At Casa Colina, John is taking swim with an occupational therapist. It has been so rewarding on so many levels. John is 5. In January, he was not water safe.
I've had private swim instructors for 3 years try to teach him in my parents pool. He is good at distraction and a master of manipulation. He was in charge more than the teachers, having them resort to baby games you'd play with toddlers or use in a mommy and me classes. He'd sit on the edge or on the step, they'd splash water on his legs and the two of them would sing silly water songs that would end with John being pulled into the pool. John would love this so much that they would do this over and over. He wouldn't attempt picking anything off the bottom of the pool, would get disorientated when his head would go under water, and could not hold his breath. He hated doing anything with the kickboard and refused to do "big arms". He'd swallow lots of water and most attempts to teach him to close his mouth just didn't work. We'd resort to him wearing a life vest every time he went in the water. He had no fear at other times and would want to jump off the edge, but then do nothing to try to swim to the side. The life vest made it more fun for him and put us at ease. But, that doesn't solve the problem.
This year, I talked to John's OT about moving an OT session into the pool. Casa Colina (where John is in OT) advertises an 8 week swim program that is taught by an Occupational Therapist. After speaking to her, I realized that this was the perfect fit for John. The water provides a sensory experience for him and they can work on motor planning, as well as water safety and swim.
Watching him progress so rapidly in this class has been so awesome. They work on strengthening his core, breath control, floating, swimming, motor planning, water games, swimming to bottom of pool, jumping in and swimming to the edge, etc. Having an OT teach John these skills was exactly what we needed to see improvement. He's on his second, 8-week session. He is holding his breath, swimming to the bottom and getting rings, swimming the length of the pool, and floating on his back. He used to avoid tipping his head back, but she got him to relax and float. She taught him that when he is swimming or feeling like he is sinking, he can roll to his back and float. She has worked with him, going from front to back and then back to swimming. He has some motor planning work to do on this skill, but it's a long way from sitting on the edge singing songs and being splashed in the legs! They work a lot on strength, endurance, muscle control, motor planning, etc., while playing games and swimming. It's a great fit and I'm so thankful for the programs we have found for John.
Showing posts with label Casa Colina. Show all posts
Showing posts with label Casa Colina. Show all posts
Tuesday, July 12, 2011
Monday, September 6, 2010
John Update
It's been so long since I updated the blog, so I thought I would write about what John has been up to. First of all, John will be turning 5 in November and we have kept him in preschool this year. He is attending two schools. La Verne Parent Participation is a co-op preschool that he attended last year and is continuing for 2 days a week this year. He stays for an additional 2 hours in the afternoon for a pre-K program. On the other days, John is attending the "Little Learners" program located in the local My Gym facilities. He goes for 3 hours and it's a great setting for him because the equipment in the room gives him a little bit of self-directed OT (complete with ball pit, trapeze bars, balance beam, monkey bars, slides, bridges, tunnels, trampoline, etc.)
Last September, John visited with Autistic Specialist, Dr. Bauman, at Casa Colina and she recommended a few things for us since John wasn't qualifying for services. To address the problem of separating from me, potty training issues, and behavioral issues in the home, we hired a therapist to come in the home. For most of the year, she came weekly and helped John work on conversation skills, feelings, changes in feelings, writing his name, a few exercises for body awareness, and set up monthly and yearly goals for him.
After months of working together, we realized together that what John needed more than anything else was OT. He was excelling when it came to one-on-one activities and has been reading for a year. Sensory problems and lack of body awareness seemed to be the reason for most of the problems we were encountering (which we had known for years, but finally were able to get the appropriate program for him). We had an OT evaluation, which resulted in a recommendation of 2 times a week. While we waited on the waiting list for therapy, our in-home therapist worked with the OT to come up with activities we could do in the home to help John.
Once we started OT, we changed his in-home to just once a month. It's great to continue having someone help with goal setting, charting progress, and recommending new programs. There are a couple of huge things that helped John make leaps and bounds and I'll detail them below.
BASEBALL
John discovered Major League Baseball this year. After going to a minor league Quakes game, he was hooked. He follows the stats, the scoreboard, the game, the players, etc. He quickly became an Angel fan and a rowdy Dodger fan. What is so significant about this is that prior to baseball, John would not play ball (any kind of ball), wouldn't play catch, couldn't catch a ball, etc. Since baseball, something clicked in John's head, and he started surpassing his monthly/yearly goals. He is obsessed with dates, scores, and stats. Every morning, he is up before anyone else and he is on the computer checking MLB.com and checking the scores. He gives us the update on who won, what inning the home runs were scored in, and what player hit them. To him, Dodgers are the "right team" and everyone else is the "wrong team". He has attended about 15-20 major league games so far this season and last night went to batting practice at the Dodger game and came home with an official MLB baseball that a Giants fan gave him. He turned to my husband and said, "Daddy, some Giants fans are nice!" Yes, John, there are some. ;) (to quote my husband's Facebook status today).
CASA COLINA KIDS CREW
Casa Colina has this amazing program to teach social skills. It's an 8-week class that John is about 5 weeks into. John has learned and applied each lesson he has learned at this class and it's such a delight to watch. The first week was about greetings and salutations. The second week concentrated on body awareness while talking to others. They discussed body position (direction facing while talking), eye contact, etc. The third week they talked about personal space and used the concept of being a "space invader" when they got too close to someone else. John took this lesson to heart and spent the next week self-regulating himself. He didn't like the idea of being a space invader. He'd put his feet on me an then ask, "is this a space invader"? Every lesson concentrates on social awareness and skills that are used during everyday communication. It has proven to be so useful for John and is something I'm so glad was recommended to us. We have 3 weeks left of the program.
NOW THAT SCHOOL IS BACK IN
From the first day of school, I realized how much we've progressed over this last year. John is a different kid this year at school. He is social with the other kids, stays with the group, able to hold focus and attention, and learning to write his numbers. (since he has had very low fine motor skills, controlling a pencil is difficult.) I can't wait to see where this next year takes him developmentally. This journey we've been on has been very tough at times, but it has also been one of the most rewarding things our family has been through too. This next year is going to be a big year for John. We've come so far and I'm so proud of my little guy.
Last September, John visited with Autistic Specialist, Dr. Bauman, at Casa Colina and she recommended a few things for us since John wasn't qualifying for services. To address the problem of separating from me, potty training issues, and behavioral issues in the home, we hired a therapist to come in the home. For most of the year, she came weekly and helped John work on conversation skills, feelings, changes in feelings, writing his name, a few exercises for body awareness, and set up monthly and yearly goals for him.
