Advanced Pediatric Therapies


Get Outside!

Every summer, I’m asked to compile a list of outdoor activities for families.  Our service model changes over the summer from weekly visits to intensives.  During that time, we encourage families to get outside to play and to MOVE!  There are so many fun games and activities to choose from.  Here is just a partial list:


For the little ones:

  1.  Crawl around with your mason jar and find some cool bugs and leaves.
  2. Dig in the dirt, use a shovel and get messy!
  3. Play in the sandbox, making sure to have buckets and cups to lift the sand.
  4. Water the plants with heavy buckets of water.
  5. Use an old sprayer to mist the plants or “paint” a brick wall.
  6. Dig up some rocks that you can then paint.
  7. Put some rags in a bucket of water.  Make a chalkboard target on an outside wall.  Throw!!
  8. Climb a tree.
  9. Help Dad wash the car.
  10. Take the dog for a walk, the more pulling the better!
  11. Play tug o’ war.
  12. Go on a nature scavenger hunt.
  13. Jump rope.
  14. Stack rocks and make a sculpture garden.
  15. Make a mud pie.
  16. Run through the sprinkler, then spin through the sprinkler, then jump through the sprinkler, get creative!
  17. Blow bubbles outside and watch them fly away.


For older kids:

  1. Set up a zip line in the back yard.
  2. A slack line is also great for older kids.
  3. Ride your bike around the neighborhood, try to balance on a chalkboard line in the street.
  4. Go for a swim.
  5. Power wash the back deck. Take some before and after photos.
  6. Hang wet clothes outside on the line.  Or hang artwork, or photos. Host an art show.
  7. Go skateboarding or scootering around the neighborhood.
  8. Play bocce ball in the yard with friends.
  9. Play hopscotch or foursquare in the driveway.
  10. Bring fresh flowers or veggies to a friend.
  11. Deliver newspapers.
  12. With supervision, climb a ladder and wipe some windows.
  13. Play some kickball!  Or volleyball!  Or tennis!
  14. Set up a tent (by themselves) and sleep in it in the backyard.
  15. Do a potato sack race.

Give us some of your own ideas!


Update:  If you have younger kids, check out these cool articles from PBS Kids on Sneaking in Learning over the summer and Best Free Apps to get kids outside.

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Are Temper Tantrums and Sensory Meltdowns the Same Thing?


Does this look familiar?

I read a great article recently about sensory meltdowns and it was a great reminder to talk to the parents we work with about a dynamic that can very easily be misinterpreted.  So what is a “temper tantrum?”  Most of the time,  temper tantrum is easily recognizable in toddlers and maybe even teenagers!  Your child is not getting their way, or what they want and they pitch a fit, screaming and crying.  They can roll around on the floor, sometimes even hitting their heads against a wall in the extreme.  A temper tantrum is often being characterized by a child being told “no.”

In contrast, a sensory meltdown could better be described as a “release,” or overflow of emotion as a result of being exposed to a sensory input that feels unpleasant or even intolerable.  In the article, the mom describes her 9 year old daughter as holding it together then crying in the car after cheerleading practice became intolerably loud.  Of course, when your child is younger and can’t tell you what the upsetting force was, it gets trickier.  If you see a meltdown coming on, you can ask yourself or your child a few questions, based on your knowledge of them and what sets them off:

  • Is it too bright in here?  Do you need your sunglasses?
  • Do we need to leave?
  • Does your body feel funny?
  • Are you uncomfortable?

Assure them you are there to help.  However, once your child is in a meltdown, they are already experiencing “fight or flight.”  This means that their nervous system has gotten involved, and you are less likely to be able to intervene. At that point, you can:

  • Talk as little as possible.
  • Give them space to breathe, cry, whatever they need to do.  This is what the mom inherently knows to do in the article.
  • Remove them from adverse environment.
  • Plan for next time!  Make a “retreat” in your home:  a quiet space with noise cancelling headphones, quiet music, dim lights and away from anything unpleasant. Maybe some gum, a quiet toy but no screens.


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Advocate for Recess!


I remember being in school and the teacher calling this out to us in the lunchroom or class.  It meant (hooray!) it was time to get outside and get all our wiggles out.  Recess means a break from having to sit in one place, use our brains intensely and not having to listen closely to a teacher.  It meant fun, movement and a sort of freedom from the monotony of the school day.  What we didn’t know at the time was that our brains and bodies needed a reset button.  Recess was not a reward, but rather a reserved time just like art, math or lunch.  In our current test-driven educational environment, not only is recess in jeopardy, but it’s value has been called into question.  Recess is not a privilege for kids who are well behaved or get good grades.  Research has shown it to be essential to your child’s development.

Recess in recent years has been limited and even cancelled.  Schools are feeling stress to improve kids’ grades and test scores and the more time spent in the classroom, in their opinion, the better.  Leading educators have been calling this into question more and more in recent years, citing many studies that say that by doing so, we are putting the health of kids at risk.

