The Power of Play

We get told all the time that Play is the most important occupation for
children; play is how children learn, occupy their time, create and grow.  There is loads of research out there about what play is and how children play.  Reading all the information, I understood the complex theory, constructs and philosophy about play and embraced it with vengeance in my previous practice.  I think because play has always (well hopefully at least mostly) been part of my practice, I did not really understand or comprehended the power of play or how simple play can be until this week.

Case Study 1
Bong; a 5 year old with CP, GMFCS 4; MACS 2 (I think he previously may have been GMFCS 3, but his muscles have tightened, reducing function).  He attended therapy and the PT and I noted he had potential to stand and walk.  He was instructed to ‘tindog’ (stand) and he tried, as hard as he could; he is one internally motivated person with the most amazingly beautiful personality.  He would get to a crouched position with his knees in about 30 degree’s flexion.  I then had a small ephinpy, what is Bong’s motivator to stand? Why should he stand? We are just telling him too.

So I grabbed a simple toy for him to reach for; a target. I wish I had before and after photo footage!  All of a sudden he was able to stand at full length and sustained it for 3 times longer, especially when his twin brother was holding the toys and teasing him with it a little; turning a mundane reach activity into a simple game. Magic!  My mantra to myself and the colleagues became, “what is the child’s motivator to do this activity?”  ‘Motivator’ was a common term with mutual understanding of the definition, some colleagues are already rolling their eyes at me, because I am saying it all the time!

Case Study 2
Gwen is a 6 year old with a un-diagnosed condition, she presents with whole body low tone, limited head and trunk control, and very low endurance, or so we thought.  She has great cognitive skills and the most beautiful smile.  Again Gwen was instructed to try a bridge position to assist with building core body strength.  I watched as Gwen rushed though the movement with limited to no control, and was not able to hold the position for longer then a second.  Her face told an amazing story of effort, pain and discomfort; a little like some of those boys at the gym trying to break a record.

So I grabbed a doll and a car and turned her bridge into a real bridge, driving the car and walking the doll under the bridge.  Gwen’s control became much greater and she was able to hold her bridge for 10 seconds! The most important thing I observed was her facial expression, there was a smile and laughter as well as a colleagues comment of “wasn’t that improvement amazing!”

Case Study 3
Carla, a preschool honors graduate, recently diagnosed with TB meningitis arrived with a deeply traumatic fear of hospitals/clinics and anyone touching her, especially her left side which was now weak and had lost a lot of movement.  The first session was soul destroying for all involved; with a push to complete range of motion treatment sessions despite the distress, for fear of further loss of movement.  The plan was to try a graded approach to orientate her to the clinic and people involved as a safe and comfortable place to come.

We had a new clinician come to our next session, and it was amazing.  She approached Carla just like a sister, calm and friendly.  We started the session with Clara and the therapist reading stories; the only activity that Carla enjoyed and found calming in the previously session.  Again is was magic, watching the therapists natural play skills engage, relax and build confidence with Carla.  The most amazing thing was watching the therapist engage Clara with no toys!  The therapist turned all the activities into games by mirroring the movements Carla was doing, making fun and being silly.  To see Carla go from being completely distressed in one session to laughing in the next was mind-blowing; full credit goes to the social worker for this change and her natural ability to play.

For me, these sessions have really awakened the play element and power of play in me.  It has clarified that while research, questioning, and theorizing the complexities of play is essential; and I still strongly believe needs to be continued, explored and researched;  play can be very simple, very powerful and not only in learning and development. Play in action does not have to be complex, it is so simple, and it does not have to have ‘things’ to make it effective.  All Play  needs is someone who is a little creative, fun and willing to get on the floor and be a little bit silly :) Bring it on!

Disability...What Disability?

