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Recommendation for OT? I'm not so sure


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So I just need to talk through this situation with some people who have been through this (possible) 2E thing. We have just finished a round of 12 weeks of vision therapy at the recommendation of my son's optometrist. She said that his vision is definitely improving. However, she said between things we had talked about before and things she noticed about his behavior during exams, she's concerned he might be in need of OT to help his vision therapy be more effective (ie to help him be able to concentrate and work harder).

 

I'm not so sure about this recommendation. What she's basing it on is:

a. very poor handwriting skills. I'm not sure this constitutes a delay so much as a mismatch in interest (more interested in learning multiplication and playing video games than in drawing, coloring, and writing). And from what I've read, it's extremely normal for bright children to be a little delayed in fine motor skills. His handwriting has been improving by leaps and bounds at school this year, and I think it will probably just get better with practice.

b. weird attention patterns, as in the ability to tune everything else out and focus on what he wants to do or things he finds interesting. I find myself having to actually touch him in order to get his attention, and he gets frequently distracted. But then again, what 5 year old boy doesn't? And gifted 5 year olds, more so. I'm of the persuasion that thinks ADD is over diagnosed, so I am inclined to resist sending my son in for "attention issues" so young.

c. slight social awkwardness. He tends to be pretty quiet and then pop out at random points with seemingly unrelated information. But I am like this myself, and I can usually follow how he got from point a to point b. There's also that matter of using noises rather than words to express frustration, but again, that seems developmentally appropriate to me. His teachers at school have said that he has a hard time sitting at circle time and keeping his hands to himself. His teacher identified it with "flapping" type behaviors, but to me, it doesn't look that compulsive. It just looks like a little kids who's excited and likes rough, physical play.

 

None of these behaviors are so severe as to interfere with our lives at all. Sure, we have discipline methods to deal with them, but they are getting better, not staying the same or worse. But then again, I have always felt like my child was a little different, but is that just because he's gifted or because he has (other) actual issues?

 

So my questions are:
1) Given this information, would you go in for an OT eval just to see?

2) Is there any harm in an OT eval? Like diagnoses that could follow him around, making me more paranoid.

3) Is there any harm in delaying an OT eval until he's older and we can establish if the issues really are issues or just being a 5yo gifted boy?

 

I'm not one to ignore a doctor's advice normally, but I feel like young kids are over diagnosed, and that this is totally jumping the gun. I'm not completely convinced about the need for vision therapy either; I don't see any tangible changes from it, though two separate eye doctors has both said that his tests are better after this 12 weeks. Another reason I'm hesitant is because this kind of therapy eats up so much time. Doing 1 hour of vision therapy a week, plus 15 mins practice daily nearly threw me over the edge. I don't know what kind of mess we could get into.

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Oh, forgot to mention one other thing which is probably relevant. He took the WPPSI-IV and scored much higher (124) in the verbal and reasoning areas and much lower in the processing speed and working memory areas (90 and 70). I think the lower scores on the latter may have been due somewhat to tiredness and be being annoyed at being at a long test on what is usually his "video game day" (ie Saturday), but they are at least somewhat valid. And the vision therapy is supposed to help with the processing speed issues.

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I know this is not what you want to hear, but everything you have posted would lead me to have my child have a complete neuropsy evaluation (I'm not sure about the OT suggestion. I think that would be more along the lines of treating a symptom vs understanding the underlying cause.

 

The sloppy handwriting might be a sign of muscle weakness. That combined with low processing speeds, hyper focused attention, and the behaviors described in "c" are all indications of something out of the ordinary 5 yr old boy behavior.

 

Fwiw, yes, waiting does have consequences. The most effective therapies for positive long term outcomes are those which they receive when they are young.

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I don't have experience with ASD, so I can't tell you anything from that point of view.

 

I can say that my non-autistic, non-ADD (should such a thing even really exist at the levels it is currently prescribed for), 5 year old kindergartner has a few of the same traits.

