OTS 164: Reflex Integration Challenges and Solutions in School-based OT
- Jayson Davies
- Dec 16, 2024
- 43 min read
Updated: Dec 18, 2024
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Welcome to the show notes for Episode 164 of the OT Schoolhouse Podcast.
Have you ever wondered how integrating reflex patterns could enhance your approach to therapy?
Join us as we discuss the world of reflex integration with Kokeb McDonald. She shares her journey and discusses the importance of understanding the root causes of developmental delays. You will learn about the MNRI program and how Kokeb has adapted its principles to create effective treatment plans within occupational therapy practice.
This episode offers valuable insights into how addressing reflexes can lead to significant improvements in motor skills, attention, and overall functioning. Tune in to learn more!
Listen now to learn the following objectives:
Learners will be able to understand what reflex integration entails and its role in school-based OT
Learners will understand the importance of reflex integration in occupational therapy, particularly in addressing self-regulation and sensory processing issues.
Learners will understand how movement activities can be integrated into classroom settings to support reflex integration and improve student outcomes.
Guests Bio
Kokeb Girma McDonald is a pediatric occupational therapist and the founder of the Reflex Integration Through Play™️ (RITP) program. She is the mother of two wonderful children, and has extensive professional experience working with young people of all ages and backgrounds since 2004.
Recognizing the need for practical and universally accessible primary motor reflex integration programs, Kokeb created the Integrating Primitive Reflexes Through Play and Exercise book series and the Reflex Integration Through Play™️ method to empower and reassure frustrated parents, and to offer fellow professionals a tool to expand their clinical reach.
Quotes
“Think of it as, building a house…if the foundation is messed up, cracked, anything you build on top of it will be faulty. Yes. It will stand, but you're going to be fixing things all the time.”
-Kokeb McDonald, OTR/L
“At the end of the day, it's all interconnected…When you impact one thing, it impacts another.”
-Jayson Davies, M.A., OTR/L
“Reflex patterns are a response to sensory input.”
-Kokeb McDonald, OTR/L
“I learned that it's important, especially for OTs, to go back and review anatomy and movement patterns, like the functional movement pattern because we've forgotten what that looked like, what functional movement pattern looks like, what is the most efficient movement for this specific task.”
-Kokeb McDonald, OTR/L
“All of a sudden you start to see results in other areas as well. Things start to come together…and the client doesn't have to struggle as much.”
-Kokeb McDonald, OTR/L
Resources
👉MNRI
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Episode Transcript
Expand to view the full episode transcript.
Jayson Davies
Hey there, and welcome back to the OT schoolhouse podcast, where education is an essential occupation. Today, we're taking on a topic that has been stirring up much debate in the school based ot world, reflex integration. It's a concept that's gaining traction, but it also raises questions like, How does reflex integration fit into school based occupational therapy, and more importantly, how do we ensure it supports meaningful occupation based outcomes for the students we serve to help us unpack this. I'm excited to welcome Kokeb McDonald, a seasoned occupational therapist and creator of the reflex integration through play program, over at integrating reflexes.com With nearly two decades of experience and a passion for empowering ot practitioners and parents alike, cocoa has developed practical strategies that make reflex integration accessible, effective and yes. Occupation focused in this episode, we'll address the controversy of using reflex integration in a school based setting. Then we'll shift into how you can integrate reflexes within your play based interventions in a way that respects your time, your expertise and your students goals. If you've ever wondered how, or even if reflex integration belongs in your practice, this is the episode for you. Kokeb, insights might just change the way you approach your next session. So settle in, and let's dive into our conversation with our OT colleague, kokeb McDonald
Amazing Narrator
Hello and welcome to the OT school house podcast, your source for school based occupational therapy, tips, interviews and professional development. Now, to get the conversation started, here is your host, Jayson Davies class is officially in session.
Jayson Davies
Kokeb. Welcome to the OT school health podcast. How you doing today?
Kokeb McDonald
Great. Thank you for inviting me.
Jayson Davies
Absolutely. It has been a minute since we addressed reflex integration here on the podcast, I'm excited to have you on, especially because actually, the last person that we had on to talk about it wasn't an occupational therapist, so I'm excited or an OT practitioner in general. So I'm excited to get your point of view here, kind of your background into it, and how you implement it into ot practice. So this should be a fun one. Great. All right. Well, I want to kick it off by first asking you how you even kind of got into the world of reflex integration. You know, occupational therapy is a wide range world. There's so many different ways you can go, but you have really, kind of, I want to say, narrowed your focus to just reflex integration, but it's definitely an area that you now kind of specialize in. So I'd love to learn how you kind of got into that.
Kokeb McDonald
Great, yes, I started out from maybe 20, 2005 or so right after I became an occupational therapist, as I'm working on treatment planning, and I think I felt just stuck with my treatment planning, and felt like I'm working on specific activities, but not really figuring out the causes or the root causes of why certain kids are delayed in their development, and why am I doing this specific exercise? So I think I was researching a lot with one my co worker was an OT clinic. I was working for an OT clinic, and we found out in Poland at someone called maskadova, who's doing this program. This was before the svelana moskatova was the mnri program was here, and that's when I started taking the courses. It just made sense to me, and made sense the root causes of the development and how to even create a treatment plan. And I think that's what got me and when I put those treatment plans in my sessions the clients that I was working on, like task after task, like tying shoes, time shoes, or like handwriting, hold them, you know, the pencil grasp and focused on when I actually implemented these reflex patterns, like when I'm looking at it and I'm putting the treatment plan as part of the implementation, the kids start to doing really well. And it just made sense. It made sense that I fell in love with it.
Jayson Davies
Yeah, and say that name of the program again. I've never heard of it as
Kokeb McDonald
MRI. It's moskatova method. Svetlana moskatova, she.
Jayson Davies
I've heard of the shorthand. I've never heard it all the way out, okay.
Kokeb McDonald
longer. Mnri is a longer one, but I just go with her name. I took several courses through her program, and then I start to implementing it as part of the OT I mean, it's done differently, and mnri, the process is different, so I start to implement it as part of OT process.
