Posted April 14, 2014 by pehl

It feels like a huge cop-out to use the excuse of “being soooo busy” as a reason to have not done something. So I won’t. Rather I will admit that I’ve been procrastinating, because it is something that I’ve dreaded doing – for nearly a whole year. This “something” is admitting that we at Early Choice are no longer providing Speech Therapy at our clinic. Although I haven’t yet figured out how to remove “Speech Therapy” from the heading on the front page of the website, I have taken down the page devoted to it.

It is a decision that was not made lightly, but that was forced upon us by virtue of the changes, which have occurred with respect to insurance reimbursement in this area of pediatric therapy.  The truth is that last summer we had a Speech Therapist at our clinic. Despite the fact that we received plenty of referrals and  plenty of evaluations were performed, the primary insurance company we were dealing with, which shall remain nameless, refused to authorize service for those children following the evaluation. It is an unfortunate fact that many insurance companies, (more and more in fact,) do not consider lack of speech and/or language skills – particularly articulation – to be a medical condition, and therefore consider Speech Therapy to not be “medically necessary”.

Well, needless to say, it is impossible in a private practice, to establish a caseload for a therapist when this is the prevailing attitude. Our Speech Therapist decided she needed to look elsewhere for work, and who could blame her? Certainly not us, but we hated to see her go. Since this type of insurance debacle is becoming common practice, (you’d be wise to not get me started,) we made the disappointing decision to discontinue speech therapy at Early Choice. I do, however, happen to know of some great speech therapists who are in private practice and whose contact information I am happy to pass along.

I apologize for the inconvenience and thank you for your understanding,




Spring Has Sprung

Posted April 10, 2013 by pehl

Yea,  we all survived the move to our new clinic location!  Early Choice Pediatric Therapy is officially a part of the Hazel Dell neighborhood in the Professional Plaza at 9317 NE Highway 99, Suite L.  We’ve pretty much settled into our new site, although we still have many plans for hanging more swing and climbing options and prettying things up.

While we facilitated the move and cleaned out the other building spring arrived.  One day we looked around and noticed the bulbs popping up and the trees blooming out, and WOW!  Here it is, spring, in all it’s glory and including its wildly unpredictable weather patterns.

Finally, the kids can GO OUTSIDE and PLAY!  And I would love to hear from all of you what they play.  No matter what they play they’re feeding their sensory systems.  This is the time to dust of the trikes and bikes, make sure everything works, take off those training wheels that are no longer needed and go for it.  We have wonderful urban trails here in Vancouver that are family and bicycle friendly.  The Discovery Trail is miles long with parking lots in multiple places so you can throw the bikes in the truck, van, (trunk?) and go for ride.  If you don’t ride maybe you can walk and your young’n can ride.  Or for that matter you could all walk.

Long walks are great for children of all ages, and let’s face it, we adults  benefit from moving too, and getting some fresh air, wet or not.  Kids don’t mind getting wet so put on your boots and grab your umbrella.  Two miles is not too far for a 3-year-old, providing it’s fairly flat and the adult doesn’t have an agenda, (meaning a time limit.)  Some caveats: Don’t bring the stroller for ‘just in case he gets tired.’  If you do he will get tired.  Also, when he does get tired do not carry him.  This is why you mustn’t start off with a time limit.  He needs to build endurance, then strength will follow.  You can stop and have a brief rest, but stand firm.  Make him walk.  A drink of water can be magic in this situation.

Spring is also a great time to consider your plan for the summer time when school is out.  How will the children be entertained?  Robin and I both have a strong bias for swimming lessons.  Swimming is one of the best strengthening activities out there.  It also requires bilateral function, thus strengthening bilateral integration skills in a manner that few other activities do. When we ask, “does your child know how to swim?” we aren’t talking about playing in the water.  We want to see the kids able to actually swim across the pool.  In this part of the country, with so much water all around us, it’s imperative for children to learn how to swim.

Our community centers, the Marshal Center and the Firstenburg Center have great day camps of all kinds for all ages.  Sports, science, arts & crafts, they all have a lot to offer including the social skills necessary to navigate in a group of peers.  Also, don’t forget to check out the Vancouver-Clark Parks and Recreations Department programs which include both individual and group options.