After months of working together, we realized together that what John needed more than anything else was OT. He was excelling when it came to one-on-one activities and has been reading for a year. Sensory problems and lack of body awareness seemed to be the reason for most of the problems we were encountering (which we had known for years, but finally were able to get the appropriate program for him). We had an OT evaluation, which resulted in a recommendation of 2 times a week. While we waited on the waiting list for therapy, our in-home therapist worked with the OT to come up with activities we could do in the home to help John.
Once we started OT, we changed his in-home to just once a month. It's great to continue having someone help with goal setting, charting progress, and recommending new programs. There are a couple of huge things that helped John make leaps and bounds and I'll detail them below.
BASEBALL
John discovered Major League Baseball this year. After going to a minor league Quakes game, he was hooked. He follows the stats, the scoreboard, the game, the players, etc. He quickly became an Angel fan and a rowdy Dodger fan. What is so significant about this is that prior to baseball, John would not play ball (any kind of ball), wouldn't play catch, couldn't catch a ball, etc. Since baseball, something clicked in John's head, and he started surpassing his monthly/yearly goals. He is obsessed with dates, scores, and stats. Every morning, he is up before anyone else and he is on the computer checking MLB.com and checking the scores. He gives us the update on who won, what inning the home runs were scored in, and what player hit them. To him, Dodgers are the "right team" and everyone else is the "wrong team". He has attended about 15-20 major league games so far this season and last night went to batting practice at the Dodger game and came home with an official MLB baseball that a Giants fan gave him. He turned to my husband and said, "Daddy, some Giants fans are nice!" Yes, John, there are some. ;) (to quote my husband's Facebook status today).
CASA COLINA KIDS CREW
Casa Colina has this amazing program to teach social skills. It's an 8-week class that John is about 5 weeks into. John has learned and applied each lesson he has learned at this class and it's such a delight to watch. The first week was about greetings and salutations. The second week concentrated on body awareness while talking to others. They discussed body position (direction facing while talking), eye contact, etc. The third week they talked about personal space and used the concept of being a "space invader" when they got too close to someone else. John took this lesson to heart and spent the next week self-regulating himself. He didn't like the idea of being a space invader. He'd put his feet on me an then ask, "is this a space invader"? Every lesson concentrates on social awareness and skills that are used during everyday communication. It has proven to be so useful for John and is something I'm so glad was recommended to us. We have 3 weeks left of the program.
NOW THAT SCHOOL IS BACK IN
From the first day of school, I realized how much we've progressed over this last year. John is a different kid this year at school. He is social with the other kids, stays with the group, able to hold focus and attention, and learning to write his numbers. (since he has had very low fine motor skills, controlling a pencil is difficult.) I can't wait to see where this next year takes him developmentally. This journey we've been on has been very tough at times, but it has also been one of the most rewarding things our family has been through too. This next year is going to be a big year for John. We've come so far and I'm so proud of my little guy.
Wednesday, May 27, 2009
NeuroPsych Evalutation Report
We received the evaluation report from Dr. Seibert regarding John's evaluation from Feb-April.
At the time of this test, John is considered 3 years, 2 months old.
Listed below are some of the highlights from the 12 page report:
Areas of concern defined by parents:
1.He needs to be taught certain things that other kids seem to pick up naturally
2. Demonstrates some echolalia (repeats the ends of some questions when asked)
3. Preoccupations with narrow areas of interest and focus (in phases)
examples: clocks, lining up cars, left-turn arrows, train tracks,& reading clothing tags
4. Frustration tantrums -- problems managing anger
5. Craves sensory stimuli (specifically with hands/touch, chew non-food items)
6. Trouble with eating (messy eater, prefers to use hands, overstuffs mouth)
Areas of concern Socially:
1. Limited eye contact
2. Unable to show comfort to others in distress
3. Some pretend play
4. mostly parallel play
Areas of Concern defined by Current Teachers:
1. Little Attention Span
2. Easily Destracted
3. Limited Spontaneous Speech
4. Limited to no interaction with other children
5. Loves sensory activities (finger painting, eating with hands, feet in sand)
6. Limited interest in classroom when given free time (lines up cars or 'reads' a book)
7. Delayed academically
8. No eye contact
Things the teachers did not notice:
1. No strange or odd preoccupations
2. No behavior problems
3. No transition tantrums
Observation In the Clinic over 2 observation days:
1. No tantrums or upsets
2. mild mannered
3. Reduced eye contact
4.quiet most of the time, with only one-word utterances
5. Poor intelligibility of speech
6. Fairly distractible, but was able to maintain focus if sitting on lap, bounced, or squeezed
Observation at School:
1. John did not remain on carpet square during storytime and had to sit on teacher's lap to maintain focus
2. Wandered room
3. Responded to yes/no questions
4. Kids lined up to wash hands, John consistently wandered out of line; needed re-direction
5. Food placed in front of him, told to wait, kept putting hands in spaghetti; needed to be reminded to wait multiple times
6. Facial expression blunted most of the time
7. Complied with verbal instruction but never made eye contact; appeared not to be paying attention, but would respond appropriately
8. Messiest eater in the class
9. After lunch, wandered over to line up cars
10. Wandered to book area, opened book, sat down, and "read" it
11. On playground, rode tricycle alone most of the time
12. Smiled at girl who climbed on "caboose" of tricycle
13. Stopped bike purposely to have 2 other girls crash into him; all giggled; John repeated again
14. Gravitated to outskirts of playground most of time
15. Seemed to be "in his own world"
ADOS test (Austim Diagnostic observation Schedule):
1. John responded to name by turning toward examiner
2. Poor eye contact; used eye contact to get the examiner to do something again
3. Showed some shared enjoyment with examiner, but not consistent; interested mostly in having sole control over a toy; needed to be re-engaged to play with examiner
4. Did not spontaneously give objects to examiner; but would comply after repeated requests
5. Could show functional use of toys when prompted but did not demonstrate any symbolic play on own
6. Did not initiate any social interactions, but did not mind the examiner playing alongside him
7. Produced single word utterances, most not intelligible
8. Showed only occasional, unusaual sensory behavior -- objects in mouth
9. According to ADOS, fell within the spectrum, but not autism, per se
GARS test completed by parents scored an 81 -- meaning "possibly" has autism
Other Tests Administered:
1. Parents should request an IEP (Individulaized Educational Plan) from Bonita Unified School District based on this second opinion requesting:
3. Parents should seek additional play and social opportunities and instruction for John with peers close in age; John needs facilitation to initiate and sustain engagement with other children and verbal cues to help him play
4. Seek parent education and support services
At the time of this test, John is considered 3 years, 2 months old.Listed below are some of the highlights from the 12 page report:
Areas of concern defined by parents:
1.He needs to be taught certain things that other kids seem to pick up naturally
2. Demonstrates some echolalia (repeats the ends of some questions when asked)
3. Preoccupations with narrow areas of interest and focus (in phases)
examples: clocks, lining up cars, left-turn arrows, train tracks,& reading clothing tags
4. Frustration tantrums -- problems managing anger
5. Craves sensory stimuli (specifically with hands/touch, chew non-food items)
6. Trouble with eating (messy eater, prefers to use hands, overstuffs mouth)
Areas of concern Socially:
1. Limited eye contact
2. Unable to show comfort to others in distress
3. Some pretend play
4. mostly parallel play
Areas of Concern defined by Current Teachers:
1. Little Attention Span
2. Easily Destracted
3. Limited Spontaneous Speech
4. Limited to no interaction with other children
5. Loves sensory activities (finger painting, eating with hands, feet in sand)
6. Limited interest in classroom when given free time (lines up cars or 'reads' a book)
7. Delayed academically
8. No eye contact
Things the teachers did not notice:
1. No strange or odd preoccupations
2. No behavior problems
3. No transition tantrums
Observation In the Clinic over 2 observation days:
1. No tantrums or upsets
2. mild mannered
3. Reduced eye contact
4.quiet most of the time, with only one-word utterances
5. Poor intelligibility of speech
6. Fairly distractible, but was able to maintain focus if sitting on lap, bounced, or squeezed
Observation at School:
1. John did not remain on carpet square during storytime and had to sit on teacher's lap to maintain focus
2. Wandered room
3. Responded to yes/no questions
4. Kids lined up to wash hands, John consistently wandered out of line; needed re-direction
5. Food placed in front of him, told to wait, kept putting hands in spaghetti; needed to be reminded to wait multiple times
6. Facial expression blunted most of the time
7. Complied with verbal instruction but never made eye contact; appeared not to be paying attention, but would respond appropriately
8. Messiest eater in the class
9. After lunch, wandered over to line up cars
10. Wandered to book area, opened book, sat down, and "read" it
11. On playground, rode tricycle alone most of the time
12. Smiled at girl who climbed on "caboose" of tricycle
13. Stopped bike purposely to have 2 other girls crash into him; all giggled; John repeated again
14. Gravitated to outskirts of playground most of time
15. Seemed to be "in his own world"
ADOS test (Austim Diagnostic observation Schedule):
1. John responded to name by turning toward examiner
2. Poor eye contact; used eye contact to get the examiner to do something again
3. Showed some shared enjoyment with examiner, but not consistent; interested mostly in having sole control over a toy; needed to be re-engaged to play with examiner
4. Did not spontaneously give objects to examiner; but would comply after repeated requests
5. Could show functional use of toys when prompted but did not demonstrate any symbolic play on own
6. Did not initiate any social interactions, but did not mind the examiner playing alongside him
7. Produced single word utterances, most not intelligible
8. Showed only occasional, unusaual sensory behavior -- objects in mouth
9. According to ADOS, fell within the spectrum, but not autism, per se
GARS test completed by parents scored an 81 -- meaning "possibly" has autism
Other Tests Administered:
- DAS-II - Differential Ability Scales - Verbal & Non-Verbal Cognitive Development; John scored in the 66th percentile for Verbal Comprehension (average) and 58th percentile for Naming Vocabulary (also average); For the Non_verbal section, he scored in the average for Picture Similarities, but scored mildly impaired on Pattern Contruction; His total scores for this test was a 96, and fell within the average range (39th percentile)
- Although the examiner felt that the scores need to take in account that John had a very low attention span, needed frequent re-direction to the tasks at hand, cues to remind him to persist in his effort, prompting to consider the full range of answer chocies before responding, etc.
- PLS-4 - PreSchool Language Scale - measures comprehension and expressive language skills; John's auditory comprehension scored of that of a 2-year 11 month old child (average range for his age) Most advanced skills he showed was the ability to distinguish activities that were day from activities at night. He could understand picture analogies, identified objects, identified colors and common activities, understood quantitive concepts (one vs. all), and descriptive concepts (big vs. small) Could follow 2 step commands, but COULD NOT show spatial concepts (on, off, in, out of), pronouns (I, me, you) or negatives (show me the baby that is not crying) His scores resulted in that of a 2-year 8 month old, which is on the low average for his age range.
- VABS-II - Vineland Adaptive Behavior Scale - questionnaire filled out by parents; day-to-day functioning;
- Communication scored low at 1 year 11 months;
- Expressive Language scored at 2 years, 10 months;
- Written Language was HIGH at 4 years, 3 months - able to recognize upper and lowercase alphabet, own written name in printed form;
- Daily Living Skills ---
- Personal Care-2 years 9 months,
- Domestic Care - 2 years, 2 months;
- Community Functioining HIGH at 4 years 5 months
- SOCIAL skills - low at 1 year, 7 months;
- Play behaviors -1 year, 10 months
- Coping - 2 years, 7 months
- Fine Motor - 3 years, 5 months
- Basic Language skills have caught up to low average-average range, he still shows delays in speech intelligibility, as well as in pragmatic use of language in social/communicative ways
- Delays in age-appropriate social and play behaviors
- Shows some atypical restricted and repetitive behaviors
- Falls short of Autism Diagnosis at this time
- However, meets criteria for PDD-NOS, Pervasive Developmental Delay, Not Otherwise Specified, otherwise known as "atypical autism"
- He has shown signs that intervention boosts his progress
1. Parents should request an IEP (Individulaized Educational Plan) from Bonita Unified School District based on this second opinion requesting:
- Placement in a classroom with a better teacher-to-student ratio than a typical educational classroom; Should have curriculum appropriate for average-range overall intellectual level, but with resources that meets his needs for supervision, assistance, difficulties for sustained attention, and facilitation for social activities OR in a regular classroom with a one-on-one aide
- John clearly needs speech therapy to address intelligibility and language pragmatics
- John should receive an OT evaluation to address sensory issues and motor skills concerns
3. Parents should seek additional play and social opportunities and instruction for John with peers close in age; John needs facilitation to initiate and sustain engagement with other children and verbal cues to help him play
4. Seek parent education and support services
Thursday, October 30, 2008
Visit with Dr. Bauman & John's Diagnosis
On Tuesday, John, Bill and I visited Dr. Margaret Bauman, who is an Autistic Specialist in Child Neurology out of Massachusetts General Hospital. She works with Children's Services at Casa Colina and travels every quarter to visit. We had an hour-and-a-half appointment with her for a second opinion/diagnosis and next steps.