We recently celebrated Simon’s foundation day.  Foundation day is a community awareness activity,  while acknowledging and celebrating the beginning of Simon, over 28 years ago.  This year they chose to have a sports day with the theme, “Magkarawat Kita Gabos”, “Come lets all play”.  There were over 200 participants, from 3 years old to 40 + years old.  There were labels everywhere, “that ones CP, that one is limb deficient, oh and she is deaf, that one is intellectually disabled”. Every label was represented at least once.  We played tunnel ball, hacky sack (with a bunch of loose rubber bands tied together, worked a treat as it was a slower movement compared

to a ball), pin the tail on the water buffalo, sack races and a number of local games.

Interesting, the labels faded very quickly and soon were no where to to be seen.  Names, people and personalities not only emerged but were celebrated.  Everyone participated in everything; where had the disability gone?  There were tears of laughter, loads of smiles, participation, excitement and what I found most interesting, the abundance of confidence to just get in and have a go, no matter what and with absolutely no fear of failure.  It got me thinking, Nata?(why?)

Who, what and how is ‘disability’ created? Because from what I have just witnessed; these people may have looked different, walked different, may not have heard or saw the same as I did, but they were in no way disabled...at all! Who is creating the disability label and placing it on the person.  How did the disability just disappear like that? What were they doing that was so different?

Simon works very hard on first raising the confidence of the person.  They hold workshops that highlight the persons strengths, not focus on what they can’t do.  It made me reflect on the Australian health systems and question, do our systems really create empowerment for people or does it create a dependence, and more disability, due to its focus on ‘problems’.  While I can not answer these big picture question or change thing on a large scale quickly, I surely can and have asked myself these same questions.  Am I affording empowerment or and I affording disability though my ‘therapy’.  How can I ensure that I empower and build confidence not create more disability and dependence.

With OT I especially think its about utilising the abilities of a person and thinking outside the box for 'intervention' or 'rehabilitation'.   I feel that we loose this sometimes, with pressures of wait lists, high caseloads and a mentality of right, ‘how can I help?” It is through this that we loose sight of the persons true abilities as well as their own strengths to be creative and problem solve.  Today, I saw a 7 year old boy with bilateral upper limb deficiency (above elbow), and leg length discrepancy of 20 cm, walk the full street parade of 2 km, play every game, draw an amazingly detailed picture with his toes, and eat independently with his arms; no adaptive devises, fully independent going for it.

One child (12 yo) impression of the theme, He said every person in this picture has a disability, can you see them???

The creative genius of the person really shone today, and focused it for me, how often in the past did I underestimated it, sometimes allowing the professional v’s client power relationship to over take.  The person is the real expert in themselves and are so cleaver in figuring out how to modify activity and environment something ever so slightly to enable participation.  It was great to see the kids with vision impairment, play ‘soccer’ with a tin can with a rock taped inside the can, so that everyone can see the ‘ball’.  It really re-enforced my role as a sounding board and creative thinker to a person, and not the ‘professional’ or ‘expert’.  How important it is to empower, not to do. Today it really emphasized to me, being an OT is not necessarily about making things easier but possible.  The young boy was putting in a massive effort but was able and passionate about doing the things the way he was.

Some of the communities we go into we get stuck on the idea of 'rehabilitation' being to make someone normal - eg if someone is an amputee we may ask them what they need and they'll say - Money, for a prosthesis.  However this person may have had no leg for 10 years and gets around fine without a leg - works in the farm, feeds his family... performs all his occupational roles, however its the community that needs the rehabilitation (to their way of thinking and limiting someone with no leg) and actually all he needs is some adaptive techniques on how he can go about his ADLs to reduce the chance of secondary impairments. We need to look at the functional level of the individual and focus on improving function within context.

As OT’s should we really be looking at changing the person, maybe the person focus should be about building confidence, and our focus should be more on community education.  This may be old news for those who have been in the industry for longer then I have, however what I really would like people to think about is, no matter what you do... am I really empowering and making the disability disappear or am I adding to the disability?