Enjoy your walk, Elizabeth



Time Flies When You’re Having Fun

Posted October 24, 2012 by pehl

I received a wonderful surprise just the other day – evening, actually.  I had completed my preparations for the new week on Sunday evening and was lazing about when my phone chimed indicating a new email in my ECPT account.  I do my best not to attend to work related issues on the weekends, but I don’t often succeed.  This time my lack of discipline was rewarded with the previously mentioned surprise – an email from a former client who left our practice about 8 years ago when they moved out of town.  I truly do love it when “our kids” come back to us.  Robin and I often wonder, “…what has become of so-and-so.  Let’s see, he/she would be…what? 12 – no 15 years old by now!  Wow, time flies when you’re having fun!”

I asked the sender, J. permission to post her email as I felt it would provide hope and encouragement to those of you who are just beginning “the journey.”  It’s a long road ahead for many of you, with much hard work and often some heartache and tears.  But it also includes the joy of growth and independence gained.  In response to my request J. wrote back, “I’d be honored to help others.”  So here it is:

Do you remember helping a little three-year-old boy, S. and his family 9 years ago?

We moved from Vancouver to Southern California after we’d worked with you both for about 18 months.  Robin started with casting S. for toe walking after he’d had Botox injections in his legs.  She provided PT to address S’s toe walking.  Then Elizabeth added OT and introduced us to Sensory Integration Therapy.  Dr. Willis helped with the AD/HD and sleep issues….

You started us on a very long journey.  We knew so little at the time and all the information was overwhelming.  Not only did you provide therapy for S., you cared about the mental health of Mom and Dad too.  You both were saviors for us at this time.

Fast forward many years…..S. is in sixth grade now.  At age 5 he went thru several intense neurological evaluations and we learned that the ‘something more’ was Autistic Spectrum Disorder, specifically Asperger’s.  We went thru school district evaluations and S. has had an IEP since Kindergarten.  He has always been mainstreamed but with a one-on-one aide.  After all the hard work and thanks to a wonderful support team, S. is now in the Gifted and Advanced class, completely independent.  There are still challenges, but he has made amazing progress.

There was more, but in an attempt to not be self-aggrandizing I edited out the parts that were the most touching to Robin and myself.  My point for posting it in the first place is to provide a sense of the possibilities that lie ahead.  I am honored to have been trusted with this young man’s care, and to have had the opportunity to work as a team member with his parents and I know this is true for Robin also.  We learn from each child we touch and each family we teach, which is what keeps our work exciting and new.  It’s true that time does fly when you’re having fun.

Blessings to all of you as you walk your path, Elizabeth

Anxiety in Young Children

Posted August 27, 2012 by pehl

In perusing my most recent copy of Advance for Occupational Therapy Practitioners, I discovered an article regarding the role of OT in treating Anxiety Disorders in children.  Titled, “Treating Pre-Adolescents with Anxiety Disorders”, written by Jill S. Feldman, OTR/L, C/SIPT I decided it was exceedingly pertinent to my personal OT practice and have decided to share it here.

Ms. Feldman states that children who had a primary diagnosis of anxiety disorders and had given up on “traditional types of therapy” began to filter into outpatient clinics.  In my practice I have never had a child enter therapy with a diagnosis of anxiety disorder.  Rather, many of the children who enter my practice display symptomology of anxiety disorder, but have not been diagnosed.  I have often wondered over the years, and to this day, why that is.  I can only assume that it is a regional issue, as Ms. Feldman writes from the southern US in Georgia.  Also it seems that there is a distinction made in this article regarding whether the anxiety disorder is a result of inadequate sensory processing or a primary diagnosis, i.e. considered a mood disorder.  Nonetheless, diagnosed or not the issue is the same – children with anxiety disorder benefit from receiving Occupational Therapy.

From the article:

Treating Pre-Adolescents with Anxiety Disorders

The Anxious Child

Anxiety is a rather tricky phenomenon.  However, the beauty of occupational         therapy is that, initially, the therapist does not have to focus on whether a child is anxious.  Instead, the therapist concentrates on the symptoms of the anxiety.