First of all, I want to say that it was a pleasure to talk to her. She does research into the causes of autism, as well as treating patients with Autism and has a good understanding of the development of children. She suggested so many things and gave us such a good analysis of the situation.
To see Dr. Bauman, an exetensive packet of information must be supplied that includes birth records, hospital records, any testing scores, analysis, or assesments, etc. She also met with John's teachers at Casa Colina and spoke to them about their observations. When Bill, John and I arrived, we went into an office with lots of toys to keep John occupied. (6 months ago, they wouldn't have kept his attention, but today, John was able to play most of the time without being re-directed. During the last half hour, he became more 'needy' of my attention and even started to do things like climb on the table and laugh after I told him to stop)
Dr. Bauman talked to Bill and I a long time, asking us questions about his development, behaviors, things we've noticed, therapies we've done, improvements we've made, etc. After our discussion, she gave us her assesment of John.
She believes that John has PDD-NOS. To understand this, let me break it down.
PDD is the category, which is Pervasive Developmental Disorder.
There are 5 disorders that fall under the PDD category. They include Autism, Asperger's, Rhett Syndrome, fragile X syndrome, and PDD-NOS.
In simple terms, the NOS, means Not Otherwise Specified, meaning that many symptoms are present that resemble those other 4 disorders, but not enough to receive a diagnosis.
Now, to make it clear, PDD is the autistic SPECTRUM, so all 5 of these diagnosis are on the spectrum, but to a varying degree, with PDD-NOS being the one that shows the least amount of symptoms.
There are a few things that she pointed out that are a cause for concern. A few that we talked about are:
- his lack of interest in people, limited eye contact
- his play skills (allows others to set the framework of play and then he 'learns' play, rather than naturally picks it up)
- his irregular sleep patterns
- sensory issues
- eating issues
In moving forward, she would like to find out WHY John is showing these symptoms and if other things are wrong. She is sending us to 3 other specialists to begin with.
1. a developmental optomitrist - She wants visual perception, visual tracking, and depth perception looked at. Not what he sees, but how he sees. This could lead to an explanation of limited eye contact or limited social interaction. (From PubMed.Com: The role of the optometrist in treating children experiencing learning disabilities embraces numerous areas beyond the customary optometric services. Etiological, diagnostic and therapeutic factors are discussed stressing visual functional disorders, perceptual-motor and developmental lags and cognitive style.)
2. a Gasteroentologist, which will test him for acid reflux, which could explain his poor sleeping patterns, resulting in tired, lazy, and poor concentration/attentive skills. She also wants them to confirm or rule out a lactose intolerence, so we know if we should keep him on or off dairy.
3. a Neuro Psychologist that would look at cognitive skills and agree/disagree with the diagnosis. A neuropsychologist is a psychologist who specializes in studying brain behavior relationships. Neuropsychologists have extensive training in the anatomy, physiology, and pathology of the nervous system. (Sensory issues & problems deal with the brain's inability to process the information correctly that the nervous system is sending it) This person can also be involved in the IEP (Individualized Education Plan) meetings with the School District. She can help to be an advocate for John's Educational Needs.
After seeing these 3 specialists, we will then re-visit Dr. Bauman in January.
The other thing that is recommended to do is at Casa Colina. We are getting a swallow test done with a speech pathologist. The teachers at Casa think he is aspirating while eating. (inhaling food/debris into the wind pipe or the lungs) This is caused by apraxia or low tone in the mouth. Basically, poor oral motor skills causing his muscles within his mouth to not work together while eating. (She also told the START teachers that we may want to consider a sleep study because if he is truly not sleeping well, it would explain many of the symptoms John shows during the day from lack of sleep.--although she didn't mention it to Bill & I)
Now, as far as moving forward with his "education", she gave us a bunch of advice. She says she does not want to see him in an autistic class or a class with kids who have behavioral problems because she believes John needs models in the classroom to teach him how to interact socially. She is afraid that it will hinder his development to "learn" by picking up on autistic behavior and not have a model that he can raise up to. She said that Katie has been John's best teacher and helps to structure his play.
So, she recommends that he be put in a preschool program that is "integrated" with children who are "normal" , as well as slightly delayed, but not with kids that have behavioral problems for fear he'd model the behavior. She wants him in the bottom or the middle, as far as skill set, but not at the top. She says other states have wonderful programs for this, but she doesn't think California has anything set up like this. She said that the integrated class would have 2 teachers and then a one-on-one aide for John to be guided back into participation if he wanders.
For me, Dr Bauman's words, diagnosis, and advice validated all the feelings that I have had --- some days feeling like it's "textbook autism" and then other days that seemed like the diagnosis was wrong. But, to be clear, the diagnosis was never wrong. 6 months ago John was a different kid. He had no speech, his cognitive level was very immature, he had no joint attention (ability to point out objects), etc. After understanding this disorder, the only diagnosis he should have received 6 months ago was autism. The fact that we are at PDD-NOS is an indication that early intervention is working, that Neurofeedback is working, and that with prayer, hope, hard work, and a battle plan, there is a chance for healing.
First of all, I want to say that it was a pleasure to talk to her. She does research into the causes of autism, as well as treating patients with Autism and has a good understanding of the development of children. She suggested so many things and gave us such a good analysis of the situation.
To see Dr. Bauman, an exetensive packet of information must be supplied that includes birth records, hospital records, any testing scores, analysis, or assesments, etc. She also met with John's teachers at Casa Colina and spoke to them about their observations. When Bill, John and I arrived, we went into an office with lots of toys to keep John occupied. (6 months ago, they wouldn't have kept his attention, but today, John was able to play most of the time without being re-directed. During the last half hour, he became more 'needy' of my attention and even started to do things like climb on the table and laugh after I told him to stop)
Dr. Bauman talked to Bill and I a long time, asking us questions about his development, behaviors, things we've noticed, therapies we've done, improvements we've made, etc. After our discussion, she gave us her assesment of John.
