Meet The Experts is a series of interviews with professionals in the field of Child Development.
Karen has travelled from Dublin to Toronto to London to meet with people who have worked tirelessly to find new ways of treating children with sensory difficulties.
Pauline Moran is a pediatric occupational therapist with over 20 years experience working with children with developmental changes.
Pauline runs a Sensory Integration Clinic in Kilcoole, Co Wicklow. Pauline qualified in 1994 from the London School of Occupational Therapy, Brunel University. She began working in Paediatrics in 1996 and has great experience working with children with a variety of different conditions.
Pauline has specific expertise in the area of sensory integration (SI). She is SIPT certified and is an advanced practitioner in sensory integration through the SI Network UK & Ireland with the University of Ulster.
She is also an advanced Practitioner in Therapeutic Listening. Pauline has always been proactive in her continual professional development. She has a depth of training and certification reflective of her commitment to course attendance each year.
Nothing gives Pauline more joy than seeing her clients’ progress to reaching their potential. She educates, liaises and works closely with parents, teachers, schools and other professionals. She works holistically with the children, referring the children to other professionals when required.
Pauline looks at occupational performance throughout the child’s day in particular, certain things that might be affecting their behaviours and routines and then understanding what exactly is affecting the child’s function.
Watch Karen’s interview with paediatric occupational therapist Pauline Moran below:
What Does a Paediatric Occupational Therapist Do?
KOC: So today, I’m here in Wicklow in Ireland, an absolutely beautiful spot. I’m here to meet an expert in the field of child development. She’s a paediatric occupational therapist with over 20 years of experience, working with children with challenges and helping them achieve their greatest potential. So I’m delighted to introduce today, Pauline Moran. It’s lovely to be here with you today, Pauline. You have so much experience in the area of occupational therapy. You’ve worked with thousands upon thousands of children over the years and helped so many children achieve their potential. So, it’s funny, when families come to me and I might say to them, I think your little one needs a little bit of occupational therapy or whatever. Parents often say, what does an occupational therapist do? So a lot of people haven’t heard of occupational therapy. Can you tell us a little bit about what a paediatric occupational therapist does?
PM: From when the child first gets up in the morning, to when the child goes to bed at night… you look at their occupational performance, look to see how are they getting on with their behaviours, with routines, are parents finding that they’re unable to get them dressed in the morning, some kids may have difficulty putting their socks on, they have difficulty with different clothes because they’ve got some tactile issues. And some parents, they’ll give them an instruction, and they’re not paying attention. So it’s just all about understanding what’s affecting the child’s function during the day. It can be at home, sometimes it can be at school, and usually, the parents have realised there’s something not quite right, and we need to help them with A, B, or C. So that’s when they will come to me because it’s affecting their function.
Who Would a Paediatric Occupational Therapist See?
KOC: Who do you see, who would normally come to you? Is it children with specific diagnoses, or children that don’t have a diagnosis? Is it across the board? Who comes to you?
PM: Well, I see a lot of different conditions. Some kids have got no diagnosis at all. So they may have some sensory issues. So the parents are just seeing that they’re having an awful time getting them dressed in the morning. They’re not responding to their name being called, they’re having some auditory issues. There’s a lot of tantrums at home. I see kids that may have Down Syndrome, so they do have specific conditions. I work with a lot of autistic children. I work with some children with cerebral palsy because I’m also bobath trained. I can work with tonal issues as well. I work across the range of dyspraxic, kids with ADHD – some children have got a firm diagnosis, but some haven’t got any diagnoses at all. I work with very young children. From the age of one up to about 14, but I’m seeing some older kids now because I’ve got a bigger space to work from.
KOC: You’ve moved into the most beautiful space, you’ve created the most beautiful clinic space.
You see children right across the board. Some children may have a diagnosis and that can be anything, any developmental issues, from autistic spectrum disorder, ADHD, dyspraxia, cerebral palsy, spina bifida, you name it, right across the board, different syndromes. And as you say, on the other hand, children come to you who don’t have any diagnosis at all and will never have a diagnosis.
PM: The parents may see that they’re having great difficulties in handwriting, they’re having great difficulty with attending at school. They’re very anxious, or you’re having to be withdrawn from school because of their anxiety. So sometimes they might come to me because of that issue. It’s really about information gathering, to begin with.
