Ep. 65 Early Intervention: The GAME Approach

Can a home program alone replace clinic-based therapy? This week, we put it to the test with a randomized controlled study on the GAME intervention (Goal, Activity, Motor, Enrichment) for toddlers with developmental delays. We discuss the steps of the GAME intervention, supportive parent coaching, and how you can implement this in your own caseload tomorrow. Plus, Michele shares about a rough consult, Lacy tries something new with student groups, and there's a tiny dragon too! 

We share our own thoughts in the Research Review and encourage you to read the original articles too.

Gündoğmuş, E., Bumin, G., & Yalçın, S. S. (2024). Effect of Early Intervention on Developmental Domains and Parent-Child Interaction Among Children With Developmental Delay: A Randomized Controlled Study. The American journal of occupational therapy: official publication of the American Occupational Therapy Association, 78(6), 7806205110. https://doi.org/10.5014/ajot.2024.050706  

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Transcript

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SPEAKER_00 0:00

We know that the earliest years for our littles hold the biggest opportunity to change their future. And in this podcast, we're reviewing an early intervention program that really helps our kids to thrive. Welcome to Ideas of Play, where we discuss pediatric research to help you apply the ideas to your daily practice. Each week, we'll review evidence-based ideas to make you a better therapist. I'm Dr. Michelle Alanis, Director of Pediatrics at a Rehab Hospital in Southern California, and with me is my good friend and former coworker, Lacey.

SPEAKER_01 0:39

That's me. I'm Dr. Lacey Wright, an occupational therapy professor in Kansas City. We're pizzo tees who love research and making it fun. We've helped thousands of therapists just like you to become more informed, more playful, and more effective in their sessions. This week we'll be talking about an early intervention approach called GAME. But first, our favorite segment, nailed it or failed it. In therapy sessions, you'll have these moments where you absolutely nail it. And those times that you spectacularly fail it. We want to live in an atmosphere of growth, so we celebrate both. Michelle, you are up this week for a failed it.

SPEAKER_00 1:25

And spectacularly failed it, did I? Sometimes it can be kind of hard to find failed it's because you know, mostly a failed it is like you got fourth place. Like, not bad, but you didn't make the podium. But this one was like last place. So I was consulting on a case. This is a kiddo that's being treated by someone else and they're having a really hard time. So I was brought in to see if I can like suggest some sort of useful thing to do with him. And it's a a boy with level three autism, high, high anxiety, and I think probably OCD, just based on what I saw. And I go into the session like fully prepared. I have the environment set up. I'm like really ready to just like join in his world and imitate him and connect with him and then be able to do some work with him because this is like my sweet spot, right? Doesn't that kind of sound like a kid that I would thrive with?

SPEAKER_01 2:21

Yes, this is totally your kind of kid. If I had this kid, I would bring you in for support as well.

SPEAKER_00 2:27

Yes, exactly. So here I am, like expecting that I'm gonna nail it. And instead, this child was like just eloping the whole session, like trying to run, like at first I just followed him because I was like, well, what's the worst that can happen? Well, you know, we're in the clinic. Like, where are we gonna go? Because he left like the gym space, but then he was like going into other treatment spaces and then he was like trying to climb on things or like getting in where other people were treating. So like it was not a safe situation. So I couldn't let him do that. So now I'm in the inevitable position of like, oh my gosh, I have to like physically block him, which I never want to get into a position where I'm either having to physically block a child or like physically guide a child where they're escalated. But it's like, oh my gosh, he's not safe. What's happening? So I eventually like get him back to the treatment space, and he's just running and like upset and anxious. And I I mean, I think even just having a new person in the space was freaking him out. And then mom's there because she came in because she was so excited that this expert was gonna come in and help, and then mom's super anxious, and then like their energy is like feeding off of each other, and it just went terrible. Like, at no point did it remediate, and I was able to do anything with them. And um, I just left feeling so defeated because I could see the defeat in the mom's eyes. Because she was really looking for some hope. Yeah, you know, so many times families come to us, and that's more than anything. They need us to be the givers of hope, to support them in their resiliency, to encourage them and say, like, you got this, it's gonna get better, like we're gonna find a way. And to come in with that hope and leave defeated, uh, it just like broke my heart.

SPEAKER_01 4:16

Oh, that sounds really hard. You come in hoping to have a great session offer all these ideas, and it's a worse session than what would have happened without I hadn't have been there. Yeah.

