setting.

1. ____________________________________2. ____________________________________3. ____________________________________

• What additional equipment do you need in order to complete group IM?1. ____________________________________2. ____________________________________3. ____________________________________

Lab 3 – Incorporating IM into Your Discipline Specific Functional Goals

• List 3 goals that you may typically work on with the pediatric population.1. _____________________________________________2. _____________________________________________3. _____________________________________________

• Review the benefit of IM use in achieving those goals.1. _____________________________________________2. _____________________________________________3. _____________________________________________

• List 3 custom IM activities for each goal. 1. _____________________________________________2. _____________________________________________3. _____________________________________________

Marketing IM with the Pediatric Population

1) Budget…. 2) Target group3) Treatment setting4) Payment sources 5) Referral sources6) Advertising7) Local competitors?8) Prepared information 9) Intake process10) Budget …..

Communicating with Other Healthcare Professionals

• By example• By results• Literature• In-services• Peer review/case

studies

Communicating with the General Public

• Community sources articles/advertising

• News-media interviews• Word-of-mouth• Literature flyers• Free IM screening• Parent-friendly inservices

Communicating with a School Team

• Assess school routines, teaching style and student need

• Teacher in servicing classes• Use of empirical data,

academically relevant case studies to tune in with each teacher’s perception of need

• Lead by example – impact by performance

• Market also to grant writers and parent-teacher organizations to raise funds for IM programming

Workshop

Consider the following areas as they apply to your practice and try to give one example of each:

1. Whole body movement with IM___________________________________________________________

2. Deep pressure play with IM___________________________________________________________

3. Music with IM___________________________________________________________

4. Adaptations for positioning with IM___________________________________________________________

Workshop

Consider the following areas as they apply to your practice and try to give one example of each:

5. IM to increase auditory attention ___________________________________________________________

6. Sensory-tactile interventions with IM___________________________________________________________

7. Role playing with IM ___________________________________________________________

8. Fine motor coordination with IM___________________________________________________________

9. Core strengthening exercises with IM___________________________________________________________

Workshop Sample Answers

1. Whole body movement with IM– Firm pressure through child’s shoulders– Rolling side to side in a sheet– Rocking child back and forth in your lap

Workshop Sample Answers

2. Deep pressure play with IM– Use of resistive band to access triggers– Use of weighted blankets during IM activities– Having child lie under a mat or

cushions/beanbag during activities

Workshop Sample Answers

3. Music with IM– Strap jingle bells to moving extremity (i.e., arm

or leg, during clapping/stamping activities)– Shaking maracas/beating a drum to the tempo

beat– Dancing from foot trigger to foot trigger during

paced rhythmical music

Workshop Sample Answers

4. Adaptations for positioning with IM– Holding child on your lap– Sitting in a beanbag– ‘Hiding’ under a table

Workshop Sample Answers

5. IM to increase auditory attention– Turn taking on the beat– Turn taking to different repetitions (i.e., you hit

5 times, another child hits 3 times, I will hit 1 time)

– Answering questions of increasing difficulty during IM (i.e., What did you have for breakfast this morning?)

Workshop Sample Answers

6. Sensory – tactile interventions with IM– Use of speakers in place of headphones– Use of soft gloves when clapping to dampen

touch stimuli– Use of a toy to manipulate the trigger (i.e., a

soft play hammer)

Workshop Sample Answers

7. Role-playing with IM– Sitting in a tub ‘boat’ and rowing by slapping

trigger hand against the side– Pretending to be a fairy princess waving her

wand and ‘tapping’ a giant pumpkin– You be the IM teacher then I will be the IM

teacher…what shall we do?

Workshop Sample Answers

8. Fine motor coordination exercises with IM– Isolated digit tapping onto hand trigger, with

use of finger puppets– Holding manipulative with specific grip and

tapping hand trigger– Squeezing hand onto hand or foot trigger to

strengthen grip

Workshop Sample Answers

9. Core strengthening exercises with IM– IM sitting on ball– IM sitting on t-stool– Reaching overhead and towards feet

sequentially to hit trigger targets

Review

Are we there yet?

Exam

We know you’re tired…but…da-da-dahhhh

Exam Review

1. What is the recommended time-frame for IM interventions with a pediatric client?a. 2 weeksb. 15 weeksc. 2-15 weeksd. It varies, dependent upon the individual

treatment plan.

Answer: d

Exam Review

2. True or False : An infant of 18 months is too young to participate in a modified IM program.a. Trueb. False

Answer: b

Exam Review

3. What signs would indicate distress during IM activities?a. oral-motor overflow, focused attention,

sweating, breath-holdingb. increased fidgeting, sweating, pacing,

improved articulationc. oral-motor overflow, sweating, decreased

attention, increased verbal agitationd. increased fidgeting, decreased attention,

improved breath control, skin pallor

Answer: c

Exam Review

4. True or False: You may introduce IM tasks gradually, then build up a routine so that the child comes to expect IM as part of their session - just as they would any other of your discipline-specific activities.

a. Trueb. False

Answer: a

Exam Review

5. True or False: Group treatments may be used for all IM students.

a. Trueb. False

Answer: b

Exam Review

6. The following may be used as motivational strategies with the pediatric population:a. verbal praise; stickers; preferred activitiesb. bubbles; high five; rest breaksc. turn taking; edible treats; control choicesd. all of the above

Answer: d

Exam Review

7. The following are good choices to help calm a student:a. decreased volumeb. a large work spacec. light pressure during activitiesd. bright lighting

Answer: a

Exam Review

8. True or False: Multiple triggers can be a useful tool for IM modifications: True or False?a. Trueb. False

Answer: a

Exam Review

9. Which of the following can you incorporate into your IM sessions?a. musicb. whole body movements/rhythm experiencesc. auditory processing gamesd. all of the above

Answer: d

Exam Review

10. Adding specialized (pediatric) IM programs to your practice can offer you:a. increased referral baseb. teaching opportunitiesc. career developmentd. all of the above

Answer: d

Q & A