What Are the Signs that You May Need to See a Paediatric Occupational Therapist?
KOC: So what are the red flags for parents that would indicate that they need to come to a paediatric occupational therapist? What are the signs that they will see at home? That would suggest “Oh, Crikey, we need to talk to an OT”.
PM: Well, sometimes the children may have siblings. So the parents have realised, their sibling has never done this before. It’s so much more difficult to get them out in the morning. If it’s affecting their function, and it’s affecting their self-esteem, and it’s affecting the whole family. Then they need to bring them to a paediatric occupational therapist – if it’s affecting their lives.
KOC: So it’s everything from sensory processing difficulties to coordination difficulties, gross motor difficulties, fine motor difficulties – writing, dressing, buttoning, all that kind of thing. Throwing, catching a ball, all of that.
PM: It could be speed in handwriting. It could be accuracy in handwriting. It could be they’re having great difficulty with spelling or having great difficulty in sport. It could be that they’re not able to catch a ball. Or even the parents are noticing that when they run, it’s not quite the way they should be running as they’re tripping over – they’re sitting at the table, and all of a sudden they’re on the floor. They just realised there’s something not quite right, but they can’t put their finger on it. But they feel that they need to get it explored and figure out what they can do to help their child right.
KOC: So as you say, it can impact right across the board, can’t it? Everything, all the skills that you’ve mentioned there. So they are the red flags that parents need to look out for. The other thing that parents often say to me is, what’s the difference between an OT and a physio/physiotherapist. So what would you say?
PM: Well, we do crossover a little bit. It’s like we cross over with speech and language therapists. But with occupational therapy, it’s more holistic. So it’s to do with when the child gets up first in the morning to when they go to bed at night, a very holistic approach. It’s looking at their behaviour throughout the day and it’s looking at their performance throughout the day, to see what their strengths are, what their weaknesses are. To see what are the parents concerned about? What would they like to be better at? And it’s about information gathering and finding out what is that child’s strengths? What are that child’s weaknesses? And what’s their developmental performance at the moment? How can we push them forward and help them to reach their potential in life?
What involved in an assessment?
KOC: What would the initial meeting look like for a family? What’s involved in the assessment process?
PM: Well, usually, it would start with a telephone conversation with the parents. And sometimes parents like to explain to me what they’re concerned about, and why they would like me to assess the child. Sometimes the parents would have got information from their GP, from a speech and language therapist, from whoever they’ve been working with. It could be even a school, a school may have said, they feel that something is going on with their child, and let’s get them assessed by an occupational therapist. And they may feel that they’re not doing so well in PE, or they’re not able to hold the pencil properly, they’re not able to keep up with their peers, they’re not able to attend as long as other children. They may be just getting up off the chair, speaking out during class and not being able to follow the rules. So first of all, a telephone conversation. And then sometimes the parents will send me, by scan, their old reports, for more information about the child. But then when they come to me, it’s all about information gathering. So I give them questionnaires to fill out. So it’ll be the sensory profile, it will be an occupational therapy referral, the information about their past medical history, and their personal information, what the child’s behaviours are like during the day. What their concerns are, and what they feel the child’s strengths are. So I would go and analyse that later on. I also give out a school questionnaire, which goes through the sensory behavioural aspects of the child in school. So what the teachers are saying is where the child is at the moment – going into the different sections? Are they able to sit at the table? How are they getting on with the other peers? So there’s a lot of questions and they will give responses to them. And then I will do a standardised assessment with the child, which can take two hours, but it can take up to three hours as well. I would usually do it an hour at a time because that’s plenty for a child.
KOC: And it’s dependent on age as well. Not every child will be able to attend.