 

I was told the exact same thing about circle time (to the extent that he was not allowed to sit with the other kids at circle time), and his handwriting is pretty atrocious.  He was (and is) both easily bored, completely non-internally-motivated to do things he finds boring, and ahead of the normal Ker in math/etc., which manifested as behavior issues in PS to the extent that they were making ADD noises (weighted blankets, etc.)  That was the day we withdrew him from PS.

 

Here is the thing: he can focus just fine on things he either finds worth his focus for his own reasons or worth his focus because he's learned there's no other option (cleaning up a room, for instance).  

 

He hasn't had an IQ test so I can't say anything there, and no vision problems like your DS.

 

 

Anyway, just a perspective of: at least some of these things are normal.  Some may not be; use your best judgment, I guess.

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I also have no experience with ASD. However, I don't think you are describing anything that out of ordinary for a five year old boy. Most five year olds don't like to sit still in a circle. Yes, many are trained to, but there will always be amoung them a few who are not people pleasers and run around or find it difficult. Many five year old boys hate handwriting. But since he's improved leaps and bounds, why worry yet? Social awkwardness-- kids at this age are still figuring out rules. If he hasn't sat through three years of preschool, he is still figuring them out more than most these days;). What kid isn't socially awkward at five. Unless, it is more describable and way beyond the normal range of course. But blurtting stuff out of nowhere --totally normal.

As for attention, as described as a video game addict, probably normal that you have to touch him to get his attention. Video games teach you to ignore even the fire drill. :).

 

If all this isn't affecting life quality day to day, why bring it up. Wait and see how he grows. If its not blaringly obvious, then just live and enjoy.

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My two cents:  I would get the OT eval now, specifically for vision purposes, and then also plan on a full neuropsych eval at some point in the near future (I'd prefer to wait until the vision stuff has been handled if possible, as that can affect the results, plus it might be nice to get a WISC, for which one would need to be 6 y.o.).  I'd ask the COVD what she thinks about a timeline for getting the full neuropsych eval and whether she can recommend someone.  I'd also ask the COVD for more specifics, if she has them, on why she thinks OT might help.  I'd probably see the particular OT that the COVD recommended, as not just any will do.

 

FWIW, here's what happened with my dd:  she started VT for tracking issues around 6.5 y.o.  The VT exercises were torture for dd - very slow and difficult.  Around the same time, we had just gotten her into the local top OT place for an eval for SPD.  The OT place recommended a short but intensive program (3x per week for a month, then a month off, then 2x per week for a month - that's it; it was in combination with listening therapy).  We ended up putting VT on hold while we did OT, just for logistical reasons and so as not to overload dd.  When we returned to VT three months later, the difference was astounding - even the vision therapist was amazed.  It was far easier for dd to complete the vision exercises after OT.  No more torture.  The OT people explained that the ocular motor issues were "downstream" from central nervous system issues, so that once the bigger central nervous system issues, the root cause, were addressed, the VT was the fine-tune work on the ocular motor problems.  During the OT, I didn't feel like I saw any difference (I kept thinking it was a joke), but the affect on her particular vision issues was obvious and undeniable afterward.

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From the other side, and what sometimes seems an unpopular stance around here: My son at that age also had some similar issues to what you are describing.  The PS people had all kinds of crazy ideas about what was "wrong" with him, but that I knew were totally off.  We have batted around ideas of getting different evaluations, but have thus far always come down on the "we don't need it yet" side of the fence, because many of the issues disappeared when he was removed from a PS environment and allowed to learn/operate in his own best way and at his pace.  DH and I recognize most of DS's issues from our own childhoods, and as DS ages, we are definitely seeing him grow out of some things, and with maturity he is becoming much better able to handle certain situations that were formerly meltdown-inducing.    For us, I think if he does have any ADD or other diagnose-able conditions, they are on the mild end of the range and with parental reading and research and support, they are for us nothing that needs outside intervention yet.  DD also has some issues, the most significant being speech.  She's been evaluated for just that and is recieving therapy, because that's something that needed an expert's help.  Her other attention/possible 2E traits?  Like her brother, this is something that DH and I see as mild in her case and not requiring outside help, because DH and I already feel like experts on this type of child.