Many times the child’s heightened state of awareness causes difficulties with planning and organizing.  This often results in a heightened emotional-sensory response.  In other instances, if the child primarily has praxis and sensory-processing concerns that cause the anxiety, the occupational therapist can address these core issues and not talk or try to discuss feelings – an approach which is often challenging for children in this age range…

In many cases, occupational therapy’s role is to be a safe place where the child can literally just relax.  There are no consequences to imperfect performance as long as there is effort, nor are there time constraints.

In addition, the activities presented are often designed to reduce the children’s arousal states.  Linear movement, deep pressure, proprioception and oral input, in a fun and low-pressure setting, help to set up an internally organized child.  In turn, discussion is often more beneficial because the child is more apt to share, process and assimilate what has transpired in therapy.

Scales and Self-awareness

In my experience, these pre-adolescents know that they feel anxious when they are anxious.  They understand the difference when they are not anxious, but do not have the ability to feel the “in-between” stages.  Some children know their triggers, but most do not…  [As an aside, because the author does not identify any ages in the article, I would have to say that in my experience children don’t have the personal insight into their feelings and the language capacity required to discuss them escalating or not, until they are about 7 to 8 years of age, possibly a bit younger, but not much.]

[The author goes on to discuss the Alert Program/How Does Your Engine Run? by Mary Sue Williams and Sherry Shellenberger, which makes use of “engine-run” language to provide the child a way of talking about how he feels and train him to recognize triggers and learn strategies he can employ to decrease his arousal state.  She also discusses The Incredible 5-Point Scale by Kari Dunn Buron and Mitzi Curtis, which can be helpful in identifying triggers and what decreases arousal states.  Both of these treatment strategies require a certain level of self-awareness that I don’t see developing until around 7 or 8 years.  In children with developmental delays this may take even longer.]

Fun Breeds Success

Once the child understands how his body works from a cognitive perspective, introducing sensory-motor activities may be highly beneficial.  Although many of the linear swinging, bouncing, “crashing,” scooter boarding, gum chewing, straw blowing, and other tasks are designed to make the nervous system feel good, they are also fun.  Many children with anxiety disorders have trouble just having fun.  [I read this as indicating that Ms. Feldman, as a therapist, teaches the cognitive components first, and follows this with sensory-motor play.  I work with a lot of children under 7 and I introduce sensory-motor play first and allow the child to feel the change, but rarely talk about it at those young ages.]

…Once they start seeing successes in therapy, these [anxious] children are able to generalize the skills they have learned to other environments.  This progress is further extended when family members see growth and provide even more encouragement.  In addition, movement inspires language, facilitating discussions that might not happen because of a lack of organization of thought processes.


 As I continue to see young children, often under the age of 5 years, who clearly display behaviors associated with anxiety I am confident that sooner is better.  That is, the child’s brain has the most plasticity under the age of 6 years, meaning that change in structure, as well as on a neurobiological level, occurs faster and more easily at these young ages.  That is not to say that if a child is over 6 years old change won’t happen, but it will be a more lengthy process.

Questions?  Insights?  Comments?  Start a conversation in our parent forum or email Elizabeth at

5 Skills Your Child Needs for Kindergarten Success

Posted August 9, 2012 by pehl

Whether your child is beginning kindergarten in a few weeks or is further along in his academic career there are 5 skills he will require for classroom success this year.

Attention to Task:  Your child needs to have developed the ability to remain focused on an activity for up to thirty minutes in some situations and in some classrooms.  More realistically, at least to begin the school year, ten to twenty minutes is not unusual.  How long is your child able to attend to a learning activity (not including electronic games or computer-based learning programs) without requiring your attention, assistance or re-direction?

Sitting on a Chair:  This may sound silly, I mean most kids can sit on a chair, right?  Probably, but how long can your child sit still in a chair?  How long can he sit while attending to a task or story without standing up or fidgeting?  And as long as we’re talking about sitting let’s discuss sitting on the floor.  Your child will likely be expected to sit criss-cross on the floor with the rest of his class for periods of time, often in a circle or group.  First of all can he sit criss-cross?  This means, of course, with his feet crossed IN FRONT of him, not under his knees or behind/to the side of his hips, (i.e. W-sit. W-sitting is just plain awful for the development of his feet, knees and hips.  Don’t let him do that.)  If he can sit criss-cross, can he do this without touching the kids on either side of him?  How long can he sit in this position without touching anyone else?