Jayson Davies
Well, yeah. I mean, it sounds like you've been on this, been working with Reflex integration for close to 20 years, about and now and and it's interesting because, I mean, I've been an occupational therapy practitioner Since 2012 is when I graduated. And I can say with pretty certainty that. In 2012 like primitive reflex. Reflex integration was not a common word, and that was in 2012 and you started, you know, almost a decade before that. And so it wasn't till, like, I feel like, around like 2018 maybe 2020 that we started to hear more about reflex integration. And so it's just really, it's really amazing that you kind of learned about this before it became kind of a trendy thing, which is very cool. And so it sounds like you've done a lot of training, and now you're kind of doing your own trainings, right?
Kokeb McDonald
Yes, yeah. So about 2019 it's when I first published my first book and creating a treatment plan that therapists can easily follow, especially if I was thinking OTs in mind, and I was thinking of a home program and parents, what are the activities that they can easily incorporate in the classroom, at our home, or in the clinic, with mnri, with other work? I mean, they're very effective as well. It's a very hands on work, and it's not as easily. You're not easily able to implement it in our session, because we have 30 minute session. We're do functional skills, and we're in the classroom. We're doing group session. The idea for me was like, How can I implement what I've learned, but for OTs and because we have to charge insurance, right? So we have to stay in our framework, but we can still do that. There is a very effective way, and play base is one way that we do with us, like reflex integration through play, and how to do it in a play based and more functional way. So I've been actually doing that for a long time, and when I start writing the book, though, I start to because, you know, I didn't tell you the story. It's because I injured myself and I couldn't see clients as much. So it became like, Okay, what am I going to do with all this knowledge? It became to like, I might as well create this treatment plan for other therapists to use or for parents to use. And ended up being, you know, I was able to share it so it created a snowball into what it is today.
Jayson Davies
Yeah, yeah, yeah. And you mentioned something really key there. A moment ago, you talked about how you really kind of adapted it to fit into the occupational therapy world. And I think that's important, and we're going to really dive into kind of how you did that, but I just want to touch on that fact alone, because we do see a lot of or at least I'm seeing a lot of different reflex integration programs out there on the web and whatnot, a lot of trainings, but a lot of times it doesn't have that occupation focus, and it's a lot about doing the exercises without putting it into the functional outlook and whatnot. It sounds like that's kind of what you've managed to do here, right?
Kokeb McDonald
Yes, yes. So for for OTs, we focus on activity, daily living, functional skills. So what do we focus on? Play place for kids, especially if you're focusing on pediatrics, even though adults do the same work as well, classroom engagement, social skills and sensory processing and modulation and regulation. And for therapists like, how can you, I mean, we talk about it more too, but as How can you address, or even when you start screening, how can you screen these motor patterns, these reflex patterns in your client's body doing play. Why is this child having a difficulty climbing the play structure? Or why is he hesitant? Why is he setting a certain way? Those kind of questions we constantly are looking at as OTs, and for a new ot can be very overwhelming. And no, I was very overwhelmed and not being able to, you know, where am I starting, right? So that was a big question for me. But when I looked at, when I learned these reflex patterns, it just outlined it. It gave me like a framework to follow that was really easy. And then the idea now, with with our certification program is like, Can we get a lot of OTs come and teach them exactly how I learned it? And then it's been exciting to see teaching them this framework and having them screen, having them be able to observe in a playground, in the classroom, walk in. Our goal is like, I want you to be able to go on a playground and observe a client and see what these patterns and then now you can create a treatment plan accordingly, and a play based way, like they're already, you know, triggering all these reflex pattern already. But how do you address it? How can you address it? And the way you already are doing and probably in a clinic, you just don't know what you're looking at, because sometimes they just don't know what they're looking at. And so we talk about that as well.
Jayson Davies
All right. Well, let's go ahead and actually, in a way, take a step back here. You know, because I sometimes, and I do I'm guilty of this too, is I assume that? P. People who are listening know what everything is, and that is not always the case. So I want to first ask you here, how do you explain reflex integration to someone who just kind of isn't familiar with it, whether it be an occupational therapist, occupational therapy assistant, or maybe even like a parent, what's like the easy way to understand reflex integration.
Kokeb McDonald
Okay, so the easiest way to explain it is to the for parents, I tell them, think of reflexes. Because we're in the bay area here a lot of tech people. So I tell them, like, think of a code. You know, it's like we are born with this reflex patterns in our body that are there for survival mechanism, and babies in the womb were born with all these reflex patterns, and it helps the baby survive for the first year and then supposed to integrate in the whole body so that more voluntary movement patterns in sensory processing and integration and learning and higher functioning level needs to happen. So think of these are codes that they are there. The child is coded, you know, and then it comes out. So each reflex has its own sensory trigger and it has its own motor response. So you can learn to find out what these all these reflexes are, patterns are and how they're influenced by sensory triggers, and then what their motor response look like. So that's one way that the therapist will learn, one of the things that would teach them. But when these motor reflex patterns, when they're stay active, because after a certain time they should say dormant, and more postural reflux or sensory processing, the child starts to learn the environment. They start to respond that should happen. But if that doesn't happen and it's improperly integrated or not integrated and their body, they start to interfere with motor skills, coordination, sensory processing, self regulation, attention, and the child, or even later on, adult, starts to get overwhelmed and start to have a lot of compensation. You know, ways out how to deal with the body as well. So I don't know if that is a longer way of explaining it, but that's that's in brief, that's how I explain it.
Jayson Davies
Yeah, yeah. And let's go kind of a little bit deeper. Let's kind of talk to maybe someone who has a little bit more of that information and the medical background, per se, when it comes to talking about more the brain, the spinal cord and all that, are you able to kind of share a little bit about how the mechanisms within the body, I guess, how the reflex and reflex integration and retained reflexes, what's going on in the body with that, and how it impacts.