SPEAKER_00 4:27

Yeah. I mean, ultimately, I think that the therapist has established rapport with him. And so I've just been trying to like work with the therapist and give some ideas and um, and really they don't even need my ideas. They're great doing fantastic work with him. Um, so thankfully, you know, they have been able to like come alongside this family and give them support. But I, on the other hand, total failed it.

SPEAKER_01 4:53

Well, at least you know a little bit more about the kid, so you can provide maybe even more support from a distance.

SPEAKER_00 5:01

I actually think the takeaway from this is that the therapist is like, oh, okay, nobody knows what to do. All right, I got this. Yeah. Because there is always that feeling of like, would this child do better with a different therapist? I know a lot of people have felt that way, especially newer ones. And so just seeing like, okay, someone with a lot of experience and skill with this population was a disaster. Like, okay, can't be worse than that.

SPEAKER_01 5:25

Yeah.

SPEAKER_00 5:26

Yeah, I think I'm more empowered the therapist than anything, which is a good thing. Yeah, great. Okay, Lacey. Lift us up. That means you're here for the nailed it. Tell us what went well.

SPEAKER_01 5:36

Okay, Michelle, it is almost the end of the semester, and I am excited for the summer, but I'm starting to reflect back on things that went well, things I could improve for next year. And I'm so excited that I tried a new version of putting students into groups. Yes, we talked about this. Yes, episode 16 about keeping them in the same group all semester and strategically grouping them, and it went so, so well. I'm gonna keep it for next year. Oh, that's exciting. Yeah. So I had groups of about five students, and the study we looked at, I think they grouped them according to like their Clifton strengths. I chose to group them according to their Kolb's experiential learning style. Like some students like to jump in right away, some like to reflect first and then try things. So it was a mixed group with at least one student from each type of these Kolb experiential styles. And what I saw in class was that they were all engaged. Some students got the conversation started while others reflected and then added in later. Wow.

SPEAKER_00 6:55

And did you ask them what they thought of it? Because I know one of the things when we had that episode, we were saying is like if you got with a group that you didn't like or didn't vibe well with, and then you're stuck with them for a long time.

SPEAKER_01 7:08

I told them that this was something I was trying at the beginning, but they didn't remember. So at the end, when I reminded them, it was almost like a reveal of how I put the groups together, and they were like, Oh yeah, I'm whatever on the Kolb's experiential, and I was more the reflector, and they were starting to put it together and said that they really enjoyed working with the people in their groups.

SPEAKER_00 7:29

That is awesome. You really did nail that. Now, do you guys do the Kolb's like K-O-L-B? What is Kolb? It's like a learning style.

SPEAKER_01 7:38

Yeah, it's a test that they take in the first semester, and then I took that info with the groups when I put them together in their second semester. So the Kolb's experiential learning loop talks about how people have an experience and learn through it, and it goes round and round, and people are comfortable in different parts of the phases. We went through four different cases in these same groups throughout the class. Um, but it was more seeing how some people are just more comfortable in different areas of the learning cycle and the process. And I wanted to see how that whole process could come together with a group of students.

SPEAKER_00 8:16

So you put together all the little key ingredients so that they would work together and you made this amazing group. Mm-hmm. Yes.

SPEAKER_01 8:23

Great groups. It worked really well. Definitely gonna do it again next year.

SPEAKER_00 8:28

Nice work, Lace.

SPEAKER_01 8:31

Our next segment is the research review, where we translate the latest pediatric studies into practical therapy strategies you can implement tomorrow. This week, Michelle is reviewing an article on early intervention. What do you have?

SPEAKER_00 8:46

All right, Lacey. This week's journal article is titled The Effect of Early Intervention on Developmental Domains and Parent-Child Interaction Among Children with Developmental Delay, a randomized controlled study. So it's basically like an early intervention study for kids with developmental delay. It's so good.

SPEAKER_01 9:06

Well, I can't wait. And being a randomized controlled study, there's not a lot of those in OT.

SPEAKER_00 9:11

So no, this came out of Turkey, which is super cool. It was published in AJOT. I chose this article for two reasons. One, because we have an early intervention program that I'm actively working on um improving and investing in. So I'm always looking for ideas for that program. And number two, one of our playmakers, Frederica, asked for intervention for three to six-year-olds with special needs. Now, this is a little younger than three, but I still thought it was really applicable. Great. Let's get into it. So a little background here. The intervention that they were trying out is something that's already well established with kids with CP. And I was just dead as I was reading this because it seems like all roads go back to Iona Novak. Oh, I know. She's the best.

