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109 - LiveWell Talk On...Occupational Therapy for Autism (Kendra Kregel, OTD, OTR/L)

episode 109

Ep. 109 - LiveWell Talk On...Occupational Therapy for Autism

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guests: Kendra Kregel, occupational therapist, Witwer Children's Therapy

Dr. Arnold:
This is LiveWell Talk on occupational therapy and autism. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint health - St. Luke's Hospital. April is autism awareness month. Today I'm talking with Kendra Kregel, occupational therapist at UnityPoint Health - St. Luke's Hospital, Witwer Children's Therapy Center. That's a long title. Kendra is passionate about providing early intervention to children with autism and their families. Welcome.

Kendra Kregel:
Thank you.

Dr. Arnold:
You're an occupational therapists, so you're a clever person because I think all occupational therapists are just clever people. They have clever solutions to common problems. I think you have to kind of have this clever streak and problem solving streak in you to be an occupational therapist. That's my experience. I've never met you before, but I can almost guess your personality type as far as that goes. So how did you tie that in, how did you become interested in autism, using occupational therapy to help autism?

Kendra Kregel:
So when I started in, I've always loved kids, always loved pediatrics. So I knew going into occupational therapy, I wanted to work with kids. And one of our kind of specialty areas is working with kids who have sensory processing difficulties. And that's, you know, taking in sensory information appropriately, interpreting it, and then having a motor response to it. And so a lot of kids that we see who have autism also have sensory processing difficulties, which make day to day activities more challenging for them. And so that really, you know, that's where we become a big component to the team when working with kids with autism, is that sensory piece and how it impacts their ability to do their day to day functioning skills.

Dr. Arnold:
Yeah. And I think probably should also clarify for some non-healthcare listeners, that occupational, although that is typically thinking of work or employment and occupation, but it's really activities of daily living and living life.

Kendra Kregel:
Right, exactly. And so for a lot of kids, you know, it's meeting their developmental milestones, their play skills, self-care skills, their ability to focus and attend at school, being a student. All of those things are their occupations. It's things that are meaningful to them, but also those things that you have to do every single day to be functioning and independent as possible.

Dr. Arnold:
So I guess in a way, this kind of surprises me, perhaps it shouldn't, but it makes me optimistic as well. So if someone has autism, usually a child. I mean, they live to adulthood, but usually you're dealing with the children. Things can get better. I mean, I guess I was wrong in assuming that you kind of have autism and you're kind of stuck with it. Explain that. I mean, tell me about some of the progress that you can see with someone they go from how they were when they met you to later on in therapy.

Kendra Kregel:
Yeah. So there's, I'm going to just kind of go off of a few kids in particular that I've had quite a lot of experience with. And that, you know, they're coming in, they might be younger, they might even be older, but they're having these huge meltdowns with day-to-day tasks. Where parents can't go to the store without them, you know, having a huge meltdown where they're falling on the floor, kicking, screaming. Going to school is harder, daycare, having these changes in their routine, and just every little task that they have to do every day is so challenging for them and for their family. So that's kind of when they come in. And then what we like to see when they're, you know, when they're ready to discharge walking out the door, is that they can do their day to day routines. Whether that is through compensations adaptations, that we help with the family, you know, changing the environment, changing parts of the activity demands. Helping them process through their coping skills and their ability to regulate themselves. So that the goal is that they can go through those day to day tasks without having those severe meltdowns without completely falling apart, and to still be able to participate in all those areas that they need to do every day, whether it's at home, in the community, at school.

Dr. Arnold:
So is it the sensory overload that precipitates some of that, and then you teach them how to deal with that intake? Kind of walk me back through that sensory perception.

Kendra Kregel:
So sensory, there's a lot of different areas within sensory processing. So you have what we call hypersensitive, where a little bit of sensory information coming into them is way more than maybe you or I would perceive that. And so they get very overwhelmed. And so they kind of fall apart really quickly. There's other kids who are more hyposensitive, where they need a ton more input, a bunch of input for them to even register it. So sometimes those kids are moving constantly, crashing into things, bumping into things. They might be really loud or up in your face, and they don't have as much of that personal boundaries, because they don't really know where their body is in space. So they're constantly moving to figure out where it is. And so, and then you have kids who go back and forth, and many kids do.

And then you have, you know, your five senses that most people are familiar with: sight, taste, sound, smell, and hearing. But then you also have a couple other sensory systems like your proprioceptive, or your body awareness systems, your vestibular or movement systems. And so any one of those could be hypersensitive or hyposensitive. And if one of them is off, it's going to impact how the whole body system works. And so if one is low, the others might be high, they might be low. And it's constantly fluctuating every day and every minute of the day. So one minute of the day you might be super low registering, and then after you do some activities, you might be more high registering. And so we kind of help the families and help the children to figure out, in certain moments, are there certain preferences. What are they trying to tell us through the behaviors they're showing us? And then how can we help reduce those behaviors by feeding that sensory need before it gets to the point of a meltdown or where they're constantly having to run around and they can't sit in their chair. How can we help feed kind of that sensory system to help that body feel good and be able to do those tasks? And so, that's where we help give the parents. And then if the child is old enough, we help with the child to be able to be more self-aware of the things that they need throughout the day to help keep their body feeling in a good place.