Kokeb McDonald
Yes. So the reflex, these primitive reflexes, are housed in the brainstem. So the brain stem is also considered like the reptilian brain. That's the most primitive part of the brain. That's one of the brain part that develops. So that's the first thing that develops. So that's where breathing, heart regulation, anything that we're not regulating intentionally as housed. So we have to know first that that's the first thing that needs to develop, and then after that is maybe the sensory regulation the midbrain and the cortical one will develop. So usually for a therapist, we get asked to come to work with a client, especially like school based is when a teacher or parents see a challenge in the child's attention, which is in the frontal cortex, right? So the last thing that develops, we usually are called when regulation or anything of you know before that needs to develop, which is the reflexes at the foundational level, right? So that's affected. And then we usually get asked when he can't attend. He can't sit still, he's not focusing on copy from the board, all those kind of reasons. That's when the therapists are called, and what it tends to happen traditionally, as we try to tackle that, okay, he can't catch a ball. Let's practice catching a ball. He can't write. Let's work on writing instead of what is it really going on that this child is falling behind? Because, yes, you can solve one thing, which is the writing, but then this child is going to be struggling 10 other things if we don't figure out the root cause. So with the therapist is that the idea is to learn to go back and the brain stem level and see, can we work on the foundation? So think of it as building a house like if the foundation is messed up as cracked anything you build on top of it will be faulty. Yes, it will stand, but you're going to be fixing things all the time, right? So you don't want a house like that. So you want to go back and build the foundation. So. Think of the foundation as you brain stem, and then you building everything that's up on top of us. So the great thing about creating a treatment plan that goes back to the foundation and making sure that you're not missing any hole is all of a sudden you start to see result in other areas as well. Things start to come together, which much easier and you don't have the the client doesn't have to struggle as much. And even as a therapist, you don't have to waste that much energy or time to work on the client, because by fixing on the foundation level, others, you know, even speech starts to improve, coordination, attention, parents will say like, oh, all of a sudden they're, you know, we're not fighting about homework anymore, right? So he's attending. He's more coordinated. Oh, he's becoming interested in sport, because your goal might be one thing, you know, but then he can start to see other improvements. Absolutely, you know, earlier you started down the path. And I want to come back to this now is, you know, there's reflex integration, and then there's also reflex integration that an occupational therapy practitioner might actually implement, and that's kind of what you've done here. And so I kind of, I know we can't go into full detail on this, but how do you start to connect in occupation, such as a specific piece of play or education on task behavior, whatever you might want to be, what might want it to be. How do you then connect that to specific reflexes, or specific unintegrated or integrated reflexes? I mean, I know it's an entire evaluation process, but what is some of those processes that go through your head? Or are there already some research that has kind of tied some of that together for us? Yes. So when you start to learn about these specific reflex we talk about sensory triggers and then how the body is influenced, which is the motor response, and some of them will have your response as well. For instance, the common one, one of the first book I wrote about, is the moral reflex. So the moral reflex actually is, can be a powerful reflex, because it influences the child and self regulation as well. Because what, as you know, if the reflex stays in and the body stays active, can create, like, the fight or flight response, like constantly on guard, the client will stay on guard in these when that happens, it's not like the child can stop it, because it's a reflex, right? So even with the name, you can tell, right? So they cannot wheel it away. Or it's not like, don't it's not a behavior thing. It's a primitive reflex which is housed in the brainstem level. So we have to really go back and address it if we seeing these patterns in the body. So once the therapist is starting to learn to assess and a client, so what you can start to see is like, Okay, whenever we with the sensory trigger, the child is having all these sense symptoms. So we have symptom checklist. For instance, we can look at any multiple symptoms we're looking at to see, can, you know, is the child getting car sick? Some of the symptoms for us, for instance, it can be like, hesitant to climbing up and down a certain playground can be one thing for them, and then easily startled. That can be another thing, auditory processing issue. They might melt down. They might have a hard time with sounds or and then all these kind of things that we're looking at, and then heart palpitation, ice bulging or like a sudden movement next to them might be threatening to them. So all these things that we're looking at, and we're also testing, we're screening, physically screening as well, to see and then we start addressing those so and that way, yes, one of the main things some OTs are asking the classroom is self regulation. And usually we do other things. We do the symptoms part, okay, let me teach you how to regulate. Let me teach you like the, you know, the cortical levels like, Okay, I'm gonna teach you how to not act that way. Or it could be a behavior thing. So, but then it's we were we really are not solving but my body constantly respond like this, whether I want it or not. I know in my head I get it, but I'm constantly on on guard, right? So you we didn't really solve it. So for us, it's like we do need more research. We do need more work. Even in our program, we're doing a research right now. We're gathering research and collecting data as well in our program, because I find it very necessary, especially for OTs. So yes, we do need to do that and improve in this area. That's like one way motor skills as well. There we have. We can look specifically on motor coordination and crossing midline. There's for everything. Can think of you. Can we have like a framework that you can start looking at to see, like, which one are we looking at? Right? So why can't we have kids who sit specifically on their heels, for instance, that is like a telltale sign of stnr, for instance, like they because they can't sit on 9090, degree, that OTs we look at in the classroom. So we keep saying, feet on the ground, they'll never solve that problem, right? So I can put an icon next to the table and the picture. I mean, we've all done that. At least I've done it's like, if I just point to him, you sit, but he his body doesn't work that way, right? So instead, we have to look back and be like, let me help you. Let your body actually function with efficiency.
Jayson Davies
Yeah, yeah, absolutely. And I really like the way that you are talking about this, because you're definitely talking about it from an occupational perspective, and it kind of brings something to mind. And I just I this wasn't in the questions that I asked you. So bear with me here, because this comes straight from a OTA. They do. They're like, Choose Wisely campaign, and I'm sure you've probably seen this, and it says, don't use reflex integration programs for individuals with delayed primary motor reflexes without clear links to occupational outcomes. And so I guess my kind of question there is, is there ever a case where a primary motor reflex, whether it is integrated when it shouldn't be, or vice versa, doesn't necessarily impact occupation to the point where you say, You know what look this child still has the moral reflex, or this child still has another reflex, or they don't have a reflex, but it's not actually impacting them at this time. Does that ever come up? Or do you tend to see that typically, if they have a an integrated or unintegrated reflex, there typically is that occupational connection?