SPEAKER_01 9:57

She's everywhere.

SPEAKER_00 9:59

Before we started this podcast, I didn't even know Iona Novak, you know, because I don't do a lot of work in CP. But now, ever since we had her on the show and we reviewed her article, I feel like, oh my gosh, she is everywhere. She's done so much interesting work. So, anyways, the queen of CP research. She absolutely is, and just super cool. So they created this intervention, and game stands for goal activity and motor enrichment intervention. Game intervention. Okay.

SPEAKER_01 10:30

So they're not actually playing games. I was hoping for a game. I love games.

SPEAKER_00 10:34

No, they're not actually playing games. They're just trying to think of a clever way to help us remember the name of this intervention. You know, it's like the other the other week when we did maps. Yes. MAPS. Exactly. So this week we're doing game. And it's essentially what it is, is it's an intervention that has all of those principles that you would think of coming from Iona, where you're collaborating with the parent and the child to set goals and then you're doing high-intensity, context-dependent training, right? Yep. That sounds like her. So they took that intervention and they were like, how could we apply this to just kids with developmental delays? Because that's what we get a lot when we're dealing with early intervention. They haven't been diagnosed with something per se. And so they adapted it for this new population and they designed a really cool study.

SPEAKER_01 11:25

Okay. So this program was really good with CP and they're looking to expand it across more diagnoses.

SPEAKER_00 11:33

Yeah, they wanted to see like if we did this with other kids that do not have CP, would it also be effective? But they added their own flair to it. Okay, cool. So they set up this randomized control study, which means that there's two groups going head to head. They were randomly assigned to the group, and we're gonna see which one comes out on top. One of my favorite types of studies. And they recruited 70 kids, 7-0. That's a lot of kids for OT research.

SPEAKER_01 11:59

Good, yes, nice check. Lots of kids. We're off to a good start.

SPEAKER_00 12:04

Lots of kids. It's a high-quality intervention design. And the two groups that they designed were one of the groups is the game intervention plus a home program. And then the other one is just home program only. So I thought this was really interesting because they're like, if we just like train parents to implement stuff at home and help them to do a really good job of it, is that good enough? Or do we need to actually see them in the clinic as well and work with them every week? So that's the head-to-head that they set up.

SPEAKER_01 12:34

Okay, super cool. And what outcome measures did they look at? How did they measure and determine the winner?

SPEAKER_00 12:41

A lot of different ways. They have the infant toddler sensory profile, classic. They use the Bailey, another classic kind of motor skills. You know, it goes across all five domains of development. They also added in the ages and stages questionnaire. Are you familiar with this?

SPEAKER_01 12:56

Yeah. Ages and stages, classic, but the difference is it's more of a screening tool, whereas the other two are assessments. So this were just looking at development across five different domains to see if they need to be further assessed.

SPEAKER_00 13:09

That's right, Lace. And then they also had another test which I had never heard of before, and that is Picolo.

SPEAKER_01 13:18

Picolo.

SPEAKER_00 13:22

It stands for parenting interactions with children. Checklist of observations linked to outcomes. And essentially it's like they do a 10-minute video recording of the parent playing with the kid, and then they rate the parent and child based on like affection, responsiveness, encouragement, and teaching. Ooh, I like this.

SPEAKER_01 13:43

When you can videotape and go back and objectively review something, especially for a parent, a lot of times we're getting input from parents, but if you're observing and rating that interaction, this sounds like a really cool tool.

SPEAKER_00 13:57

And then the final thing they did was they actually had a compliance checklist where they were basically having parents like document that they were doing the home program. So I was really interested to see like what percentage of compliance did they have? Because I find that to be really problematic in my practice.

SPEAKER_01 14:14

Uh-huh. Yep, for sure. And what does their checklist look like? Maybe if I rearranged my checklist, it could be better.

SPEAKER_00 14:23

Yes, we'll have to ask them for their checklist because it wasn't published. So that was the outcome measures they were using. And as a reminder, there were two groups. There was the game intervention plus a home program, or there was home program only. Which one do you want to hear about first?