 

I think that on these boards there are a high concentration of people for whom evaluations have been essential.  And that's fine and great for those families, and I hope no one will claim I am saying otherwise!  But sometimes it is easy to forget when reading evaluation advice that a parent's instincts can be keen...if mommy-gut says get evaluations, get more evaluations.  If mommy-gut says otherwise and wait, or pick and choose among the possible additional evaluations, or do some more research on your own before deciding, that very well might be the right choice too.  IMO.

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I think that on these boards there are a high concentration of people for whom evaluations have been essential.  And that's fine and great for those families, and I hope no one will claim I am saying otherwise!  But sometimes it is easy to forget when reading evaluation advice that a parent's instincts can be keen...if mommy-gut says get evaluations, get more evaluations.  If mommy-gut says otherwise and wait, or pick and choose among the possible additional evaluations, or do some more research on your own before deciding, that's ok too.  IMO.

 

Since I posted upthread recommending evals, I just want to clarify that I am not one that normal believes that most kids need evals.  However, I am also the parent of an adult Aspie who we didn't seek evals until he was 12 even though he definitely exhibited ADHD behaviors when he was little.   I stood on the side of being able to assist him on our own and he was thriving.   However, what we saw as thriving was really more along the lines of coping and not impacting his life as a younger child.   Those issues only became more prevalent and diminishing in quality of life with age.   The older he became, the more pronounced the behavioral deficits became.

 

My biggest regret as a parent is that we didn't seek interventions when he was little.   He has a high IQ with low processing speeds, muscular weakness and hyper-focus attentive issues.    Those are the easily identifiable traits.   However, he is now so  impacted by all of his issues, many executive functioning issues on top of others, that at this point, age 22, he is completely dependent upon us and the most adult world responsibility he can cope with is working part-time at Goodwill.   So, when I posted that the best interventions are those received while they are young and that the repercussion if there is an actual problem that could have been addressed is that the most effective therapies have been missed has long term implications, they do.   

 

The only thing an eval can do is clarify.   No one on this forum can identify whether there are serious concerns or not based on the description in a post.  I have absolutely zero idea if there is a real concern.  However, the recommendation by the COVD bears weight. 

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8, I don't disagree regarding the COVD recommendation, and I thank you for the clarification. 

 

And I should have pointed out that at no point have we suspected ASD for either of our kids, so I have no experience with that.  My main point was just that evaluations are not always necessary, and that it is a highly individual thing. 

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Since I posted upthread recommending evals, I just want to clarify that I am not one that normal believes that most kids need evals. However, I am also the parent of an adult Aspie who we didn't seek evals until he was 12 even though he definitely exhibited ADHD behaviors when he was little. I stood on the side of being able to assist him on our own and he was thriving. However, what we saw as thriving was really more along the lines of coping and not impacting his life as a younger child. Those issues only became more prevalent and diminishing in quality of life with age. The older he became, the more pronounced the behavioral deficits became.

 

My biggest regret as a parent is that we didn't seek interventions when he was little. He has a high IQ with low processing speeds, muscular weakness and hyper-focus attentive issues. Those are the easily identifiable traits. However, he is now so impacted by all of his issues, many executive functioning issues on top of others, that at this point, age 22, he is completely dependent upon us and the most adult world responsibility he can cope with is working part-time at Goodwill. So, when I posted that the best interventions are those received while they are young and that the repercussion if there is an actual problem that could have been addressed is that the most effective therapies have been missed has long term implications, they do.

 

The only thing an eval can do is clarify. No one on this forum can identify whether there are serious concerns or not based on the description in a post. I have absolutely zero idea if there is a real concern. However, the recommendation by the COVD bears weight.