She believes that John has PDD-NOS. To understand this, let me break it down.
PDD is the category, which is Pervasive Developmental Disorder.
There are 5 disorders that fall under the PDD category. They include Autism, Asperger's, Rhett Syndrome, fragile X syndrome, and PDD-NOS.
In simple terms, the NOS, means Not Otherwise Specified, meaning that many symptoms are present that resemble those other 4 disorders, but not enough to receive a diagnosis.
Now, to make it clear, PDD is the autistic SPECTRUM, so all 5 of these diagnosis are on the spectrum, but to a varying degree, with PDD-NOS being the one that shows the least amount of symptoms.
There are a few things that she pointed out that are a cause for concern. A few that we talked about are:
- his lack of interest in people, limited eye contact
- his play skills (allows others to set the framework of play and then he 'learns' play, rather than naturally picks it up)
- his irregular sleep patterns
- sensory issues
- eating issues
In moving forward, she would like to find out WHY John is showing these symptoms and if other things are wrong. She is sending us to 3 other specialists to begin with.
1. a developmental optomitrist - She wants visual perception, visual tracking, and depth perception looked at. Not what he sees, but how he sees. This could lead to an explanation of limited eye contact or limited social interaction. (From PubMed.Com: The role of the optometrist in treating children experiencing learning disabilities embraces numerous areas beyond the customary optometric services. Etiological, diagnostic and therapeutic factors are discussed stressing visual functional disorders, perceptual-motor and developmental lags and cognitive style.)
2. a Gasteroentologist, which will test him for acid reflux, which could explain his poor sleeping patterns, resulting in tired, lazy, and poor concentration/attentive skills. She also wants them to confirm or rule out a lactose intolerence, so we know if we should keep him on or off dairy.
3. a Neuro Psychologist that would look at cognitive skills and agree/disagree with the diagnosis. A neuropsychologist is a psychologist who specializes in studying brain behavior relationships. Neuropsychologists have extensive training in the anatomy, physiology, and pathology of the nervous system. (Sensory issues & problems deal with the brain's inability to process the information correctly that the nervous system is sending it) This person can also be involved in the IEP (Individualized Education Plan) meetings with the School District. She can help to be an advocate for John's Educational Needs.
After seeing these 3 specialists, we will then re-visit Dr. Bauman in January.
The other thing that is recommended to do is at Casa Colina. We are getting a swallow test done with a speech pathologist. The teachers at Casa think he is aspirating while eating. (inhaling food/debris into the wind pipe or the lungs) This is caused by apraxia or low tone in the mouth. Basically, poor oral motor skills causing his muscles within his mouth to not work together while eating. (She also told the START teachers that we may want to consider a sleep study because if he is truly not sleeping well, it would explain many of the symptoms John shows during the day from lack of sleep.--although she didn't mention it to Bill & I)
Now, as far as moving forward with his "education", she gave us a bunch of advice. She says she does not want to see him in an autistic class or a class with kids who have behavioral problems because she believes John needs models in the classroom to teach him how to interact socially. She is afraid that it will hinder his development to "learn" by picking up on autistic behavior and not have a model that he can raise up to. She said that Katie has been John's best teacher and helps to structure his play.
So, she recommends that he be put in a preschool program that is "integrated" with children who are "normal" , as well as slightly delayed, but not with kids that have behavioral problems for fear he'd model the behavior. She wants him in the bottom or the middle, as far as skill set, but not at the top. She says other states have wonderful programs for this, but she doesn't think California has anything set up like this. She said that the integrated class would have 2 teachers and then a one-on-one aide for John to be guided back into participation if he wanders.
For me, Dr Bauman's words, diagnosis, and advice validated all the feelings that I have had --- some days feeling like it's "textbook autism" and then other days that seemed like the diagnosis was wrong. But, to be clear, the diagnosis was never wrong. 6 months ago John was a different kid. He had no speech, his cognitive level was very immature, he had no joint attention (ability to point out objects), etc. After understanding this disorder, the only diagnosis he should have received 6 months ago was autism. The fact that we are at PDD-NOS is an indication that early intervention is working, that Neurofeedback is working, and that with prayer, hope, hard work, and a battle plan, there is a chance for healing.
Sunday, October 26, 2008
John's New Results
John was assessed on Sept. 8, 2008 for entry into the START program. I recently received his results. At the time of the assessment, John was 34 months old. There have been 3 assessments where I can compare his progress. You'll see the May 2008 scores, which were the Regional Center's. Second, you will see his Casa Colina July 2008 update scores. Finally, you'll see his latest Sept. 2008 scores.
---------- May (30 mths ) / July (32 mths ) / Sept. (34 months)
Gross Motor --- 26 months / 26 months / 16 months (??)
Fine Motor --- 21 months / 23 months / 31 months
Cognitive ---- 21 months / 24 months / 28 months
Language Receptive ---- 6 months / 17 months / 33 months
Language Expressive ---- 9 months / 17 months / 31 months
Socialization ---- 10-17 months / 10-17 months / 29 months
Self Help ---- 23 months / 23 months / 24 months
Other than Gross Motor, John improved since July and dramatically since May.
During the time from June-Sept., he attended Early Start Preschool at Casa Colina, had Speech Therapy two times a week, 5 hours a week of in-home, and 40 sessions of Neurofeedback. He began OT/SI the first week of September.
It is worth noting here: Neurofeedback claims training can make a child with autism attentive, calm, and sociable. We have seen certain behaviors disappear and have watched John become calm. John is a different person today than he was 6 months ago when all of this started. It is hard to say what specifically helped John because we've been doing so much. However, the Neurofeedback seems to show us some patterns that are worth looking into. First, when we changed his protocals (the location of the EEG monitor, training a specific part of the brain), he began to have accidents in the seat and aggressive behavior seemed to manifest. We removed those protocals and went back to the old ones and there were no more accidents in the seat during the sessions and his aggressive behvaior seemed to go away.
Secondly, for the last 4 weeks, John has not attended Neurofeedback (he went 3 times over the last 4 weeks, as opposed to 5 days a week that we were doing before)--- first, due a family vacation and then, due to a death in the family. Over the last week-to-week-and-a-half, Bill and I have noticed that typical Autistic behavior (and some sensory issues) that had seemed to disappear has returned.