SPEAKER_01 14:39

Oh, I want to hear about the one with the intervention, also.

SPEAKER_00 14:42

Okay. Okay, okay. So the intervention was one hour a day, twice a week for 12 weeks. So it's 24 hours total of intervention, very consistent with like kind of how we do things. And the parents were an active part of the intervention. They weren't just sitting in the waiting room. They were like in there learning the whole time.

SPEAKER_01 15:01

That was my question. Because it is a parent intervention, right? Like you're looking at the relationship between the child and the parent.

SPEAKER_00 15:08

Or no, I'm way off. No, it's not necessarily a parent intervention. It is an intervention, and it involves the parent also learning how to interact with their child and learning how to follow through with it at home. Because as you'll remember with Iona, high frequency, what did she say? You gain what you train. So I think the idea is like having the parents involved because they're also going to do it at home and transfer it into that home context.

SPEAKER_01 15:35

Okay. So they're there to learn the intervention and hopefully generalize it and practice it more with that home program. Exactly.

SPEAKER_00 15:42

Okay. So the parents are there and the game intervention has six different parts to it. But really, two of the things go together parent education and home program. So it's really only five pieces. It's going to sound like a lot, but as I'm telling them to you, you're going to be like, oh yeah, check, check, check. That's what we do in practice. So it sounds like a lot, but we've got this. Okay. I'm ready. All right. The first step of it is that goal-focused, intensive motor training. So collaborating with the parents, like what goals do they want to meet, and setting realistic goals. That's always an important part of it. And then providing this intensive motor training on that skill.

SPEAKER_01 16:21

These are the parts that sound very Iona Novak. I feel like these are probably key ingredients in almost all of her interventions because she believes in it so strongly and for good reason.

SPEAKER_00 16:31

For sure. For sure. The second part is environmental enrichment. And this is really like based on ASI principles, where you're creating play environments that facilitate the skills that you're trying to get, right? Like you're really enriching the environment. You're trying to bring in different challenges so that you're targeting the different skills that you're trying to develop in the child and coaching the parents on how to do that at home as well. All right. And the third one? The third category is implementing sensory-based activities. So this is where I feel like this is the game intervention that Iona Novak was part of, but they're adding in this extra element of air sensory integration. You know, we talked about how they're trying to enrich the environment, but they're also trying to bring in these sensory-rich activities that are child-centered and at the appropriate level for the child so that they can get that kind of just right challenge.

SPEAKER_01 17:30

So making sure that they're ready to receive the intervention, that they are taking it in, it's a just right match for the child and the family.

SPEAKER_00 17:39

Yeah, and they're getting that optimal level of participation and challenge. Oh, okay. The fourth category is adding in cognitive-based activities. And this is where they're trying to incorporate things that target like attention and memory and visual perception and executive function skills. So they gave examples of things like using memory cards or like matching shapes. So just incorporating in these cognitive-based activities along with the sensory-riched environment and along with the high-intensity training.

SPEAKER_01 18:52

So we've got make a goal, intensive motor training, environmental enrichment, sensory-based activities, cognitive-based activities. This makes sense. I get it, but did they say like what they actually do in a session and not these categories of activities?

SPEAKER_00 19:09

They sort of did. I actually think they did a pretty good job. They don't have a table like some studies do, where they give a sample treatment plan, but they did say like session one, the therapists perform basic SI activities based on the sensory profile. Session two. And so they go, they actually break it down by session and talk about how to like add these things in as you go along. Okay.

SPEAKER_01 19:34

So it sounds almost like a list of components that sound a lot like our regular therapy, but they're just outlining it nicely. And then they're combining it with a home program. Is that where we're going next?

SPEAKER_00 19:46

That's where we're going next. Yeah. I mean, I think this is very standard practice when you're working with kids, especially if you're coming from a Airs SI framework and they've just put words to it and operationalized it essentially so that they could test it in a study.

SPEAKER_01 20:00

Yeah, because I was looking for like some fancy new kind of intervention because it had the cool name. But I guess I'm just really reaffirmed that what I see as standard practice is good practice and worth being studied.