PM: It depends on the child. With a younger child, it’s all about finding out where they’re at developmentally. And so I use the Hawaiian developmental checklist for that. Using the Peabody will give a real idea of where they’re at, and then I can advise about how to move them forward. With the older children, if it’s an autistic child, some children cannot cope with standardised tests. So I will use play and I will use my clinical observations and my years of experience to help them to know where they’re at, to help give a home programme and to help them to move forward from there – to get the best. Every child has potential, every child can change. So we can move every child forward. With the children that are more able-bodied, then we will do standardised testing, like the movement, ABC to look at their motor skills. And we will do the visual-motor integration tests looking at their visual-motor skills, the test of visual perceptual skills, so that’s looking at their non-motor visual skills. I look at and analyse their handwriting skills and their speed. I also do the clinical labs, which are looking at your sensory piece. I do a very holistic, very full assessment and then I go away and analyse everything, put together a report, put together a list of equipment that will be needed for the home programme. Then I will give advice about what the parents need to do at home to help their children which is all goal orientated. I will be working with them, one on one with treatment. That will be, also working on what the parents are working on at home.
KOC: So it’s very holistic. It’s very detailed. There are lots of formulators as well, but there’s also of course, as we said, the whole art of therapy, with years of experience and your clinical observations. It’s tied in with formal assessment. So that’s the beauty of it. So Pauline that’s what an initial assessment will look like. I think that’s going to be fantastic for people to hear, to understand what goes on. So from there, you decide with the family, what’s required, whether inputs are required. How often would you see a child, would you see them once a month, once a week, a couple of times a week?
PM: After we finished the assessment, I would have the parents come in on their own, so I can give them feedback, give them the report, and we can talk about what needs to happen next. Then I would have realised this child needs a certain amount of treatment. Usually, it’s one on one once a week for a block of eight, and then sometimes the children need to keep going, especially if they’re on the autistic spectrum, they may need to keep going. If they’re younger, because we’ve just built a rapport, and we’ve started to get changes, we may need to keep going. With some of the kids, they can have a little break after eight weeks, and then they’ll come back maybe after two or three weeks, then we’ll give them another block of 8. They need more than one block of 8. Usually, it would be maybe a year, it just depends. It depends from child to child. Some parents are travelling a long way I know, travelling from Mayo, or they might be travelling from Galway, different parts of Ireland. So then I will set up a home programme, and we may review the home programme. They may not be in a position to bring the child for treatment every week. But I would make sure that we’re in communication by telephone, by email, and we will set them up with a good home programme, and then we would review that home programme. On the whole, the majority of kids will come once a week to me.
What Activity May Benefit a Child?
KOC: Pauline, you’ve such an amazing space here. I mean, even if we look behind, between the climbing wall and the climbing frame, just the whole lot of it, I mean, what child, just wouldn’t love, or adult nearly, wouldn’t love to experience this. So, I know you use a whole range like any good therapist, you use an eclectic approach, you use a combination of approaches, whatever, based on your assessment, what you feel is going to work for this child. So in a space like this, what kind of activities do you do? What kind of approach? Could you tell us a little bit about the approaches that you use?
PM: Well, I’m an advanced practitioner in sensory integration. I’m an advanced Practitioner with the University of Ulster and I’m also CIT certified.
KOC: You were one of the only therapists on your team that I’ve ever met who has been CIT certified.
PM: There are others in Ireland also CIT certified. There are also advanced practitioner sensory integration grades, there are others. There would be a list of them from the sensory integration network for the UK and Ireland. The Irish Association of occupational therapists has a list of private occupational therapists and other areas.
KOC: And I’m thinking there are families all over the world, because this has got to get to families, and it could be anywhere it could be in the States, Ukraine – could be anywhere. And that’s, as you said, that’s one particular speciality, especially as is in the area of sensory integration, which you also use.
PM: I’m also an advanced practitioner in therapeutic listening and I’m also bobath trained, so I can work with children that have tone issues. So with low tone, it’s not just children with cerebral palsy but it’s also children that have got their low toned issues. They might have a very poor core. So I work with those types of children as well. So with the sensory integration, I am, there is a fidelity measure. So it helps us to know what we should be incorporating in our therapy sessions, which should involve proprioception. It’s heavy work through the joints and muscles, some vestibular work. It’s not just swinging, but it can also involve the tactile piece of a messy play. We do this with bubbles. I also do some therapeutic listening throughout the therapy session as well. So I use quick shifts and different other modulation music to help throughout therapy, and we get some magical differences as well. So it’s nice. I use a real mix of treatments like developmental treatment, and sometimes it’s a matter of helping the child who has no idea how to play. So they have no idea how to interact with the space. This space can be quite big for some little children but we try to just keep it in one corner. I would set out little toys that would help them to get more interested. It’s lovely to get the engagement, the eye contact, you get some lovely results.