Things like:
Biting & chewing on shirt
Biting own skin
Chewing on objects
Frustration level is awful
Cries inconsolable again
Angry - bangs hands on table or objects when upset
Has been hard to take out in public - clingy, whiney, cranky, tantrums
Cries when I leave him in class
Tomorrow, John will begin a normal schedule of Neurofeedback training of 5 days a week. I'll report back to see if these disappear once we resume it. The goal of Neurofeedback is to train the brain to self regulate. After a repeated number of sessions, the brain will "remember" its training and be able to self regulate on its own.
He also has developed a cold. I notice that everything seems to be magnified when he's sick.
This week is a big week. Tomorrow, we go back to Neurofeedback. Tuesday, we see Dr. Baumen, an autistic specialist. Wednesday is John's assessment with the public school system and Friday is Halloween!
---------- May (30 mths ) / July (32 mths ) / Sept. (34 months)
Gross Motor --- 26 months / 26 months / 16 months (??)
Fine Motor --- 21 months / 23 months / 31 months
Cognitive ---- 21 months / 24 months / 28 months
Language Receptive ---- 6 months / 17 months / 33 months
Language Expressive ---- 9 months / 17 months / 31 months
Socialization ---- 10-17 months / 10-17 months / 29 months
Self Help ---- 23 months / 23 months / 24 months
Other than Gross Motor, John improved since July and dramatically since May.
During the time from June-Sept., he attended Early Start Preschool at Casa Colina, had Speech Therapy two times a week, 5 hours a week of in-home, and 40 sessions of Neurofeedback. He began OT/SI the first week of September.
It is worth noting here: Neurofeedback claims training can make a child with autism attentive, calm, and sociable. We have seen certain behaviors disappear and have watched John become calm. John is a different person today than he was 6 months ago when all of this started. It is hard to say what specifically helped John because we've been doing so much. However, the Neurofeedback seems to show us some patterns that are worth looking into. First, when we changed his protocals (the location of the EEG monitor, training a specific part of the brain), he began to have accidents in the seat and aggressive behavior seemed to manifest. We removed those protocals and went back to the old ones and there were no more accidents in the seat during the sessions and his aggressive behvaior seemed to go away.
Secondly, for the last 4 weeks, John has not attended Neurofeedback (he went 3 times over the last 4 weeks, as opposed to 5 days a week that we were doing before)--- first, due a family vacation and then, due to a death in the family. Over the last week-to-week-and-a-half, Bill and I have noticed that typical Autistic behavior (and some sensory issues) that had seemed to disappear has returned.
Things like:
Biting & chewing on shirt
Biting own skin
Chewing on objects
Frustration level is awful
Cries inconsolable again
Angry - bangs hands on table or objects when upset
Has been hard to take out in public - clingy, whiney, cranky, tantrums
Cries when I leave him in class
Tomorrow, John will begin a normal schedule of Neurofeedback training of 5 days a week. I'll report back to see if these disappear once we resume it. The goal of Neurofeedback is to train the brain to self regulate. After a repeated number of sessions, the brain will "remember" its training and be able to self regulate on its own.
He also has developed a cold. I notice that everything seems to be magnified when he's sick.
This week is a big week. Tomorrow, we go back to Neurofeedback. Tuesday, we see Dr. Baumen, an autistic specialist. Wednesday is John's assessment with the public school system and Friday is Halloween!
Saturday, August 16, 2008
Setting the Goals: Casa Colina
Part of the Early Intervention program is to determine at what level John is at in each of the developmental areas and develop goals for him to achieve. His one-on-one time during Early Start at Casa Colina works on these goals, as well as reinforcement in the home and other areas in school. These goals were set in July after a few weeks of observation and testing. The Current Level for each category is where he was tested at to determine starting skills for goals. John is currently 33 months old.
Here are a list of John's goals through Casa Colina Early Start. Once he is evaluated through the START program new goals will be set. I am interested to see what level he will test at in each of these categories. You will see where he has made his progress and why I consider the early intervention a success. At the Regional Center testing, he was unable to do many of these goals or his attention was so poor, it was hard to tell if he could do them or not.
Gross Motor Goals
( current level was 26 months)
John will catch a large ball (25 month skill) -
Fine Motor Goals
(current level was 21 month)
John will imitate a vertical stroke (21 month skill)
Receptive Language
(current level was 17 months)
John will attend to speaker when given 1-2 step directions with minimal prompts (22 months)
Expressive Language
(current level was 17 months)
*** this is the biggest area of improvement as far as day-to-day life at home
John will use 2-3 word sentences (27 months)
Cognition Goals
(Current level was 21 months)
John will understand the concept of 2 (33 months)
Socialization
(current level was 10 months)
John will value his property and say the word "mine" (27 month)
Self Help Goals
(current level was 23 months)
John will dress himself with assistance (30 month)
Pre-school readiness goals
John will initiate a game with another child
John will participate in a group of 3 for 5-10 minutes with minimum redirection
John will participate in a group of 9 for 5-10 minutes with minimum redirection
John will seek and maintain eye contact for 50% of his interactions
Sensory Goals
John will actively participate in a variety of sensory activities without adverse behaviors
John will tolerate heavy work such as pushing and pulling therapy balls
John will tolerate movement on a swing or scooter board
John will tolerate a variety of tactile experiences such as foam soap, play-dough, and thera-putty
Here are a list of John's goals through Casa Colina Early Start. Once he is evaluated through the START program new goals will be set. I am interested to see what level he will test at in each of these categories. You will see where he has made his progress and why I consider the early intervention a success. At the Regional Center testing, he was unable to do many of these goals or his attention was so poor, it was hard to tell if he could do them or not.