Dr. Arnold:
So let me just start with some basics. Let's say I'm an adult and I'm a parent. I'm a parent, I have a child that has autism. At what age can I consider getting them into Witwer to help them with their activities of daily living?

Kendra Kregel:
So really any age. We see through Iowa Medicaid, we can see up to age 21. We don't typically see kids that old here, we don't have quite the equipment probably for those super older kids. Some, I mean, depending on what their needs are. But really any age. A lot of the kids we see who have autism are usually, you know, they usually get diagnosed around two, three years old if they have it. And so really from there up until whenever, as long as the parents and the child have things that they want to work on and we can help provide them strategies for those things, any age really works. The earlier you get intervention, research has shown that the earlier that they receive interventions, the better the outcomes are and the quicker that changes happen many times. But you know, it's really, whenever the family feels that they're in a place that therapy would be a good time for them.

Dr. Arnold:
Is there an age—That led right into another question then, is there an age where it's too late? Or is there always opportunity?

Kendra Kregel:
I think there's always opportunity. You know, with neuroplasticity and the brain's ability to adapt and change, we can always help provide strategies to the child and to the family to help support them and meet their goals and their needs. And if we can't do it, we help—you know, kind of through social work and other areas—we help try and facilitate what would be the next area to look at.

Dr. Arnold:
Now, do you—Okay, we're at our visit, what should I expect? And I guess, do you help me develop what my goals are? I mean, so as a parent, I might just be overwhelmed talking about sensory overload. I just might be overwhelmed and need someone to say: How is this going? How's that going? How can we, you know. Is that what happens? I mean, take me through that.

Kendra Kregel:
Yeah. So what would happen when you have an occupational therapy evaluation here at Witwer. It's about a two hour long process because we go pretty extensive and we try and figure out what are all of the problem areas that might be impacting this family and this child. So we usually start out with a very extensive past medical history and current history for the patient. And then we go into more testing of gross motor skills, fine motor skills, self-care skills, strength, visual motor skills. Then try and piece together: are there certain areas where, that are more challenging of those foundational skills that would be impacting the child's ability to do handwriting. So if parents are like: Oh, they're having difficulty with handwriting. We'll look at all of the bottom foundation pieces that have to be there in order to do handwriting.

Or for a kid with sensory difficulties. If they're having meltdowns, we'll look at how is their sensory system working in all these different environments? Whether we're looking at is their sensory processing impacting their ability to sit and attend and focus to do age appropriate tasks. Could it be that it's impacting their postural stability and their ability to sit in a chair, or are they constantly falling out of their chair, getting up and running around the room? Can they not even follow simple one to two step directions because they have to move or they're falling apart when things get challenging? You know, we kind of look at through standardized assessment and through skilled observation of what we're noticing with the child, and then talking through with the parents, this is what we're seeing. This is what you're reporting. And then if they don't have specific goals that they want to work on, usually by the time that we go through everything, they've thought of things that are interesting. But we can also, you know, help guide them through and support them as well. But it's very much, parents and the child are really the leaders of the team. And so if they have specific things that they want to work on, then that's what we want to focus on are those things. There might be other areas, but if the parents aren't concerned with those areas, that's okay. And it's really, the parents are the leaders of the team. And so we take their input into account for everything that we do in coming up with goals.

Dr. Arnold:
So if you're a child, you go to an occupational therapist, you need to spend the day with Kendra, come back, you improve. Is that something that has to continue on for their whole life? Is there maintenance therapy, or is this just a singular event, a treatment plan?

Kendra Kregel:
Yeah. So we like to use episodic care. And so that's kind of what best practice is. Where the family comes in, they have specific goals in mind of what they would like for their child or that the child has specific goals that they want to work on. And once those goals are met, if the family does not have any other concerns or goals, that is a great time to discharge. You know, all of our assessments are based on age appropriate development. And so if they're scoring within normal limits for their age, they're at what their peers are doing and parents don't have any concerns, that's a great time to discharge too. So it's not a forever thing. It's not meant to be a forever thing. But then, once you are discharged, that doesn't mean you can't come back. So we have a lot of families that, you know, the child and the family they're in a good place. They feel ready to just work on home programming at home and take, you know, taking a break or discharging. And then something comes up a few months later, or six months, a year later, they can always come back in for another evaluation and get more services.

Dr. Arnold:
Okay. I need to ask a personal question. How about sixteen year old daughters who do not have autism, but they have meltdowns with being hungry or tired. Can occupational therapy help them?