Kokeb McDonald
Well, what a child does is even with with what we're saying, with the statements like it's related to everything that the child does right, like, as it will be in his plane and being a social skill and classroom as well. I have not seen anything that did not connect to that that person's occupation, or can even be self regulation. I think the way I look at it is because I'm I'm looking at it from how we deliver the program or the intervention. My understanding from that article is like they're looking at the different reflex integration intervention that are out there like that are not typically, there's like on the table you're doing hand on, you know, maneuvering, and you really cannot bill for it as an OT work, because that's the thing I was trained on that too. Are they effective? Yes, effective, but that it's not ot based. So the question is not like, the question is now like, can this work or not? The question is like, how, how do OTs implement this? And what we do? I personally think OTs are, like, perfectly positioned to use this intervention, because now we see a lot of vision therapists are using it, physical therapists are using it. Chiropractors are using it. I mean, people are are going because they can't find enough OTs who who do this work. They're moving somewhere else. And OTs, we specialize in sensory integration and reflux integration. And sensory integration, for me, is combined. I do not separate them. Like reflux integration helps sensory integration and vice versa, like, you know, is, is like reflux patterns are, you know, a response to sensory input. So for me, actually, in my opinion, when I learned sensory integration when I first started, it was difficult for me to wrap my mind around it, until I learned reflex integration, because I now finally can visually see it. I can go in a classroom and and when a teacher, like for instance, I walked in in a classroom, like couple months ago, or like few weeks ago, whatever the child is putting anything and everything in his mouth, like rocks paper. They can't put anything on the, you know, the table, because they have to chase it's not safe. Okay. How do you under How do you explain that? So I quickly.
Jayson Davies
Yeah, so hold on. Hold on. I want to stop you there really quickly. And I want to continue this because I want to role play this, actually, because for me, if I see I'm not trained in reflex integration here, so for me, going into the classroom, things going into the mouth, I'm probably thinking some tactile, you know, wanting to get that tactile sensation in the mouth. Maybe some proprioception, potentially, that's kind of what I'm thinking. Maybe taste might be involved. But from the. Sensory perspective. That's what I'm thinking now, Susanne Smith, Rowley, Zoe Mayu, they can go way beyond that and go more, but that's what I'm thinking as an occupational therapist that is SIP trained, but not like, you know, to the max. But I'm excited now to hear or first of all, is that what you would see from a sensory and then how would you go beyond that?
Kokeb McDonald
Yes. So the first thing I will think is, like, I was assessing this job. I was observing with them, and then they were just concerned, because he has behavior and other things. He's like, see, look at this, you know, like, what is he doing? So what I did is I pulled them quickly, because I need to explain to them that this child is he's not just having a behavior. He cannot control it. So I did a quick screen in front of them. So I screened his rooting reflex. Rooting reflex is a very one of like the first you know, should have been integrated, what, four months. So I screened him like this child. You can see his mouth moving, opening his mouth. He's was seven years old, or seven and a half years old, so I have to, I can explain to them right there. I said, like, this is a primitive reflex, like, so he's constantly doing that. There's also a back end reflex, which is connected with your hand and mouth. So everything you hold in your hand, goes in the mouth, because those reflex patterns are connected. So when you ask him the child, when you ask him, what's in your mouth, he's like, it's almost, he's almost surprised that something in his mouth, because he's not consciously doing he's not like walking around. Oh, a rock. Let me put that rock in my mouth, because he's smart enough in his head to understand, but when he's not thinking, when he's like, focusing on things, something in his hand is goes inside the mouth. They were saying how dangerous it was because he had they found him like a scissor in his mouth during cutting activity or so it can get dangerous. So when I showed them right? Really quickly, I said, like, hey, this should have been gone. And I even went and did that to the teacher, like, I just stroked their face, like, see nothing happened to you. And so in that way, there was almost an understanding of compassion and less frustration with the kid. And then they can understand now he's like in a brain stem level. So we really need to work on creating movement activities and to help, really, this brain to develop so that they can get to the point of like, higher level function of like, don't even expect him to sit for 40 minutes for you, because we're really in a lower level. So we have to change the expectation for the class safety and all that. But that's just one example of because, is it the solution to always give him a chewy toy because he's constantly chewing? Or can we really go a little bit deeper and see why even is there it should have that kind of exploration is very, you know, immature in a sense, like, you know, babies do that, right? They explore. It's a developmentally appropriate a certain age, but should go away, yeah? So, yeah, that's one observation.
Jayson Davies
Yeah, yeah, exactly right. Like, I would have just seen the proprioception, the tactile, but you saw, you know, the reflex, and we're able to go that route. So, yeah, definitely one thing that I have learned from discussions with people who use a primitive reflex model. You know, you hear about these different screenings, right? You're testing like you're testing this reflex, you're testing that reflex. I honestly don't know the answer to this. Is there a standardized tool at all for looking at reflexes, you know, like we have the easy, or we have the sipped, or we have the bot, you know, standardized tools. But is there actually a standardized tool, or a go to tool, even for, you know, looking at primitive reflexes?
Kokeb McDonald
Not that I know of right now, there is no standardized we should have some kind of standardized we should develop. We are developing one for our program. For instance, it's not standardized. It's really based on observation and really training the therapist. The reason, even on my program, we have them stay with us for about 12 months, and have Q and A calls and implementation in video chats and coaching is it really takes time to learn to have this clinical, sharp eye to picking up these movement pattern right? So we encourage the therapist to take a video while they're screening. So I can, we can watch them do the screening and help them pick up as well. So it really takes time. I really, I really, highly encourage therapists to not assume that you just gonna read it up and then you gonna pick it up. I mean, took me years and years, and this Like any skill, right? So it's gonna take time to learn this, but we do right now. Observation. You. We do an actual screening method and then have them train them in how to look at these reflex patterns. We also, in my program, I learned that it's important, especially for OTs, to go back and review anatomy and movement pattern like the functional movement pattern, because we've forgotten what that looked like, what functional movement pattern looks like. What is the most efficient movement for this specific task? And once you have to have that baseline, and then, you know, these reflex patterns, you can really easily screen better instead of just looking for screening. Sometimes what happens I see now a lot of posts on social media, as well as like stnr, and then they do just one thing. But for us, we screen the entire body, because there's so much that happens with the body the way they compensate. So even if you're screening one thing, you can also start observing other reflexes, kicking to compensate, right? So the same way our body does that all the time, right? So you're doing some exercise. The mouth is moving, the toes are curling, and, you know, you're moving from the shoulder. We want you only need to write from the wrist, like stuff like that. So we want to look at different patterns. We can also look at, look at in this screen.