SPEAKER_00 20:14

Yeah, and I think it's standard practice for you and me, because we've been doing this a long time. But I think when you have newer therapists, a lot of times they're just doing one piece of this. So, you know, maybe they're just trying to do a lot of repetition, for example, of the task, or they're trying to make it a sensory-riched environment, or they're targeting cognitive skills. But this is like a more robust program where in the beginning they get a feel for the child. They're basically just doing SI and then they're starting to add in these layers. So it's like a delicious layered cake. Mmm, the full package. I want some of that cake. Yes. And the frosting on the cake is the parent education and the home program.

SPEAKER_01 20:55

Okay, let's go there.

SPEAKER_00 20:56

Okay, parent education. So this kind of goes along with the home program, but the parent education is really focused on three things. First, giving the child the opportunities to trial and error things. So this is a kind of very co-opy approach where you're working with the child. It's not errorless learning. You're actually letting them make mistakes and then helping them to problem solve to see like how they can fix it. And I think a lot of times parents just try to jump in and make it work instead of you know allowing the child to try to problem solve on their own a little bit. Yeah.

SPEAKER_01 21:30

So educating them, it's okay for kids to struggle and not get it the first time because it's part of learning.

SPEAKER_00 21:37

Exactly. I think this was the hardest thing for me as a new therapist was just learning to sit and watch someone struggle. It's still hard, actually. Then the second part of the parent education was focusing on how to use the things you have at home already. Like you don't have to go out and buy all new fancy things, like just using the stuff you have at home. How can you create and sustain effective play with your child? And then finally, encouraging skill development and providing like different activities to help them achieve their targeted goals. Okay. And then all of that informs this home program where they're expecting the parents to do a one hour a day, three times a week for 12 weeks. So that's a total of 36 hours of home programming. That is a big home program that's more hours than the actual clinic time. It is more hours than the actual clinic time. And the way they're facilitating this is like with phone calls and photos and videos from home and really trying to like coach the parent on each step of this and how they can. Do it at home with them.

SPEAKER_01 22:42

So it's not a checklist and they send them on their way. It sounds like there's a lot of support with it and probably accountability.

SPEAKER_00 22:48

A lot of support on it. And I think that it's an interesting model for the study because they were like, we're doing this really intensive home program, plus we're doing our more traditional clinic-based service. Is this service, like the clinic-based service, even needed if the parents are going to practice this much at home? And I think that's probably why they did the control group as a home program only to see like what does the clinic piece add, if it adds anything at all?

SPEAKER_01 23:15

It's almost like the home program is a given, but does the clinic boost it?

SPEAKER_00 23:20

Yeah. And I think if you're doing 36 hours of home programming, like that's a lot of home programming. It better be. Yeah, I know. Like, do you really need addition on top of that?

SPEAKER_01 23:29

So we have our clinic-based with all these great skills and activities, plus our big home program for the control group. Was the home program the exact same?

SPEAKER_00 23:40

So the key ingredients of the home program were the same. And they listed them all out very specifically. I thought they were kind of funny, actually. Like the first one is check if the parent has had a home program before and don't overload the parents. It's like that's like we're asking we're asking them to do an hour a day. Like, do they already have a home program from somewhere else? Like, can we kind of incorporate something with that? Like, don't overload them. And it's like, make sure the will the parents are willing to do what it is you're asking them to do at home. And if not, then suggest something else, basically. So it's like the the ingredients were pretty basic, funny things, but also like good reminders. Like it said, no more activities than six. It's like I thought six was a big number. I would say no more than three, but I guess if you're doing it an hour a day, you maybe need six.

SPEAKER_01 24:35

But you know, these are really good reminders. I think in the past I did not check in and make sure they were fully on board and if it was feasible and all the things. I just thought it was a given and they would do whatever I gave them. So I appreciate this checklist and remembering like, hey, we got to make sure the parents are just as much on board with the home program as what I'm thinking or hoping they are.

SPEAKER_00 24:57

Yeah, absolutely. We'll put our version of this checklist in the newsletter. So that's like the home program package, and that was the same for both groups, but the home program only group, brace yourself. Those parents were expected to do one hour a day, five days a week for 12 weeks. So a total of 60 hours of intervention. Oh wow. Because basically, I think what they were thinking is like the intervention program is three times a week home program plus the two times a week clinic. So they're getting intervention five days a week, basically. So the home program's also getting the intervention five days a week. It's just all at home with the parent.

SPEAKER_01 25:34

Okay, so they're keeping the number of total hours consistent across both groups.