KOC: I’m sure parents are so thrilled because it’s so lovely to see that response from a child who hasn’t maybe been responding as much and to see all the lovely changes that can happen. So Pauline from your point of view, what changes do you see? What are the results?
PM: For example, like the first time I saw one little boy on the autistic spectrum, he is three years of age, he cried. He just couldn’t stay for the whole session. So one of the parents stayed and one left, but this was in my old space. Then when he came into this space, with lovely eye contact, a smile, he could see how colourful it was. And he was very, very happy to play with me to engage with me. And we’ve been getting some lovely, lovely sessions with him. So where you’re getting eye contact, where he’s following instructions? he’s interacting with me playing with me. And sensory integration is very… It’s all by play. The child’s occupational performance. So it’s all about the just-right challenge. You don’t want the challenge to be so hard for the child that they have no hope of being able to achieve this at all. You want it to be just right so that they feel a sense of “I did it”. It helps their esteem and it’s all about building a rapport with that child, helping that child feel trust, that he can trust you, or she can trust you, and that they that you’re rooting for them, you want to help them and they know that. They know that you want the best for them. And they come running into the session. So I work with all kinds of different children here. Some of the children are much more able-bodied, they might have a fear of heights. Just little by little, they’ll start at the first level and jump in and we’re getting nice proprioception. Moving in the foam is a heavy work, through the joints and muscles. I do a lot of activities with swings as well. So I have a lycra swing where they’re getting a lot of proprioception, they’re getting vestibular, they’re having to motor plan – they’re working on their ideation and all of that as well.
KOC: So many things are shifting and changing. It’s funny because I remember when I saw an OT at work first and started to get into the whole area of sensory integration – from the outside looking in you it just looks like play. But in reality, you’ve got this plan in your head, you know exactly where you’re trying to bring the child, depending on what you’re working on, but in terms of sensory regulation, helping them to be calmer, more focused, listening better, watch more, but also in terms of their coordination, if that’s an issue, or their handwriting or their eating, or whatever it is – you’re covering so much.
PM: Usually the first 45 minutes of my session would be working on the gross motor or the vestibular, the postural piece, depending on the child’s goal. Each child will have some goals that are a set of goals that I would be working on. The child may know the goals, but they may not know it, they may just feel that we’re just playing. The parents would know what we’re working on. So I would have a set of goals that I’m working on, it’s very child-led, some of the sessions for some of the parents feel like you’re just letting them do what they want to, but I am in charge. Like I am a couple of steps ahead of the choice. But I am allowing them to choose because that’s when you get some lovely changes as well. After all, they’re motivated.
KOC: Exactly. What I love about that, a lot of the floor time when you’re waiting, but you’re waiting, what’s that word, “expectantly”. You’ve set the whole thing up so that the child will start to initiate, they’ll start to plan better. Something is happening, as you say that just-right fit that something happens. You’ve got where something changes neurologically, from a neuroplasticity point of view, you get that lovely change, and that’s phenomenal.
PM: That’s the heart of sensory integration. It’s all about neuroplasticity. It’s all about the brain. It’s about the processing level of the brain, which is the brainstem. So it’s a bottom-up approach. So you’re helping the child process and you’re changing how they’re processing certain things. So they’re less fearful. They’re willing to try certain things. You see, like with the standardised testings, you get some lovely results. You see changes to their different percentages from when they first started, So their balance, posture, appease their hand to eye coordination, and ball skills may change. With videos, it’s nice, you can visually see the changes.
KOC: It’s interesting, isn’t it? Because people may say, are ball skills that important and is cycling that important, or different gross motor skills? But it’s all laying the foundation, and it’s not achievable for everybody. But it’s all laying a foundation within the nervous system for the development of other skills, isn’t it? So what’s the long term goal?
PM: Each child is so different and so specific. Some children are sporty, but they just want to be better at their ball skills. And they’re willing to put the work into those balls. So it’s all about finding what is the sport for that child? Because kids must move, not sitting down all the time. They must move – is it swimming? Is this horse riding, is it archery? What is their sport? And it may not be a sport, it may be something else, it may just be that they need to be active. So it’s finding what’s important to them. Then it’s about the parents, it may be that the parents are not very sporty, and they don’t mind if the children aren’t good. They may not want to be in the GAA club. It is about finding their niche and what they like and then they will be willing to put the work in.