Jayson Davies
Yeah. Yeah. I mean, I could definitely see a tool that almost looks similar to, like the sensory profile or the SPM, right, where it asks the teacher or the parent, you know, about behaviors that the teacher or parent can see, and then it kind of categorizes it into different Yeah, reflexes that that is associated with. I mean, maybe you kind of have something with that. It sounded like you kind of alluded to something similar to that within the program. But yeah, I think that would be an absolutely helpful tool for anyone who's kind of, again, you got to have the education to know where to go with it. From there, you know, once you know that it's the more reflex, you got to know what to do beyond that. But yeah, very interesting idea, if someone hasn't developed that, that would be a great tool. I'm sure that a lot of OTs would find helpful. So.
Kokeb McDonald
Yeah, yeah, we have this symptom checklist, and we're doing the screening, and the school based too. We're working on a tiered intervention, like, you know, tier one, tier two, tier three, kind of way of evaluating an intervention, because our program, we have a school program, for instance, that service the entire school, not just kids with IEPs or services. Because I really do believe everyone should get this as almost like a school based and school wide movement break. So now we everyone can get it, because we have a lot of actually, it's interesting. We have a lot of kids who are falling behind, who are not on service, they don't really qualify for service, but then are struggling and can still benefit from it. So like with a school program, for instance, we encourage everyone to use it, and then if the kit really needs service and it can get pulled out and do more of intensive work. So.
Jayson Davies
Yeah, that's awesome, a follow up to that. Specifically, I have so many follow up, but are you? You're doing tier one, tier two, tier three, just to confirm, because everyone kind of thinks about tier one, tier two, tier three a little bit differently. I think of tier one as, like, supporting the teachers. Tier two, maybe supporting the entire classroom, or a group of kids, and then tier three gets more individualized. Does that kind of align with with your tier one, tier two, tier three?
Kokeb McDonald
Yes. So luckily I have, like, I have it here, so I'm looking at it. So yeah, tier one. I was just reviewing it, editing it, so Tier one is more of like a general classroom we're doing. Tier Two is like for at risk kids, and then tier three will be individualized support. Yes.
Jayson Davies
Okay, so then, if I can really quickly ask you, how do you measure whether or not in the group sense progress is being made or not being made? Is each individual student going through a screening process, or is it like a group screening process?
Kokeb McDonald
Yeah. So what I'm in the middle of development inside of our program right now, so usually, ideally, as I'm training our therapist to go in and do like a school, like, if you have a school wide contract, for instance, and be able to if you're doing a push in. And right now, I do that with a school, and I have the entire school, like pre K to high school, so we are implementing these ritp program for the entire school, so every teacher is trained, they have access to our program. They implement that as a movement break throughout the class, and when they contact me as like, Okay, I have clients on kids so and so. I need support so and that way I'm creating it. Actually, for me, I'm like, I have the entire school, so I wanted to make sure I create this. So I'm gonna give the teachers to do a quick. Okay, have we done a school like, you know, the general classroom intervention and then, but there's some kids that we need to actually in addition to what they're doing, because we're trying to create the same activity so they won't be confused. They're already doing it. And so now we're creating a program they can pull out. And then we give them, like, five minutes or something, so do additional movement break, and they can come back again. And then when I'm screening the classroom, I can, for me, at least, because I can do it, I can be able to do a quick analysis of the child, and be able to say, like, oh, okay, we need to target this, this reflexes. So and our program that we give them so we have, like, the done for you school program that we can actually give them a playlist for the specific kid to go outside and do his exercise and come back. So the idea is, like, when we do, you know, sensory diet we've heard about that, that's where OTs do. I always been thinking. I always want my sensory diet or movement break to be meaningful and really connect brain body connection. I want, I don't want it to be like, just jump and come back. I'm like, why am I having this kid jump and come back? As is really targeting a problem. But how about if I can give him, like a five or 10 minute of exercise that really targets the challenge. And if we can create frequency that's actually can get a better result with that than seeing him once a week with me, if I can create a movement break that the teacher can easily implement, the child can go do it and come back, or the Para educator can do a comeback, or send a home program and do a comeback, you get a better result then, yeah, you know, you just shooting in the dark. Sometimes I kind of feel, I felt like that I sent ot right now, like, Okay, try this. Roll here, run here, you know, and then I'm like, we still having the same problem next year.
Jayson Davies
Yeah, yeah. And, and so I was just wondering how you how you kind of kept track of whether or not the student need to to progress from, you know, tier one to tier two to tier three, or if they're doing okay well enough in tier one. It sounds like it's primarily your observation as a therapist, whether or not you go in and observe the entire classroom, and you kind of pick out which, you know, students who may need a little bit more and which students who don't need as much. So does that sound about right?
Kokeb McDonald
Yeah, that that would be definitely a skilled therapist. Like that would be something this can can help. Because sometimes even the teacher will their kids will pull out, and then the teacher will say, like, oh, he doesn't need it anymore. He can the what we're doing already, he's can maintain. We also will teach the kid to say, like, okay, to teach, to tell them like, Oh, do you want movement break? Okay, when you want movement break, this is what you can do. So even educating them. But then they're outside of that. There are some other kids who definitely need a structure, pull out one on one sessions.