The Bicol Express Vol 2

I had an ah-ha experience this week, and I think I am finally understanding what they want me to do.  It is an interesting challenge to; 1, speak a different language and 2, try to see an image someone has created who knows the organisation like the back of his hand and want you, no needs you, to see the same thing; but I think I am getting it.

Simon’s main aim is as an advocacy agency for people with disabilities.  They have a tone of different programs, including eye and ear screening, holiday programs for children with disabilities, a rehab center, prosthetics, orthotics    and adaptive equipment workshop, Community Based Rehab (CBR), an Early Intervention Program (EIP) and direct advocacy with local and national government (all done with under 30 staff).

I will be working mostly with EIP and physically assessing and treating clients within the Rehab center (CBR program) at Galilee.  Simon’s role within these programs is as a tertiary community centre that trains, mentors and advocates for local health centers.  Simon also runs its own center (Galilee for rehab, and hopefully soon its own play program, as soon as I design it).  They do this to demonstrate a model of best practice, that other clinics  can mirror and take back to their local towns and to keep their skills up to date.  The local health centers are usually run by team of health professionals, often just 1 physio and maybe 1 Social worker, and are funded by the local government.  Each center is then responsible for sourcing their own community workers (called Facilitators within the Early Intervention Program or ROI’s for the Rehab program).  Simon also runs mentorships and training programs for the ROI and Facilitators.

My job is to design a training program for the EIP facilitators, train up the trainers and then run several workshops for the Facilitators, in an attempt to formalise the training as well as increase the skills of the current facilitators. A small job within 8 months.

I am excited about sinking my teeth into it. The outcomes still change every day, but instead of it looking like a whole new project, the idea or request just becomes another section that fits in well to the over all goal.  I got to see a facilitator in action this week within the community as well as a play group at one of the rehab centers. It was an eye opening experience.  The family I saw all had TB, very basic bamboo hut with nil sanitation and high levels of malnourishment.  It was very evident how directly malnourishment linked with developmental delay.  The Facilitator was awesome, she was one of the original members of Simon and trained as an early education teacher prior.  She was so engaging and graded the activity perfectly.

I also ran a focus group with the current facilitators to see what the training module should contain.  Lots of ideas are developing and the skeleton is taking shape.  I think I can assist a bit with the play group, currently there is no structure or planned activities for the groups, the kids turn up and complete ranging exercises and walking activities.  Watch out creativity here I come!

I start in clinic this week so I can see first hand the type of children that they see and hopefully continue to build the skeleton a little more.

The Bicol Express Vol 1

I have just completed my first week of work, some days it feels like I have been here forever as I have packed in so much and other days it feels like I have just arrived.  On arrival, Simon continues to look like a highly efficient and professional organisation.  I flew into Legaspi and the views are just amazing.  The volcano is within eye sight everywhere and makes orientating to the city a little easier.  The place is so clean, beautiful and luscious, so different to Manila.  Kuya Edward is my boss and he met me at the airport with his wife, Erlynn who also works for Simon.  They took me for a tour of the city and surrounding areas.  The people are just so nice, welcoming and eager to interact with a 'westerner'.

I have moved into a family's house in a granny flat style room.  They are very supportive, know the workings of Simon and a great mentor for the project.  The people in the Philippines are so family orientated and call me uncle, grand nephew and just wrap you up with family like support.

The view from my bedroom! Note the volcano!

The project is taking shape, so far my mission is to assist with implementing functional input and goal orientated focus into their early intervention program.  At the same time, I will be working within the rehab program to see how OT may impact on the service.  Once we have established this I am to complete a manual and training within these areas.  There are focus groups booked in already!

I visited the village, which is a purpose built town for people with disabilities affected by the mega typhoon in 2006.  It is an amazing atmosphere of support and community.  I have met 4 of the children who live there, each with a traumatic story, but surrounded by the most supportive and loving families and community.  It was difficult to see some of the kids, and know what services are available in Aust and how they may look and function if they were in a different setting.  Most of these are medical based i.e surgeries, btx, and other medication.  But this is why I am here, to see what can be done!