Following Directions:  There is a huge emphasis on auditory learning in our classrooms today.  Children need the ability to understand spoken language in order to learn concepts, of course.  But even before that they need to be able to complete multi-step commands.  For example, “Go get your coat and backpack and line up at the door.”  Is your child able to follow 2 and 3 step directions?  Now see if he can do it without your use of hand gestures.

Sharing:  The classroom environment is one of cooperation.  There is a great deal of sharing these days. In fact little, as I understand it, belongs to a child individually other than his coat and backpack.  I’ve been told that boxes of Kleenex, pencils, erasers, glue, all of those items on the back-to-school list are pooled and shared by everyone.  And that’s the easy part.  What about sharing the basket of crayons and markers, knowing how to wait or ask for the red one, waiting for a turn at the drinking fountain, or giving someone else a turn?  Does your child know how to make a polite request or how to respond to one?  Does he know what to do if he isn’t ready to give up something he’s using?  Does he know what to do if something is taken from him by someone else who doesn’t yet know how to be polite?

Pencil Grasp:  Granted I’m an Occupational Therapist so I have a bias about this particular issue.  But although you might think kindergarten is the time to start practicing this, the truth is kids have already been practicing for 2 or 3 years.  And many of them have established bad habits.  It’s really difficult to train away an inefficient pencil grasp, so let’s look at what’s good and what’s not so good.  An efficient pencil grasp allows mobility of the fingers and pencil, marker or crayon.  It is exemplified by the tripod grasp.  The tripod grasp uses the pad of the index and thumb to guide the pencil with the middle finger providing “mobilized stability”; the ring and little finger are held close to or into the palm.  Also, the pencil lays against the web of the thumb rather than standing straight up.  Many children wrap their thumbs around their index and middle fingers in order to stabilize them on the pencil.  This grasp lends strength, but disallows mobility.  There are many variations on this type “power grasp”, but all have the same outcome.  How does your child hold a marker or pencil?  When he colors does he move his fingers and hand or does he move his whole entire arm?  Does he change the angle of his hand to accommodate the needs of the page, or does he turn the page this way and that?

Here’s to a fun and safe Labor Day weekend and a bright and happy first day of school!  – Elizabeth



Posted July 8, 2012 by pehl

All of the children with whom I work have sensory processing difficulties of one sort or another, to one degree or another.  Because all of the sensory channels work together synergistically it is highly unlikely for any one system to be unaffected.  But the one sensory channel that is the most over-looked and taken for granted is the visual system.  It is also, in many ways, the most important, as well as the most controversial.

A child with perfect eyesight may suffer from significant visual difficulties, which can negatively impact academic learning, sports and daily function.  Visual development and behavior begins at birth and progresses along a continuum with clear milestones.  By the age of 12 months visual tracking skills are typically mature and this is one area I screen in all of the children I see.  A typical 5-year-old should be able to visually track a moving target horizontally, 180 degrees in both directions without moving his/her head, (upon request) and without any jerks or loss of pursuit at midline.  This same child should be able to do this in the vertical plane as well, follow a moving target in a large circle both directions and in random patterns that cross his midline and should also be able to maintain convergence on an object moving towards his nose to approximately 2- 4 inches from his nose.  If I see any difficulties including fatigue with this exercise, I have concerns.

Another visual screening tool I use is a game of catch with a playground ball of approximately 9-inches in diameter.  A five-year-old should be able to catch this without allowing it to touch his/her body, consistently.  If the child traps the ball against his body, closes his eyes, looks away and guesses or grabs at it, or consistently misses the ball, his visual skills are not supporting a functional outcome, and again I have concerns.