SPEAKER_00 25:39

Yes, they're keeping the dosing consistent. And just to be perfectly clear, the intervention program is two hours a week with the therapist, three hours a week at home, parent only. And the home program is five hours a week at home, parent only. And then the therapist is just like coaching them via phone calls on how to do it.

SPEAKER_01 25:59

All right. So is that the setup? Do I need to guess the results? You do guess the results. I'm gonna guess. And I'm hoping a full home program alone won't replace clinic-based services, hypothetically. So I'm gonna vote for clinic plus home program was better.

unknown 26:18

Ding, ding, ding, ding, ding, ding, ding.

SPEAKER_00 26:20

Yay! You are correct. Now, the cool part is both groups showed improvements in most of the measures. Great. So even the parents that were just getting home programs and not getting a lot of extra help from the therapist, they were able to make some good gains just by like getting this education on how to help shape the environment and enrich the environment so that their child would improve. But in almost all measures, the intervention group outperformed the control group. Excellent.

SPEAKER_01 26:52

Yay! OTs know what we're doing, and it's good to coach and do the things in real life to refine it before passing it off to parents.

SPEAKER_00 27:01

Yes. And I think one of the things the author said why they think it worked is because the parents actually get so much more training when they're in the session with you. So it's like not only are you giving them a robust home program, but you're also training them how to do it. It's like on-the-job training, so to speak.

SPEAKER_01 27:18

Having a field work in OT versus reading from a textbook. It's different.

SPEAKER_00 27:21

Yeah, totally different. And I thought the improvements were interesting. On the Bailey, basically, all the subtests improved more for the intervention group than the home program one. And then on ages and stages, same story. And then on a peak aloe. Remember, that's the one where they're like videotaping the parents and looking at things like affection and responsiveness and encouragement, the intervention group also won on all accounts. And then this part really was interesting to me. They went through on the sensory profile and talked about each of the subsections and how much more the intervention group improved over the home program group. And it was a lot. So on sensory seeking and avoidance and low registration and general processing, the intervention group outperformed the home program group. And sometimes it was like nine times more or like twenty times more.

SPEAKER_01 28:20

Huh. Cause I've heard that the sensory profile isn't necessarily supposed to be used as a pre and post because a person's sensory profile is just their sensory profile. So it's interesting that they chose it and that there was quote unquote improvement in the different areas.

SPEAKER_00 28:39

I thought that was super interesting too, because you're right. This is normally used to characterize the population, but not as a pre-post. And it's also used for like that data-driven decision making where we're like understanding what the child's unique profile is and then shaping the activities for it. But I'm wondering if it's because it's in this young population where everything's still emerging and changing that they thought it would make sense to use it as a pre-post.

SPEAKER_01 29:03

And then what about the home program compliance? Did they do it?

SPEAKER_00 29:08

They this is the part that I'm like, I don't know, show me the money on it because I don't believe you. As they said, they had a hundred percent compliance in both groups.

SPEAKER_01 29:18

What 100%? Right.

SPEAKER_00 29:21

Have you ever met a family that's 100%? I mean, they were giving them a lot of support with like the phone calls and stuff like that. And they're part of a research study. And so I know when I'm doing a research study, the families that are doing it are pretty invested and they know that you're like collecting data. So it's a different situation than like your real real world kind of treatment. But 100%, come on, you didn't miss a single day. Your kid didn't get sick one time, you didn't like do 30 minutes instead of an hour one day. I don't know about that.

SPEAKER_01 29:51

I don't think I would have done 100% compliance.

SPEAKER_00 29:54

I know I would have done it.

SPEAKER_01 29:56

And I feel like I'm pretty dedicated, but whatever. We'll believe them. We'll give it to them.

SPEAKER_00 30:01

Regardless, whatever level of compliance they had, it definitely showed improvements. So I just thought this study was so interesting because it's very relevant to what we do, our intervention. And I liked that the article itself has each session broken downwards, like session one, do this. Session two, try this, session three, add in this. It's not like step-by-step what to do, because of course that's all driven by the child, the goal that you're working on with them and their special profile, but it guided you as to how you can incorporate all these layers of the intervention over time to get the full, robust intervention.

SPEAKER_01 30:38

So I really like that part. And to cue therapists to remember to look at all of these different areas. We all have our favorite things that we gravitate towards, but remembering that it's a full buffet that we want or all the layers of cake, as you said before.