I agree with you completely. I would ather err on the side of caution and be proactive rather than regret time that is lost.
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c. slight social awkwardness. He tends to be pretty quiet and then pop out at random points with seemingly unrelated information. But I am like this myself, and I can usually follow how he got from point a to point b. There's also that matter of using noises rather than words to express frustration, but again, that seems developmentally appropriate to me. His teachers at school have said that he has a hard time sitting at circle time and keeping his hands to himself. His teacher identified it with "flapping" type behaviors, but to me, it doesn't look that compulsive. It just looks like a little kids who's excited and likes rough, physical play.

 

None of these behaviors are so severe as to interfere with our lives at all. Sure, we have discipline methods to deal with them, but they are getting better, not staying the same or worse. But then again, I have always felt like my child was a little different, but is that just because he's gifted or because he has (other) actual issues?

 

If your preschool teachers have concerns, I would take those seriously.

 

One option that people here often overlook is that your school district has a federal mandate to screen these kids through Early Childhood Special Ed or through their normal procedures, regardless of your enrollment status. If your insurance doesn't cover a full neuropsych exam this could be a useful middle ground and provide potentially useful services.

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OTs are not allowed to diagnose. We pick treatment diagnoses based on our evaluation and treatment focus, but do not give medical diagnoses. However, I have never practiced pediatrics, so I may not be the best person to answer your second question.

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My inclination is that the VT has his/her specialty, and it's not OT. My kids did VT, and I saw minimal results from it, despite our efforts at doing home activities. The VT was also very opinionated about our other therapies/efforts, and I guess I am a little chapped about that (hence my first comment). Do YOU feel your child needs another eval? That's what is important.

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The dynamic of an optometrist referring a patient to an occupational therapist for presumptive treatment of an undiagnosed behavioral/neuropsych problem, just feels like a weird short circuiting of the whole health care support network. Where are the psychologists and the medical doctors coming into play here? I don't feel like declining your *optometrist's* observations about something completely outside of their narrow field of training quite qualifies as "ignoring a doctor's advice."

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The dynamic of an optometrist referring a patient to an occupational therapist for presumptive treatment of an undiagnosed behavioral/neuropsych problem, just feels like a weird short circuiting of the whole health care support network. 

 

It should be for diagnosis and treatment of a potential central nervous system/sensory processing problem (SPD) directly underlying the vision problem that the optometrist is trying to treat (as was the case with my dd - ocular motor as a subset of sensory motor issues).  Neuropsychs don't typically diagnose or treat SPD, though in their big-picture, issue-spotting role, they may come across it in their patients and subsequently refer out to OT.  (SPD is not in the DSM and there is still some controversy about it.)

 

If the optometrist is not trying to treat something directly underlying the vision, rather just vague behavior, I agree that she may be going at this the wrong way.  However, it is not uncommon for vision stuff to have a sensory root cause; maybe she's going with her gut, in which case she ought to explain better.

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The dynamic of an optometrist referring a patient to an occupational therapist for presumptive treatment of an undiagnosed behavioral/neuropsych problem, just feels like a weird short circuiting of the whole health care support network. Where are the psychologists and the medical doctors coming into play here? I don't feel like declining your *optometrist's* observations about something completely outside of their narrow field of training quite qualifies as "ignoring a doctor's advice."

 

As Wapiti outlined before me... the issue is more complex...

 

I think an underlying issue is many insurance policies have a relative unwillingness to pay for full neuropsych exams for perceived academic deficits. The issue of an OT eval  vs a full neuropsych eval looks different if you are looking at a 6mos fight with your insurance company and then a 18+mos waiting list for the full exams and/or ~$4000+ out of pocket vs no waiting list and ~$300 out of pocket for the OT eval. Which one is a better option is too situation dependent for me to say but this may be your VT's  experience. For complex situations the full eval is clearly superior but due to our complex insurance situation the calculus for neuropsych vs other evals is clouded in our current system.

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As Wapiti outlined before me... the issue is more complex...