Likewise the manner in which a 5, 6, 7-year-old sits while writing or coloring at a table is full of clues to his visual function.  Can he hold his paper or project still with his non-dominant hand, while his dominant hand is busy?  Does he hold his chin in his non-dominant hand?  Does he cover the eye on the non-dominant side after working for a few minutes?  Kids can be cagey about this – it can appear that he is holding his head up, when in fact he may be doing both, covering his eye and holding his head.  Does he always tilt his head to one side, or turn his head so one eye is closer to the page than the other?  I’ve seen children who do all of these things, (not one child who does all of them, but often a couple) and they all had difficulty with writing and/or reading.

Yet another big red flag with respect to visual function is the child who “just doesn’t like to _______” color, draw, write – you fill in the blank.  Kids start wanting to use a writing tool as soon as they’re able to take yours away from you, so not wanting to, or not liking to color just isn’t a typical response.  I worry about these kids and I feel that it is my job to try to figure out the, “why not?”

One strategy in figuring out the “why not”, and/or the “why” is an assessment by a Developmental/Behavioral Optometrist.  This is usually where the issue becomes controversial.  Unfortunately not all insurance companies will pay for these evaluations, or reimburse for vision therapy.  Their reason is often because they consider it to be “experimental” and this is unfortunate because it’s been around almost as long as Occupational Therapy, which officially began in the early 1900’s.

The field of Behavioral Optometry was founded in the 1920’s, based on the work of Dr. A. M. Skeffington.  I found the following quote from Dr. Skeffington in Seeing Clearly, by Lois Hickman MS, OTR, FAOTA & Rebecca Hutchins MS, OTR, FAOTA:

“Vision cannot be separated from the total individual or from any other sensory systems, as it is integrated in all of human performance.  Vision is learned, and therefore, trainable…Behavioral optometrists put a major emphasis on the prevention of vision problems as well as enhancing visual related performance which is at a level less than the individual’s potential.”

Did you know that once a child enters school, approximately 75% of all classroom learning is through the visual pathways; that 90% of the people who have problems with their visual skills are never diagnosed.   I agree, it’s a little overwhelming but as Dr. Richard Kavner, OD, FAAO says, “…seeing, more than any other sense, guides and shapes a person’s behavior and experience of life…it is one gift all people deserve.”


Posted March 20, 2012 by admin

I regularly receive referrals for children with difficulties related to handwriting, which are most often accompanied by concerns regarding poor attention to task and high activity level. I rarely directly assess handwriting skills, per say. I play some tabletop games with the child, which allows me to assess grasping and visual-motor development. I have them draw a person, which in my opinion reflects their perception of their own body. But for the most part I attend to how they use their body: how they sit in a chair, how long they can sit in a chair, the position in which they hold their head when they have a writing tool in their hand, or when they are looking at something on the table top, and hopefully there is time to also assess their movement patterns away from the table. Alas, this is not always possible, but neither is it critical – much can be learned through the interview process.

When I tell parents that one of the contributing factors to immature handwriting and poor attention to task is that their child is lacking in strength, more often than not they think I’m crazy. In response to this news I routinely hear statements along the line of, “How is that possible? He runs all day long!”

I see and hear the parent’s confusion, disbelief and down right disagreement with my assessment, so I offer this explanation: Movement requires far less strength than static positions and ‘fast’ is far easier than ‘slow’. Consider for a moment how you feel when you are required to stand in a line for a long period of time, or how it feels to stroll around the Expo Center at a home show, or even a store at the mall. Now consider how long you are able to sit in a chair without moving, shifting or getting up to get coffee. Does sitting in an upright chair for long periods make you tired?

When I see a child that runs everywhere rather than walk, who crashes to the floor or into a wall or into an adult rather than stop himself BEFORE crashing, who crashes involuntarily because momentum gets the best of him, I see a child who lacks core development and strength, and also usually, head control.

Adequate core strength and head control are critical to the child’s ability to walk in a controlled fashion, to avoid crashing and bumping into others, and importantly to sit still in a chair for prolonged periods of time in a manner that facilitates attention to task and thus learning. The ability to actively listen while sitting still, to maintain a flexed-neck position for reading and writing – to hold everything still while moving only a hand and arm while writing – well clearly it’s all more complicated than it first appears. Rest assured that if a child is able, he will and if he doesn’t, there is always a reason why.