KOC: It’s interesting what you say there. In a lot of the videos that I’ve created, I talk about the whole sensory end of things and how to look at the different senses. And I’m very much like you, an advanced practitioner in sensory integration as well. Over the years, I’ve heard different people say, “Oh, I don’t think sensory integration works”. As a clinician with over 20 years of experience, there’s no doubt in my mind that sensory integration works. What’s your thinking, as an occupational therapist with advanced training in that area, and many other areas?
PM: There is research out there, and there is a fidelity measure to help people measure, regarding sensory integration and the effectiveness of centre integration, there are also skills that people can set, helping you to have a level where have they improved? So there’s research out there to show the effect. I know, I’ve been working with children since 1996. It’s been an area that I love, and I’ve been working in for many, many years. It’s that orienting response which is a response to a child who comes in very distressed and when you can get a child calm, at peace and willing to engage with you. It’s a wow moment. Often that will happen during treatment in sensory integration. I do use lots of other approaches as well. So it’s finding what’s right for that little child.
KOC: This is the thing that’s come up again and again, in all the different experts that I’ve spoken to. It’s really about looking at the pieces of the jigsaw, isn’t it? There’s never one piece that’s the total answer. It’s finding that good will come with the right combination for that child, that helps them achieve their greatest potential.
PM: Some children have great difficulty in making sense of their senses for function. And that’s what sensory integration is all about. It’s helping them figure out what sensory area they’re having difficulty with. What areas do we need to help them to excel in? To be less fearful. Like some of them are petrified about certain sounds, about trying different tastes. Certain foods they will not touch. Even different lights, some children, have got great difficulty in filtering. So they may have visual filtering difficulties. So for example, if they have a whiteboard at school and there’s a lot of information around it. They’re looking at everything else before they look at the whiteboard. So it’s important that teachers think, “we need to keep that space clear” and just have them looking at the whiteboard. Have the other information elsewhere in the class, that’s not too distracting. Visual distraction happens all the time and auditory distractions. So some children might be just distracted by the other child turning his page. They’ve got great difficulty in filtering what’s important to be listening to what’s not. So filtering could be a major issue for some of our children. It’s very distressing for them and tiring for them. It can affect their emotional peace. So they hold it together at school, and then at home, they might have an explosion. So the parents get this very upset little child coming home.
PM: Their issues are held together all day. They’re all day and keep on top of things. But then by the time they get home, it’s just they’re just…
KOC: in meltdown. Really what we’re doing is helping the whole family. Yeah. So if you have a happier child, you’re going to have a happier family. Just even going out for meals to restaurants can be really difficult for some families. Just the normal little routines can be a real chore, haircutting, nail cutting, hair brushing, just little sensory pieces that make a huge difference to a child and the parents.
PM: Other people take for granted that in general, it’s only when there’s something that the process isn’t happening quite right, as you say if the filter isn’t quite right, or that something is happening there that the child isn’t processing that information quite correctly.
KOC: Pauline, you’ve helped so many children over the years. I mean, you’ve helped so many children achieve their potential. For parents listening now, are there tips that you could give parents? What would you say to parents, if they’re finding that they’re worried that their child is having issues in any of the areas that you’ve spoken about? What would you recommend? Is there anything that they can start doing today at home?
PM: The proprioceptive piece, which is the heavy work of your joints and muscles. Say you’ve got a scale between one and ten, the child needs to be at number five so that they can attend and focus, and they can sit down and eat their meal. They can sit down and do the jigsaw puzzle, listen at school and all of that. So if a child is sleepy, they can be very lethargic, looking, very tired, propping up their head. But also they may within seconds be fidgety and up, and you just want to mix up. They can swing very quickly, some children, not all. For those types of children, even the children that are lateritic, need heavy work as well. That’s going to bring them up to number five, and it’s not that it’s not different exercises. It doesn’t need to cost a lot of money. It can be a worldly straw. And making a bubble mountain you’ve got like a bale wind into it. You’ve got a basin with very liquid or bubble mix and blowing. And get them to use their diaphragm and a big blow to work in their mouths like heavy chewing. So like the apples, like the carrots. Some of them won’t touch carrots, so they can use chewy tubes, blowing bubbles. you want it to be challenging, not too challenging but a bit of a challenge. The traction, the monkey bars are excellent. Going up the incline of the slide, you’re climbing up and coming down. The wall, the climbing wall is excellent.