SPEAKER_00 30:54

We love our food. It must be around lunchtime when we're recording this. Yeah, and I also thought it was really interesting to think about how I might implement this in my recommendations because it was so parent-heavy. And I thought it would be so cool to bring a client in and with a twice-a-week recommendation and one time a week have it be like my regular session, and the second time use that coaching CPT code that I've had a lot of success billing and coach the parent once a week on how to do it at home. So I was I was just trying to think about like how I might incorporate this in. Or not everybody's insurance will allow you to use that coaching CPT code, or they don't have telehealth benefits, you know, you have to check that stuff out. So the families that don't have that, you could still do two times a week, but have one session be therapist-led and the second session be parent-led, where it's almost like a demo return demo, like where one session you're working with them and the parents supporting you. And then the next session, the parent is the lead and you're there to support them, kind of like we do with level two field work students when they first start.

SPEAKER_01 32:01

Mm-hmm. Yeah. I was thinking how I might explain this to a parent initially, you know, especially working with little ones. We know like it's such a malleable time neurologically to get in repetition and see big improvement. So I would almost explain it as, hey, we want to really give you a strong treatment plan that covers five days a week. But I'm gonna be with you two of those days and empower you to do those other three days. So not even set it up as I'm doing two days and you're getting a home program, but this is a five-day-a-week intervention. Yeah. And just setting that expectation right off the bat.

SPEAKER_00 32:38

Yeah, that's such a smart way to approach it and to help get buy-in for it. Another thing that I thought would be interesting is to do a follow-up study. So in this study, they did game intervention plus home program compared to home program alone. But I would be interested to see a game intervention, no home program, compared to a game intervention with the home program, just to see like how would the game intervention work as a standalone package?

SPEAKER_01 33:05

Mm-hmm. I was wondering that too. Like I almost wish they had three different groups that they were running at the same time to have that piece in it as well. Great article, Michelle. Let's wrap it up with our three questions. Let's start off with the population. Remind us who are the kiddos in this?

SPEAKER_00 33:23

These are 24 to 36 month-old kids with developmental delays.

SPEAKER_01 33:28

And what are the key ingredients? So if we're duplicating this, what are our must-have items that we need to have?

SPEAKER_00 33:35

So for the game intervention, you want to do intensive motor training, parent education, environmental enrichment, and then activities that promote sensory and cognitive development.

SPEAKER_01 33:47

And last, our mechanism of action. What is going on, or what's the why behind this and what made it a good intervention?

SPEAKER_00 33:55

The authors did speak to the mechanism of action consistently throughout the study, but what I feel like they're focusing on is like why they chose certain theories. And so I tried to look and see like why does this theory actually work? So, for example, the authors are saying, like, this works because we're using ASI principles, which like enhances sensory processing and promotes self-regulation, and therefore you have like an increase in adaptive functioning. Like that is the theory of AIRS SI, right? Yeah. But but to me, like that's a theory. It's not necessarily like, why does that work? Like, yes, those things happen, but why? And so I think it's interesting to think about for this study, they really focused on sensory modulation with when they were using the sensory input. It was an emphasis on modulation, like hypo or hyper-responsiveness and trying to target that. And we know that when we have this repeated graded sensory experience, it helps the brain to adjust a thing called neural gain control. Okay.

SPEAKER_01 34:59

You got to explain that to me.

SPEAKER_00 35:01

I know. I love it so much. Neural gain control is basically like how strongly your neurons respond. It's a fundamental mechanism where the sensitivity of your neurons have to be adjusted, right? So that sometimes they can amplify weak signals or they can suppress strong ones so that they get like this optimal level of responsiveness. And our kids are too sensitive where the neurons are getting fully saturated too quickly or they're not sensitive enough. That's a hypo-responsivity. And so the way SI works is it's giving these repeated graded sensory experiences that train the neurons how to respond through this concept of neural gain control.

unknown 35:43

Huh.

SPEAKER_01 35:44

That's a new one. I like that, Michelle. Because whenever we've talked about SI in the past, it's like, oh yeah, neurological change, but you named it neural gain control.

SPEAKER_00 35:56

Yeah, there's actually a lot of different things that are happening neurologically that's that actually explains why SI works, but I don't want to like over-geek out right now. So maybe over time, yes, I'll bring up additional ones. But this is the one for the day, neural gain control.