 

I think an underlying issue is many insurance policies have a relative unwillingness to pay for full neuropsych exams for perceived academic deficits. The issue of an OT eval  vs a full neuropsych eval looks different if you are looking at a 6mos fight with your insurance company and then a 18+mos waiting list for the full exams and/or ~$4000+ out of pocket vs no waiting list and ~$300 out of pocket for the OT eval. Which one is a better option is too situation dependent for me to say but this may be your VT's  experience. For complex situations the full eval is clearly superior but due to our complex insurance situation the calculus for neuropsych vs other evals is clouded in our current system.

 

Makes a lot of sense and I've not been down any of these paths! But it seemed to me that the optometrist wanted the 5yo seen by OT primarily in order to make him pay attention and work more diligently at his eye exercises, not because of a specific underlying concern related to the vision issues. And the OP posted the thread because her gut disagreed that he needed more therapy, but she was reluctant to go against a "doctor's orders". I guess to me, an optometrist's suggestion to do something about her 5yo's ability to concentrate would be just that -- a suggestion.

 

Now, the OP lists a bunch of red flags, and the optometrist (who's probably seen lots of kids with issues and may be speaking from that experience) and the posters here are confirming that these are red flags, so it sure does seem like there might be something going on worth investigating. But is an optometry referral to OT for the stated purpose of making him sit still longer, the most appropriate path to start the investigation?

 

I'm kind of asking for myself too. My son has a handful of musculo-skeletal issues that my mama gut is starting to tell me must be related, but I don't know where to turn first. It just feels like a diagnosis should precede therapy...right? (Of course, for me there is not really insurance involved since we have a huge deductible, and the costs you're talking about are disturbing. Ack.) I tried to start with the pediatrician but that was a non-starter so now I just don't know where to turn next. Hrm.

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I think there are many paths to getting help. There are developmental opthamologist that work with a team and specialize in VT. But they also know enough about other issues to at least make a recommendation.,

 

My sons therapies was started via WIC. WIC made the recommendation to get him in to get evaluations done. Out family Doctor could have done it but he was a just wait and see kind of guy. In the end my son qualified for early intervention and he was able to get into programs to help him. It doesn't matter how he got there. Just that he did.

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Just to balance things out... don't know the OP's ds, but I think it's good to know about all sides...

 

I worked as a third grade teacher years ago.  Teachers in my school could recommend (and would) kids for ADD/ADHD assessment. 80% of the boys in the third grade were on Ritalin for ADD/ADHD.  Only one girl was.  When in doubt, listen to your mommy gut over the teacher's.

 

Several people have suggested to me, over the years, that I should get my oldest evaluated for either ADD or Asperger's.  I have not done so.  He is quirky and intense (and gifted) and sometimes frustrating, but as a freshman in a STEM high school, he functions completely normally socially.  He has been on the honor roll all year and is being recommended for AP/University dual enrollment classes for next year.  His teachers have always had good things to say about his behaviors in class.  I think this proves he doesn't have any ADD/Asperger's issues.  

 

He may have a higher than common anxiety level (just like his father and grandmother) and "gifted" overexcitabilities (http://www.sengifted.org/archives/articles/overexcitability-and-the-gifted), but plenty of people do and it does not inhibit their ability to function normally and succesfully in their lives.  

 

I admit I bristle that people ("off the street' -- never a doctor or a teacher, but it would have been a teacher had he been in school at 5) suggest he may have attention and social challenges.  Mostly I bristle because those suggestions DID cause me to question.  They caused me to wonder where I had not wondered on my own.  One day I asked a friend, whose dd was diagnosed with Asperger's.  She had known my son for years.  She actually laughed at me when I, very emotionally, shared my concerns that were born out of *others'* concerns.  She said that there was no doubt in her mind that my child did NOT have Asperger's.  She said he was just "all boy."

 

Ds is not the typical kid, but he's never been.  However, he has completely normal executive function skills.  He is very independent.  I have no doubts that, several years from now, he'll be more than capable of attending a good university, living in a dorm, getting a great job, and living on his own.  Totally confident now that I've seen him grow. 

 

Just sharing another side...

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