Kendra Kregel:
Yes.

Dr. Arnold:
Oh great, this is good news.

Kendra Kregel:
So yes, we can help with that. And actually sleep and feeding are also areas that we focus on a lot too. Even with kids with autism or without autism too. Because when your sensory system is impacting your day to day life, your sleep is also going to be impacted.

Dr. Arnold:
Right, right.

Kendra Kregel:
Because your ability to regulate yourself and modulate. And so a lot of kids who have autism also have difficulties with sleep. So we do have strategies that we can help provide the family to try and see if they help support their sleep. And same with food. You know, there's oral motor skill deficits that might impact feeding, but there's also extreme picky eating where a child maybe only has five foods that they eat, or they don't eat foods from all food groups. We can help support the family in expanding that food variety and helping establish mealtime routines and other areas within the whole feeding realm. We can help with all of those pieces as well.

Dr. Arnold:
Yeah. I have a friend, but their son who's grown now. But when he was little, he would just—He has autism, and Mac and cheese, they couldn't get him to eat anything else. I mean, he would just refuse. But you know, he'd eat it breakfast, lunch, and supper. You know, and just be happy as a Lark, you know. And so it was hard for them to not give in, because it made him happy. But also understanding that, okay, he can't eat Mac and cheese the rest of his life, you know. And so I remember they worked on that with him, and that was interesting. No, I think my teenage daughters' meltdowns are self-inflicted for the most part. Anyway, that's—I don't think they listen to these podcasts of mine. You know, their dad's not cool, so I shouldn't get in trouble. But there's occupational therapy, Witwer has so many facets to it, such an interesting clinical service line of the hospital. I mean, every time I learn about it, I learn something new. So what are the other services that Witwer provides for patients that may have autism? Children specifically.

Kendra Kregel:
We also have speech language pathologists who they help work on social pragmatic skills, social skills, their receptive, and perceptive language skills. So their ability to talk, say the words. Not only speak, but to know what they're saying, but also to be able to interpret what people are telling them. There's also voice and articulation, and just overall executive functioning skills for kids with autism that would benefit from any of those areas. We also have physical therapists, where if the child is falling a lot and has difficulty with balance and some strengthening things, and they're already being seen by occupational therapy and we feel that they need more support, you know, that is always an option for families. We also have a physical therapist who she is trained in pelvic floor for children and working specifically with incontinence. And so kids who are wetting the bed, she has a lot of strategies and also biofeedback I believe she uses with that, depending on if you're appropriate for that. That's also an opportunity that we have for families. We have a dietician on staff who's free service to any family or any child who's getting services, whether that's occupational therapy, speech therapy, or physical therapy. She is on staff and is there to help support families with their child's nutrition. And so for some of those kids who maybe they are only eating a couple foods, she's helping make sure that they're getting enough calories, they're hitting all of their macro/micro nutrients that they need. And if there are other ways that we need to get those in, whether it's different types of multivitamins, because maybe they won't take the Flintstones vitamin, she'll help kind of figure out: are there other ones that we can take instead? So, she's just a really good resource to help parents with.

And a lot of our kids who have autism also have constipation issues. And she also helps, you know, with those high fiber diets. And making sure that even with their limited foods that they will eat, help come up with different strategies and foods to help them pass along their bowels a little bit better. We have access to a social worker here that can help families with a lot of things. If it's transportation difficulties, financial concerns, needing emergency shelters, or social security, disability, support groups, respite care, any of those things that she would be a contact for the family. And then we also have a family counselor who's available if the parents would need that service as well. So there's a lot of opportunities here that we have for families.

Dr. Arnold:
Yeah, that is quite frankly just amazing. And now all of a sudden I have this kind of sadness for families with autism, that haven't met you guys. You know, you could see how your life could be a living nightmare and how you guys can make it better. I mean, kids are hard enough to begin with and let alone you throw autism in there. And I'm sure that just the stressors and the expectations and the disappointments, can really be improved by meeting you people. So how do they meet you? Can they just call up and get an appointment, or do they need a pediatrician to refer them? How does that work?

Kendra Kregel:
They would need their pediatrician to refer them. So all they would have to do is to call their primary care physician, express their concerns and ask for a referral. Whether that's for occupational therapy, physical therapy or speech therapy, you know, any of them really. Or all of them, if they have concerns in all of those areas, we would definitely love to get them in here. And so then once they have that referral sent over from their doctor, we'll call them and schedule an appointment and get them in for an evaluation and go from there.

Dr. Arnold:
Kendra, this is really great information. And I think, you know, I love doing these podcasts because you kind of discover these hidden jewels of the healthcare system in our hospital that you don't think about. And you guys Witwer are amazing, and I always enjoy having you on the podcast. Thanks so much for taking time. Again, this was occupational therapy with autism, Kendra Kregel, occupational therapist at UnityPoint, Witwer Children's Therapy. Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.