KOC: Obviously age-dependent, people need to be responsible for things of what’s appropriate for the child’s age. But these are some lovely ideas. In terms of climbing walls, that gives again that lovely heavy work
PM: It gives bilateral, we’re having to coordinate. They’re visually having to find the next piece and then coordinate the right sides of the body with the left side of the body, the right foot with the left foot. So it’s nice bilateral activity and it’s also giving them proprioception, so it’s working on the visual and the proprioceptive, and bilateral piece. With the monkey bars, even if they can just hold on. So we’re getting traction, that’s quite nice. The swings are nice, but if they can incorporate, like maybe even if they have a ball, a gym ball or whatever, and kicking the ball so that they’re not just getting swings to get and proprioception to the legs as well.
KOC: The swinging is stimulating the vestibular. So that’s quite a stimulation. As you say, the kicking of the gym ball, depending on the age of the child, it’s giving them that little bit of heavy work.
PM: Well, basically, slow rhythmical movements are coming. Fast movements, like spinning or fast movements. So depending on where the child is at – if you’ve got a lethargic, tired child, and you’re trying to awaken their systems, it’s fine to do that. But if you’ve got a very hyperexcitable child, you want to calm them. So you want to be involving proprioception. So heavy work. So traction will be great for them. Slow rhythmical movement. So keep the swinging slow and rhythmical. Music is excellent. Using your voice is excellent. And the words, the words that you speak over your children are very, very important. Don’t speak negative words over them, encourage them. Lots of praise and encouragement. If a child is up high [loud], shouting, if you can come under with your voice, that can be very important in the family.
KOC: Of course, it can work the other way too. So if your child was kind of very lethargic, and maybe that you’re trying to stimulate to kind of wake up,
PM: You might need to put your voice up a little bit.
KOC: So there are some lovely tips there Pauline for families to get going with even today. If families want to contact you?
PM: I’m in Kilcoole County Wicklow, I used to be based in Stepaside, about twenty minutes away from where I used to be based. I’m still seeing quite a lot of Dublin clients coming down to me, this space is even going to get better and better. There’s also going to be different coloured lights that will be going up the walls, and there’s going to be different equipment coming in eventually.
KOC: I know from meeting you at so many conferences over the years and courses in the States, the UK, Scotland, and all of that, and this is years ago, and I know you’re still doing the same thing. Your level of knowledge is phenomenal. What you’re doing with the kids is just amazing. I see all the time with the kids that we work with, I couldn’t recommend highly enough to families to come to you or somebody like you. I’m just wondering, from a parent’s point of view now, you’ve spoken about possible tips, in terms of the Occupational Therapy Association – is there anything else that you feel it’s important to say to parents at this point, anything that you feel can be helpful for them, to give them that bit of hope that their child can do well.
PM: Sometimes it can be very, very overwhelming when they’re first starting. So it’s one step at a time. So start with one therapist, especially if the child has got sensory issues, you need an advanced practitioner in sensory integration so that they know how to implement – somebody experienced, that is going to be able to, help your child reach their potential, and especially if the child is on the autistic spectrum, they will need somebody that’s SI trained and that’s used to working with children with autism as well. Once you do meet, once you start the therapy, then I would often advise on the biomedical side of things with Goodwin MacDonnell. So I will be advised in terms of professionals that I feel that the child might need
KOC: That we might need to get that right combination as each child is so unique.
PM: There may be another professional that needs to get involved. That’s very important. And it’s important that, as a professional, that I would be able to relate to the periods. But not to get overwhelmed to just take one step at a time, that we can make changes, a big change, big changes that are going to help the child.
KOC: Thank you so much, Pauline. It’s been great meeting you today and talking to you as always, and I look forward to talking to you again in the future.
PM: Thank you, Karen. Take care now.