Jayson Davies
Yeah, yeah. And it's hard, because I think as therapists, we want to develop like a tier one system, or maybe even a tier two system, where the teachers can do the measuring, as opposed to us needing to do the observation and measuring. And that's really hard, especially when you're talking about things that are happening within the brain, right? Like, it's one thing to see a pencil grip, it's another thing to understand reflex integration, sensory processing, all that other stuff, right? So it's very hard to conduct a screening other than just, you know, an individual student, screening a group of students, or screening an entire classroom without the occupational therapist, or maybe even an occupational therapy assistant, even getting into the classroom to really kind of observe what's going on. So, yeah, yeah, thanks for diving into that. I know that was not planned on today's conversation, but I appreciate going down that route.
Kokeb McDonald
Yeah, yeah, definitely building it, and then we're testing it out all the time and then improving it. So that's, that's where we're at right now. Wasn't actually supposed to be public. Now you got me talking about.
Jayson Davies
All right, uh, well then, no one heard any of that. You can obviously, if you heard anything about, um, all right, going back you talked a little bit about integrating your approach with play and as pediatric occupational therapy, practitioner, school based, clinic based, home based, anything. Of course, play is huge, right? Like it is the primary occupation of a child, and it is one of the ways that we can help children make progress. So how have you kind of done that? How have you incorporated reflex integration into a play based approach?
Kokeb McDonald
Yes, just like you said, it's a natural progression for the kids, and the best way to learn is through play, and the best way for OTs is think of it when. Let's say when you are creating an obstacle course, we do that a lot, right? So we have a group session, and you create an obstacle course, and you pick out exercises. So what we teach is we really dive and break down each game you're doing an activity. Let's say you have them crawl through the tunnel. We can break down each of those movement patterns, and you can relate it specifically and to specific reflex patterns and how to even screen and observe. I think that that is the skill that we want our therapist to learn as like, Okay, I I picked five games, and I want to know my therapist to tell me I'm for each of the five games. I want you to tell me exactly what you're looking at, right? So let's say we the crawling. You know, we crawling can be working on and observing STN, R like one of the reflex that helps with the crawling is sdnr. You can look into the Galant, even in crawling, and you can also work on the atnr and during crawling, that's like, but then for the client, I tell them, for for you, it's very like, you're like a detective. You're observing every part of the body, and you're learning to pick up all these and how to observe the parent, the child, for the kid, is play. You're creating an obstacle course, but you're picking specifically the exercises that you want that is triggering the reflex pattern. It's going to challenge them just enough. But then for you to work on these brain body connection so we, I mean, the entire ot gym that you have, we can create a play based work just for that. But then for the therapist, we're teaching them how to observe these pattern, how they make it difficult for the child, let's say, to hang from the monkey bar. Why? Why is that? And their reflex parent can look through that. And which one are you working on in ball games, you can do the same, similar things. You name it. We can do it. You know, it's just really teaching therapists a tool to to assess even their work and to track.
Jayson Davies
Yeah, and, and again. You know, you don't necessarily have to have a clinic to do a lot of this. And, and maybe I'll let you share in a second, you know, like, what you can do if you don't have a clinic to do to look at some of these. But you don't necessarily have to have a si or reflex integration type of clinic to do a lot of this. What would you recommend to therapists to don't necessarily have a nice therapy space, space.
Kokeb McDonald
Okay, then a park. Do they have access to a park or playground? Playground? Yeah, so playground. So Monkey Bar is, like, one of the most common activities or even goals that I've seen written for OTs, right? So like, he will, you know, work on a monkey bar, hang from there. Like for, for Monkey Bar. One other thing we train is like, Okay, what does it take for the child to be able to hang on the monkey bar, and what reflects make it even difficult for them. So mostly, if they're more reflexes really active, or the TLR is really active, anything that makes them leave the ground would be challenging. Balance is hard. Vestibular is affected. So we work a lot on vestibular, right? So specific reflexes, the patterns you can work on. And another thing is, like the Grasp reflex as well. Like, in order to be able to alternate the hand and to cross over the monkey bar, you need to have a shoulder strength, obviously, core strength and bilateral coordination, which is etnr and all that. But the palm of grasp is one too. So we can do like, Okay, which one do you want to work on first? So sometimes we have to, you know, go back and working on the pomegras before we even work on the morrow, because the child has to be able to hang on with both hands. Because, let's say the pomegrass still active. So when one hand opens, the other one will open with it, so they won't be able to hang on, on both hands and be able to balance. So their strength is affected. Their core strength affected so being able to gradually walk them through and even how to set up a simple, like five minute session that is really like, what can actually give them, like this domino effect into the goal that they're working on. So, yeah, you can do on the playground, climbing up and down the playground, whether or not you're doing I'll ask the therapist too, like, Okay, why is that some kids have a hard time pumping on swings, right? So that can be if the sdnr is really active, or the TLR is really active. It's really hard for them to differentiate the upper body and lower body. And then you can see this awkward movement pattern like and their mind. You can see they're really, really trying, but their body is totally not following through. So you can see this disconnect with the body the brain. Body. So that's what we're going to help them. It's like, Okay, now we're going to downgrade the activity and help them.
Jayson Davies
Gotcha. Sorry, I have so many follow ups. I'm going to preface this with I am very uneducated when it comes to primitive reflex, and I really am, and I'm really asking questions that I'm genuinely interested in, and I think others that are listening might be interested in as well. A lot of what we talked about today has been more gross motor stuff, crawling, doing the monkey bars, climbing up and down different areas. You know, attention that's not really it's not gross motor. It's not any motor, but we haven't discussed fine motor at all. And I'm curious to know if there has been correlation between fine motor and primitive reflexes.