SPEAKER_01 36:13

And then we had some other like motor pieces in there. Yeah, like there's some of action with that.

SPEAKER_00 36:18

Yeah. That high intensity intervention that Iana Novak, you know, the you gain what you train. And that, of course, is because you're basically creating a neuroplasticity engine by doing this experience-dependent neuroplasticity of repetition and using like meaningful tasks and focusing their attention and giving feedback and you know, adjusting the intensity. So it just creates this neurological milieu that facilitates neuroplasticity. Love it. And then, of course, parent education, because then you get more high-intensity intervention because they're implementing it at home.

SPEAKER_01 36:57

Yeah, that just compounds it. When they're doing it in the clinic and at home, then they have more opportunities for more intense training. Yep. Very cool. And that's it for our research review. We hit the highlights and shared our own thoughts, but please check out this article for yourself. It is so cool, especially that table you referenced, Michelle. And if you have any questions about this article or other ideas to share, please send it to ideas at playpodcast at gmail.com. Connect with us on Instagram or send us a voice message. We want to hear your voice and your thoughts.

SPEAKER_00 37:31

Fun fact, Lacey, I don't know if you noticed, but we recently have, so we have 102 countries that listen to this podcast. And the latest one that just popped onto our charts is in Uruguay. So I just want to say hello to our listener in Uruguay. And now it's time for People, Places, and Products, where we talk about something or someone that we are excited about. Lacey, what do you have for us today?

SPEAKER_01 38:01

Well, Michelle, since your game intervention wasn't actually a game, I will share a game during people, places, and products. This is so fun. I went on a little mini field trip to visit a school-based therapist in Kansas City just to see what was going on. We sent a lot of students to that school district and just wanted to get to know her, check out her schools a little bit more. So shout out to Katie. She was great. And when I was with her, she played a game with a kid called Ruby's Gem Quest. Oh, I haven't heard of this. It is the cutest thing. It works on like pre-Sissor skills. And you know, I love the bubble tongs for like pre-scissor skills. You're working on the opening and closing, you're grabbing things. I think that was a previous People Places in product.

SPEAKER_00 38:49

Yeah, you had that like long time ago.

SPEAKER_01 38:52

But this is even better. It's the same concept, but it's a little dragon named Ruby. And you open the scissors to open Ruby's mouth, and you can put little gems in that is so cute. It is the cutest, and the scissors are a little bit smaller. That's where I have trouble with the bubble tongs because a lot of times they're still like a larger size. But these are little preschool hand size, and it is just the cutest game ever.

SPEAKER_00 39:24

I love that. I'm going to get that for the clinic immediately.

SPEAKER_01 39:28

And there's a whole game you can play with it. And of course, I almost never play the actual game. So you could easily just take the gems out, put them in a sensory bin or something, or just a little scavenger hunt, and then go around with Ruby and collect all the gems.

SPEAKER_00 39:42

So cute.

SPEAKER_01 39:44

Get it, Michelle.

SPEAKER_00 39:45

Get it. Today we talked about an intervention called game. Remember, the steps are intensive motor training, parent education, environmental enrichment, and activities to promote sensory and cognitive development.

SPEAKER_01 40:02

And that's it for Ideas at Play. Thank you so much for spending time with us and hearing about this cool intervention. If something in this episode resonated with you, please share it with a friend so that we can keep growing our community and be great evidence-based OTs.

SPEAKER_00 40:19

Until next time, stay informed, stay curious, stay playful.

SPEAKER_01 40:27

As I was driving around Iowa today, I saw the world's largest popcorn ball.

SPEAKER_00 40:37

I don't even know what that means. Like it's like that you can eat, like they rolled it in caramel.

SPEAKER_01 40:43

No, it's on display in the center of a town. There's a building dedicated to it because it's over eight feet tall and 4,000 pounds. Of popcorn? Of popcorn. Yeah. Like the city.

SPEAKER_00 40:57

Or is it like a big thing?

SPEAKER_01 40:58

No, no, it's it's enclosed. Yeah, it's protected and has like a big like blue ribbon around it.

SPEAKER_00 41:03

In America, we love our world's biggest. Yes. Biggest rubber band ball and the rubber world's biggest, you know, popcorn ball.

SPEAKER_01 41:11

Yes. My life is complete. Popcorn ball. Check. Yep.

SPEAKER_00 41:17

Oh, that's so funny. Only in Iowa.