Gross Motor Goals
( current level was 26 months)
John will catch a large ball (25 month skill) -
- if paying attention, he can do this, but really doesn't want or like to play catch
- this last week he did this; usually he sits on it and then wants to walk away; this week he stayed on for an entire circle around the playground
- this is a goal set because he usually isn't paying attention and needs to be reminded to "watch where he is going"
- He did this the first time and has met this goal already;
- He bounces up and down, but does not jump forward or backward with both feet together
Fine Motor Goals
(current level was 21 month)
John will imitate a vertical stroke (21 month skill)
- He will copy a horizontal stroke, but doing a vertical stroke is slowly developing
- John is doing pretty well with this, but he'd rather crumble it in a ball
- John has met this goal already
- John can close, but has a problem opening the scissors
- John has met this goal, but needs more consistency
- Attention and staying focused on the task is a big deal here; he also presses too hardand the blocks fall
- John didn't understand the concept of this at first, but is starting to want to do it on his own
Receptive Language
(current level was 17 months)
John will attend to speaker when given 1-2 step directions with minimal prompts (22 months)
- John usually needs to be re-directed and reminded what he is supposed to do
- John has met this goal
- John has met this goal
- John has a hard time staying focused
- John has met this goal
Expressive Language
(current level was 17 months)
*** this is the biggest area of improvement as far as day-to-day life at home
John will use 2-3 word sentences (27 months)
- John now says "ride in Grammy's car" "watch High School Musical" "I want playdough" pronunciation is poor and getting better, but he is using the words to make sentences and to show his wants/needs -- this area has come SOOO far
- This has been amazing to watch
- He was very verbal in class this week, meeting this goal and surpassing what was expected
- He is starting to use car and airplane sounds, etc.
Cognition Goals
(Current level was 21 months)
John will understand the concept of 2 (33 months)
- This is a very difficult concept for John; he gets frustrated and doesn't really knowwhat he is supposed to do when asked for "2 of them"
- He has met this goal
- He sometimes can do this and sometimes cannot; depending on level of focus
- He has met this goal
- Working on increasing his attention
- John has met this goal
Socialization
(current level was 10 months)
John will value his property and say the word "mine" (27 month)
- John doesn't use "mine"
- John protests when playing ball or catch
- John watches the other kids, but rarely interacts
Self Help Goals
(current level was 23 months)
John will dress himself with assistance (30 month)
- John has met this goal
- we are working on this
- he has met this goal
- he has met this goal
- he has met this goal
- he has met this goal
Pre-school readiness goals
John will initiate a game with another child
John will participate in a group of 3 for 5-10 minutes with minimum redirection
John will participate in a group of 9 for 5-10 minutes with minimum redirection
John will seek and maintain eye contact for 50% of his interactions
Sensory Goals
John will actively participate in a variety of sensory activities without adverse behaviors
John will tolerate heavy work such as pushing and pulling therapy balls
John will tolerate movement on a swing or scooter board
John will tolerate a variety of tactile experiences such as foam soap, play-dough, and thera-putty
Tuesday, August 12, 2008
John will enter S.T.A.R.T.
S.T.A.R.T. stands for Specialized Team for Autism Related Therapies
There is an opening for John in the Casa Colina START program beginning in September!
The program is one-on-one therapy through all areas of development. It concentrates on building social, sensory-motor, play, communication, adaption, and cognitive skills.
He will go through an in home evaluation in all areas to determine his Individualized therapy plan in each area.
There will be 4 kids in the class with 4 therapists -- they have some group activities like circle time, snack time, and project, but then each kid rotates through speech therapy, occupational therapy, imaginary play, etc. He will receive the Occupation Therapy/SI through this program, although he is still schedule at the end of the month to have an OT screening through Foothill Presbyterian Hospital.
This will replace the Early START program he is in now, which is the "mommy and me" preschool. It has a similar format, but is more structured with less kids, one-on-one, and no parent participation in the class. Parents watch in the observation room. He will attend, I believe two times a week. We are awaiting Regional Center's approvals to go through.
There is an opening for John in the Casa Colina START program beginning in September!
The program is one-on-one therapy through all areas of development. It concentrates on building social, sensory-motor, play, communication, adaption, and cognitive skills.
He will go through an in home evaluation in all areas to determine his Individualized therapy plan in each area.
There will be 4 kids in the class with 4 therapists -- they have some group activities like circle time, snack time, and project, but then each kid rotates through speech therapy, occupational therapy, imaginary play, etc. He will receive the Occupation Therapy/SI through this program, although he is still schedule at the end of the month to have an OT screening through Foothill Presbyterian Hospital.
This will replace the Early START program he is in now, which is the "mommy and me" preschool. It has a similar format, but is more structured with less kids, one-on-one, and no parent participation in the class. Parents watch in the observation room. He will attend, I believe two times a week. We are awaiting Regional Center's approvals to go through.
Saturday, July 26, 2008
Casa Colina: Early Start Pre-School & Speech Therapy
One of the first forms of early intervention that John received was an Early Start Pre-School class at Casa Colina in Pomona, California. The Early Start class is focused on developing the goal areas of gross motor, fine motor, sensory, communication, cognition, socialization/play and self-help. Children work individually and in groups with their parents and child therapy instructors as they rotate through a series of activity centers.
John attends the class two times a week for 2-and-a-half hours each time. Upon arriving, John must find his picture and place it on his schedule. After completion of each activity, he is instructed to "check his schedule". Using a laminated paper with a check mark on the front and piece of velcro on the back, John takes it to his schedule hanging on a wall. He places the 'check' next to the first activity, which is dipicted in a photo. The first activity is to 'wash hands'. John takes the photo to the sink, places it in a folder and proceeds to wash his hands. He is given a second 'check' to take to his schedule.
The next photo announces that its "circle time". John takes the photo and finds a square to sit on with the other children. He hands the photo to the teacher, announcing that he is ready for "Circle Time". The teacher shows the children a board that has pictures that represent different songs they can sing. Each child, in turn, chooses the song that everyone will sing. A picture of raindrops represents the first verse of the song "if all the raindrops". After the group sings the song, the child who picked the song is given a "prop" for that song. A rain stick is given for "If All the Raindrops". The child watches it fall and then is instructed to turn it over and watch again. They then must hand it over to the next child sitting next to them. After the prop makes it's way around the circle, the next child picks the song they want. John's favorites are "Boom Boom Ain't It Great to Be", where he can play the beat on the drum, "Wheels on the Bus", and "If All the Raindrops". He doesn't sing much at school, which is surprising because he does at home, but he loves the pantomime gestures and passing each of the props.
The schedule order is then different for each child, but each will have time outside on the playground, project time at the table, imaginary play, work time, and gross motor skills activities.
We have learned, through Outside time, that John loves the swing. He could swing for the whole 20 minutes. I started going through counting and alphabet games while we swing. He loves to talk and verbalize while swinging. (more on this in a later blog).