Kokeb McDonald
Oh, yeah, 100% I'm actually writing the next book on hand, which will include perfect at least. This is a plug that was not planned, but yeah, so I'm working on the hand because it took I decided not to write on the hand. Because, yes, OTs, we can tend to focus on the hand, but there's so much also we need to work on the postural reflex as well. But the hand, which is the palm of grasp, effect the hand the fine motor, the back in the one we talked about, like, have you seen kids cutting but their mouth is opening with it every time the mouth opens. Yeah, that is the AP reflex. That's the reflex that sometimes makes them like even want to put things in the mouth constantly, because something in the mouth, it goes in, you know, hand. It goes in the mouth, the hands pulling reflex, as well as connected to the hand as well even other reflexes, like atnr, which affects eye hand coordination, being able to time, that affects the hand as well. So the fine motor is also related to speech. So our grasp as there's a lot of actually, I'm researching on this because I'm about to write them. I'm writing the book as there is a correlation between the grasp and fine motor and and speech articulation, not the perception, but the articulation, which is why you see a lot of kids with fine motor challenge also have speech. Speech is a fine motor skill, right? It's a fine motor skill. And then you can see or how grasp or also affect overall strength. And then later on, even in older adults, the first thing for the quality of life is reduced 60 I think, if I'm not mistaken, are older adults because their grasp strength goes down. So how important it is actually to work on grasp for overall quality of life. Because if your hand strength is down, you know your functional skill, and you know taking care of yourself, care will go down as well. And this is really highly. Is, you know, connected. And if you notice too, like, if you had, I don't know if you have baby, or if a child, like the grass string, is so strong when they're born, you can literally an infant. You can literally lift them up and you can see how strong they are. This, like a tiny like infants, they are just born, literally, because they're so it's not because they're strong as it's the reflux. It's really strong pattern, yeah, and that helps with even breastfeeding. It helps because they tend to, you know, help with breast, you know, milk production, because they grasp on the mom's breast and then they squeeze. And that is something it helps with self regulation as well, because it's connected to it helps with the Moro reflex integration as well, because the Grasp helps, because the baby, you know, the infant, even with other animals, then research that they hold on to their caretakers. So that is all connected to grasp and hand strength is highly related.
Jayson Davies
Wow, yeah, you know. And I just casually went along with you and said, like, yeah, you know, speech movements is fine motor and like, I just, you know, went along with you, but, and it is, but I had never thought about that. And so when you said that, speech is fine motor, I think that's the way you phrased it, like, yeah. I mean, all the different movements that you have to make with your lips, your tongue, your jaw, all of that definitely not gross motor. I mean, maybe just opening your mouth, you might consider being gross motor, but everything else going on in there is definitely micro, small movements. So.
Kokeb McDonald
Yeah, very complicated. It's its own field, right? So, yeah, yeah, it's fine motor. Yeah, that's related. And then you'll see, if you go now look at your caseload and see how many kids who have fine motor challenges also have speech challenges. The correlation is very hot. Okay, yeah.
Jayson Davies
And I think we're all, you know, everyone right now, including myself, we're all thinking about one or two specific kids right now as you talk about this so absolutely and and it leads my head to a whole nother conversation, which has become kind of popular. I don't know if we'll dive into it, but about speech, kids who have speech only IEPs, whether or not they should also be able to have ot on their IEP, or if they need to have RSP or sai in order to have OT, whole other conversation. But this kind of backs up the idea that students who have a speech IEP might also need occupational therapy. So, yeah, just something to throw out there.
Kokeb McDonald
Yeah, I think it's important, like we have some speech therapists in our program as well. They take our certification program, because now more and more speech therapists are actually noticing that they need to do more than just the articulation piece of it there. There is more to speech development, like working on, I mean, co treating speech and OT is the best, and I actually enjoyed the most when I did that, especially the kiddos who have speech delay. And I can actually screen out, pull in the speech therapist, and then I show her, look at this, in in, let's co treat. So those aren't great. And then even encouraging speech therapists to do more movement activities and consider co treating with OTs and vice versa. And when our kids start doing really well and integration and coordination, bilateral coordination, I asked my team and my therapist to go and talk to their speech therapist and see if their goals are improving. And sure it is.
Jayson Davies
Wow, yeah. It's amazing how the how the brain works, and everything kind of comes together, you know, we, yeah, we like to, you know, it was always big, right? Express, I mean, it's still a big thing in, especially in, like an OT school, right? People get frustrated when they say, oh, PT works on the legs. OTs work on the arms, and, I mean, it's just another reason to be more frustrated by it, because it's all interconnected, right? Like we can't separate speech therapists from i You can separate what we each do, yes, but at the end of the day, it's all interconnected, and what what you do might impact speech not because you are a speech therapist, but because that's just the way that this child or person's brain works. Right when you impact one thing, it impacts another. So yeah, absolutely crazy. One last topic that I want to address before we move on today is a little bit about collaboration, because within school based occupational therapy, we are often tasked with supporting teachers, and we talked a little bit about this with the tier one, tier two, tier three, that we discussed earlier. But I'll ask you this way, if there's an occupational therapist, you know, listening out there today and they want to support their teachers, maybe they already have some some education with primitive reflexes. But what maybe one or two tips do you have for maybe helping an occupational therapist support a teacher, whether it be one specific kid or the entire classroom? I know carry over is always difficult with teachers. Is there any suggestion that you might have to help with the carryover?