I completed one focus group with the Rehab staff this week and nearly had a heart attack with what I thought they wanted me to do; the list of jobs kept growing and growing, and begun to include swallowing and early speech development.  I nearly hit the panic button, did they think I was super therapist!  I had a chat with Kuya Edward who put me right and said that the meeting was mostly about brain storming and the project will be refined over time.  While it may sound like they want me to do these things, this next month is mostly about getting to know the service, gaps and potential areas for development.  Phew!

I have also started language classes with Ate Erlynn, is has cased a few giggles! Put a Ba sound instead of a Ma sound and you go from wishing a good morning to cursing at them.  I have also found that learning the language has been a great in with staff members and the community, the smiles you get from the kids when trying out he language is very entertaining.  I am learning the local language "Bicol" as well as Tagalog the national language.  All languages are made up of the same vowels, and 2 letter sounds. AND each vowel has only ONE sound.  It is right up my ally, I can spell here!

A few interesting things:
Jag jeans (not sure about the authenticity!) $25 aus
Mango's and Banana's all year round are practically free as they are falling off trees everywhere
If you talk Australian most people cannot understand you, put in an American accent and they can
EVERY meal has meat and rice, and sugar, including breakfast and interesting contrast to muesli, but I am loving all the new foods and experiences.

So week two starts on Tuesday 11th as the national election is on the 10th. Here is hoping for a calm and peaceful election and not an early return to Australia!

In Country Orientation

Arrived in Manila at 8 pm at night, to be greeted by the ANGLES, the team of local team who coordinate the projects in the Philippines; and were they Angles, there was cold water bottle and everything waiting for us on arrival.  The flights were awesome, loved the A380, it was massive and full of features.

We stayed the night in Manila and met some of the volunteers already in country, this was an awesome exercise as it gave great insight into the cultural differences. Manila is very hot, and a very large city with extremes of wealth.  It was a real eye opener.

So we spent a week at a camp, meeting other volunteers, orientating to the country and culture and learning how to Karaoke! It was fully fun and awesome to see everyone develop their confidence with the mic.  To get us to practice the language and learn how to catch local transport, we had a mini amazing race within the town we were staying at.  We were given clues at each check point and further information about the country.  Very creative and interesting way to learn.  I also met my host organisation, and first impressions are that they are really busy and have a heap of programs and project to assist people with disabilities.  The level of professionalism was very impressive.  I am very motivated to get started.  From here I attend a session with the Aust Embassy and then fly out on project.  The official start is very close!

Leaving on a Jet Plane!

Well it has finally arrived! I am sitting at Melbourne airport waiting to board the MASSIVE A380 airbus to Singapore then a mad dash onto the next flight to Manila.  Packing and leaving has been a very intreresting expereince.  There were 2 key points that really made it feel like I was leaving; when I handed in my house key, it really felt like there was no return; and when I had to pack everything into by backpack.  I had it all lying out on the table and it took hours to get around to puting it into the bag (which only took a few minutes!)  Again this was a time that made it feel so real.
It has also been amazing to hear and see how people are so supportive of the project.  So many offered of support; financial, physical, emotional and spiritual.  It has just been amazing.

I feel as though I have everything and hopefully have the resourses required. Now I just have to get on that plane and within 12 hours I will be at Manila! Bring it on! I have a week in country training before starting the project.  After then I hope to blog more often as things happen. Till then.

New Fast Fact - Food

Ah the all important food!  The Filipino people are known for their food and hospitality, from what I have been told, you will frequently be offered food and have up to 5 meals a day plus snacks.  Fiesta are frequent, with an open house policy.  The town gets together with an open door policy. As you a celebrate down the street you just pop into your neighbours house which will have a vast spread of goodies on the table and eat with them, then move onto the next house until you get home!  See the fast facts for info on what specialties there may be.