I have never let John play with glue or scissors up to this point because I just felt that he wasn't ready. Well, a kid is never going to learn if you don't teach him! So, he's learning to cut with scissors and squeeze out the glue. He loves the glue and the first week called it "gluke", but has already corrected himself and says it just right! Already, he has made a shaker, 2 caterpillars, a texture book, and a flag. He wanted to glue paper with the glue side up, but he learned quickly that his hands get messy that way and paper won't stick.
He has a 20-minute one-on-one work session where individual goals are set and then worked on to meet. John sorts colors and shapes, does animal puzzles, strings beads, blows bubbles, plays with Mr. Potato Head, and various other activities to strengthen his skills in each of the developmental areas. How they play with him is the key to his success' thus far. John came in to this program very impulsive. If a teacher held two objects, one in each hand, asking for him to pick the red one, John would reach for both without listening to her directions. By the second session, they had him waiting, looking at each one and then choosing. His first reaction is definitely impulsive, but slowing him down is the key. He has a very busy brain, which is easily distracted. He learned the "clean up" song really fast and he says and signs "all done" pretty quickly after starting a task. The therapists are really good at making him do it "one more time" and "we will be all done". I think he enjoys cleaning up and finishing more than anything else, but he is learning so much.
In addition to his early start classes, he attends 2 hours of speech therapy a week. Speech therapy is play based therapy that works on his language skills. They use a reward system (for John it's bubbles) to get him to say his words. They play with cars, Play Dough, flash cards, balls, etc. while concentrating on his verbal skills. John loves coming to "school", but speech therapy wears him out. About 30 minutes into a session, John becomes distracted and begins to look around and "space out". This is the most important time to keep going --trying to increase his attention span.
We've been in the program for 6 weeks and he has improved so much! I can't believe the changes we have seen both at home and in the classroom. He tested at a 6-9 month age level for language 2 months ago. Last week, they told me his language has already gone up to 17-18 months age range.
Things we've noticed:
John attends the class two times a week for 2-and-a-half hours each time. Upon arriving, John must find his picture and place it on his schedule. After completion of each activity, he is instructed to "check his schedule". Using a laminated paper with a check mark on the front and piece of velcro on the back, John takes it to his schedule hanging on a wall. He places the 'check' next to the first activity, which is dipicted in a photo. The first activity is to 'wash hands'. John takes the photo to the sink, places it in a folder and proceeds to wash his hands. He is given a second 'check' to take to his schedule.
The next photo announces that its "circle time". John takes the photo and finds a square to sit on with the other children. He hands the photo to the teacher, announcing that he is ready for "Circle Time". The teacher shows the children a board that has pictures that represent different songs they can sing. Each child, in turn, chooses the song that everyone will sing. A picture of raindrops represents the first verse of the song "if all the raindrops". After the group sings the song, the child who picked the song is given a "prop" for that song. A rain stick is given for "If All the Raindrops". The child watches it fall and then is instructed to turn it over and watch again. They then must hand it over to the next child sitting next to them. After the prop makes it's way around the circle, the next child picks the song they want. John's favorites are "Boom Boom Ain't It Great to Be", where he can play the beat on the drum, "Wheels on the Bus", and "If All the Raindrops". He doesn't sing much at school, which is surprising because he does at home, but he loves the pantomime gestures and passing each of the props.
The schedule order is then different for each child, but each will have time outside on the playground, project time at the table, imaginary play, work time, and gross motor skills activities.
We have learned, through Outside time, that John loves the swing. He could swing for the whole 20 minutes. I started going through counting and alphabet games while we swing. He loves to talk and verbalize while swinging. (more on this in a later blog).
I have never let John play with glue or scissors up to this point because I just felt that he wasn't ready. Well, a kid is never going to learn if you don't teach him! So, he's learning to cut with scissors and squeeze out the glue. He loves the glue and the first week called it "gluke", but has already corrected himself and says it just right! Already, he has made a shaker, 2 caterpillars, a texture book, and a flag. He wanted to glue paper with the glue side up, but he learned quickly that his hands get messy that way and paper won't stick.
He has a 20-minute one-on-one work session where individual goals are set and then worked on to meet. John sorts colors and shapes, does animal puzzles, strings beads, blows bubbles, plays with Mr. Potato Head, and various other activities to strengthen his skills in each of the developmental areas. How they play with him is the key to his success' thus far. John came in to this program very impulsive. If a teacher held two objects, one in each hand, asking for him to pick the red one, John would reach for both without listening to her directions. By the second session, they had him waiting, looking at each one and then choosing. His first reaction is definitely impulsive, but slowing him down is the key. He has a very busy brain, which is easily distracted. He learned the "clean up" song really fast and he says and signs "all done" pretty quickly after starting a task. The therapists are really good at making him do it "one more time" and "we will be all done". I think he enjoys cleaning up and finishing more than anything else, but he is learning so much.
In addition to his early start classes, he attends 2 hours of speech therapy a week. Speech therapy is play based therapy that works on his language skills. They use a reward system (for John it's bubbles) to get him to say his words. They play with cars, Play Dough, flash cards, balls, etc. while concentrating on his verbal skills. John loves coming to "school", but speech therapy wears him out. About 30 minutes into a session, John becomes distracted and begins to look around and "space out". This is the most important time to keep going --trying to increase his attention span.
We've been in the program for 6 weeks and he has improved so much! I can't believe the changes we have seen both at home and in the classroom. He tested at a 6-9 month age level for language 2 months ago. Last week, they told me his language has already gone up to 17-18 months age range.
Things we've noticed:
- He sits during circle time
- John never sits still and the first day, I chased him around the room, leading him back to his square and having to hold him in my lap
- By the third class, I was able to sit behind him
- He has poor posture, which I never noticed before because he would never sit still; he sits leaning back on his hands or slumped over his knees
- His language is controlled
- There is intent behind his words; he communicates to have needs met
- "all done" and "more" have helped us understand when he is ready to do something
- he points to objects and tells us what they are
- He is engaging
- The inability to engage, which he showed during his Regional Center testing, is one huge part of the Autism diagnosis
- He is able to follow direction
- He is able to get my attention and tell me about an object or what he wants
- There is a 'give' and 'take' in play with him
- His attention is increasing
- Work wears him out
- John yawns about 10 minutes into every work session
- John gets tired after school
- John tends to have melt downs when he is tired
- Building towers with blocks
- Increase attention
- Completing tasks
- Articulation in Speech
- Jumping from 2 feet
- Decrease impulsiveness
- Stringing multiple beads
- Blowing bubbles
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