Kokeb McDonald
Yes, so I can tell you what I've learned by working with lots of years, and what I noticed is, even when why we developed a school based program is is really understanding what the teacher goal is, right? So usually we go in a classroom and focus on our goal, like I'm an OT. Here is my kiddo. This is my goal, and I'll go, do you know? But then we forget true, yeah, that is because that is our care, and then that's why we're there, and we assume the teacher is equally concerned about that. Yeah, and then what I but then, when I did this work, I think I spent about a year going to classes and just observing teachers and what they do and the amount of tasks they have on your plate, and they're just overwhelmed by like 30 kids, and we have that one kid, we want them to do something. And so what I've learned, and even I changed my approach with teachers, and we just decided, okay, what do teachers really need? And each of the teacher working with, just like your clients, they're different, right? So there, are teachers who are like, gonna learn and read everything, and they will implement everything to the team. I mean, those are great. But then there are teachers that they are overwhelmed themselves. So what can we do? So what I've noticed, in general, what works really best for teachers is when you provide a. Done for you. Curriculum based. Here it is five minutes. Just do it, because I got a first I was focused on. Let me explain to you. Let me help you understand why this is important. I'm like, they don't care because, because there's a lot of other things they need to do. So the best way is to understand your teacher, know their pattern, your own teacher pattern, what works best for them, and then suggest and ideally for me, what I do is give them a done for you program, like, we just give them, like, Okay, you have five minutes. I'm going to doing this time. Just do this exercise with the whole class. And if you want to learn more, come here. I'll show you how to do it. And when I, when I work on a client, I first, with the teacher, actually address their goal first, because they care about what they care about. So I I'll, instead of, like, telling them what I'm concerned about, I tell them, like, Okay, the reason you want them to sit still, okay, this is what's going to help them. You want to, what are the things you're concerned about? I'll help you with that. And indirectly, you'll work on on the goal. And I think that same thing with everybody else too, right? So, and, but you definitely have to, you have, I have to remember there the classroom is the teacher's domain. I don't dictate it. And then if it does, if I'm overwhelming them, I lose already the same with home program, right? So you have to figure out the parent and what they can handle. And then I if you overwhelm them, and then you're not meeting, you're not addressing the main concern. They're not going to do it. So sometimes that's why I screen in front of them, to show them, because when they say I'm concerned about this kid, like the the oral motor situation, that he puts everything in his mouth, I just pulled the kid in front of him and did the screening right quickly in front of him and proved to them that, hey, this is a not behavior. And then you can see their their demeanor starts to change. They they feel like, oh my gosh, I didn't know a poor baby, you know. Like they care more so now they're not having this battle, you know, like, you know, battle with him about behavior issues. He's not listening to me. Situation that's, that's our approach. And then offering a denfoy, easy to follow program, it's ideal, and that's we create that for.
Jayson Davies
Absolutely, yeah, and, you know, it takes a little bit of time to do something like that as a school based OT, absolutely. But I found like, once you create your template for what your program is going to look like, then it's relatively simple to plug and play. Once you have, you know, this student versus that student like you, you've got the infrastructure there. You just need to change out a few different routines that you might want this student to work on versus this student. And it's relatively simple. It takes less time. There's always that setup phase of getting it, you know, ready, but by by developing the template that can be simplified. We'll just put it that way. Definitely be simplified. And 100% agree with you on figuring out what the teacher's goal is. That is my number one go to support that I provide to OTs oftentimes like, they ask me, like, I don't know what to work on the court or what to work on with this student. Ask the teacher, start with the teacher, because the teacher sees the kid every day. They know what they want that student to do in the classroom, that's the best place to start. So, yeah.
Kokeb McDonald
And if you can solve other things for them, yeah, they will. They will definitely buy into what you're going to do.
Jayson Davies
Yep, yep. 100% All right. Well, COVID, it has been amazing talking to you a little bit about reflex integration. Thank you so much for coming on. And before you go, I want to give you a little a little moment to talk a little bit about what you're doing over at integrating reflexes.com and what you have to offer for therapists. You've mentioned books, but what else?
Kokeb McDonald
Yeah, we have a mobile app that is now public for everybody we that's where we have our therapist create treatment plans, and then they can easily share it with their clients to be able to access that. We also have made it available that parents who don't have therapists who wants to actually start a home, they can be able to access it as well and learn and be able to implement it with their client, with their child. It has activities. It's done for you, movement activities and some explanation. And constantly adding to it, we have a little bit game set there can be able to do as well. We have a certification program that we teach therapists to screen, create a treatment plan, implement and be able to, you know, create a home program and school program as well, and then be able to do that inside our program. We do coaching. It's 12 months right now. Is 12 months program access that we give them. Some of them finish it really quickly. Some of them takes them a while. To learn to implement, but they have 12 months access to our coaching and support where they can come. We have life coaching times that they bring in their cases. We do treatment planning and brainstorming, ideas and support, so that is something we provide. We have books and resources that we create for therapists to be able to implement constantly, creating those what else we have game. We have a memory game and game, a tile game that we have for a lot of therapists actually like it, because it's easily they can take it with them and they do memory game, and it's exercises, but all the exercises are picked so it can challenge different reflex pattern as well. And I think that's it for now. Yeah.
Jayson Davies
Is integrating integrating reflex.com that's the best place for everyone to go?
Kokeb McDonald
Yeah, or you can go ritp dot info and then sends them to our website, which is integrating reflexes.com.
Jayson Davies
Perfect. Well. Kokeb, thank you so much for joining us today. Really appreciate it. And yeah, we will link to all those in the show notes, as well as any other resources that we've kind of talked about today. And yeah, definitely go check out the website. Kokub also has several videos where she like shows the game and whatnot. So head on over there. Learn more about the game, the app, all of that, and especially the program, if you want to learn more about reflex integration. So Kokeb One last time. Thank you so much for coming on. We really appreciate yourself and all the knowledge that you shared.
Kokeb McDonald
Yeah, thank you so much for the invite. I appreciate it.
Jayson Davies
And that wraps up another episode of the OT schoolhouse podcast, a huge thank you to kokub for joining us today and sharing her expertise in reflex integration. Kokeb, your insights into making reflex integration accessible, practical and occupational focused have truly given us all something to think about and to apply into our school based practices. As an added bonus for listening to this episode, Kokeb is graciously offering all of our listeners 10% off her reflex integration books and games at integrating reflexes.com just use the code. OT schoolhouse, all one word to save today. And thank you, of course, for tuning in and taking the time to grow alongside us. If you enjoyed this episode, be sure to leave a review or share with a colleague who could benefit from learning more about reflex integration and its place in school based occupational therapy. And if you're looking to take your professional development to the next level, I'd love to personally invite you to join the OT school house collaborative, our growing community of school based OTs and OTs, who meet every single month to learn from experts, dive into research and implement evidence based practices together. It's the perfect way to get the support and resources you need to grow in your role while connecting with others who understand your unique challenges. You can learn more and become a member over at ot schoolhouse.com/collab, that's ots.com/C, O, L, L, A, B, with that, I hope our conversation today sparks some new ideas and approaches for you to consider in your practice. Remember, as ot practitioners, we have the incredible opportunity to make meaningful changes in the lives of our students, teachers and families we work with. Thank you again for listening in, and I will catch you in the final episode of 2024.
Amazing Narrator
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