Research has yet to prove that removing recess with raise test scores, but the following benefits have been proven for kids.  Kids who have recess:

  • Are less fidgety and more on task
  • Have improved memory and more focused attention
  • Develop more brain connections
  • Learn negotiation skills
  • Exercise leadership, teach games, take turns, and learn to resolve conflicts

The American Academy of Pediatrics put out a policy statement in 2013 advocating for the “Crucial Role of Recess” in the development of children.  It is required reading for parents and educators alike.  The paper discusses the cognitive, physical and social benefits of recess in great detail.  In addition, it states that the removal of recess should NEVER be used as punishment.

What can you as a parent do?  The excellent website Peaceful Playgrounds provides handouts, guides and presentations which are easy to download and offer lots of other resources too.  Together, we can take back recess!


from an article I wrote for
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Parenting the Highly Sensitive Child


We have lots of kids who come through our doors that parents describe as “sensitive.”  What does this mean?  The book The Highly Sensitive Child written by Elaine Aron, defines a sensitive child as… (from website)

A highly sensitive child is one of the fifteen to twenty percent of children born with a nervous system that is highly aware and quick to react to everything. This makes them quick to grasp subtle changes, prefer to reflect deeply before acting, and generally behave conscientiously. They are also easily overwhelmed by high levels of stimulation, sudden changes, and the emotional distress of others. Because children are a blend of a number of temperament traits, some HSCs are fairly difficult–active, emotionally intense, demanding, and persistent–while others are calm, turned inward, and almost too easy to raise except when they are expected to join a group of children they do not know. But outspoken and fussy or reserved and obedient, all HSCs are sensitive to their emotional and physical environment.

Sensitive kids require extra attention and modification from their families.  The best route to effective intervention is to accept them where they are and not try to change them.  You can try to change your approach to your child in some different ways, though, to keep things calmer at home and provide some much needed predictability.  Sensitive kids tend to get “triggered” more easily.  They are more emotional and struggle to not become overwhelmed.

For parents needing some peer support, this series of articles on the blog Scary Mommy is really helpful.  Raising a Sensitive Child and My Imperfect Child give perspective on what it’s like to raise a sensitive kid.  Some additional reading is a book that has been recommended by parents is by Ted Zeff called The Highly Sensitive Boy.

In any event, parents often confront a difficult issue with these sensitive (or “emotional” or “difficult” as frequently labeled) is how exactly to discipline them so as not to break their fragile spirits.  From the book and this article in Creative Child magazine, we have some ideas.

Firstly, there are discipline techniques that should definitely be avoided.  Shaming, by way of name calling and “why can’t you get this?” type of correcting are perceived very negatively by your sensitive child and be potentially very detrimental.  Teasing a sensitive child is bound to provoke their intense emotions and likely will not be felt in the playful nature that was intended.  Best to be direct.  Physical discipline is also devastating to sensitive kids and most childhood developmental specialists warn against using it with any kids.  Time outs likely will be perceived as being sent away by sensitive kids and can take an additional emotional toll.  Finally, being too permissive in an attempt to avoid tears or meltdowns is to be avoided as well.  Loving correction is best.

Discipline Techniques That Work Well:

  • Be careful of your tone.  Loud does not mean you will be listened to any better, and to a sensitive child can be even more harmful.
  • Connect first.  Remind your child you love them and gently tell them what your concerns are.  You don’t want to be perceived as threatening.
  • No time outs.  Instead, take your child someplace that will help them to calm down and peacefully explain what went wrong and what should happen next time.
  • Consequences should be mild.  Most sensitive kids will adjust their behavior based on their ability to see it displeases you and is not acceptable within the family.  Consequences that make them stand out are shaming and to be avoided.
  • Follow up.  Have play time, and use positive language after the discipline has occurred.  This restores connection.

Hope these are useful to you and your family.

Ask any of our OT’s if you have questions or ask about our lending library for resources on sensitive kids.


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Visual Timers

Why we use visual timers:

Visual timers are a great way to ease transitions for kids.  It lets them know how much time is left, mostly by color depending on the timer, so that they can be prepared when it’s time to end or say goodbye.  They can “check in” with the timer so that they know what to expect, instead of being startled by a “times up” right when they are having fun.  It’s also useful for a more dreaded activity like grocery shopping or a play, when the child wants to leave.  It gently reminds them how much time they have left.

So where can you find a visual timer for your child?

Right here. This is a list of physical timers.  But there are also many timers available as app’s from the App Store for Apple or Google Play for Android.  It’s often MUCH easier to have one on your phone, and there are many free options available.  When you have one on your phone, you can use it at the doctor’s office, at the store, anywhere.  Some kids may prefer a timer with bright colors, pictures or sound effects.  Ask your occupational therapist if you need help choosing one.  Visual Timer for a child with special needs

1. Time Timers

Time Timer Visual TimerRecommended by Autism and ADHD experts, Time Timer is one of the most popular visual timers available on the market. With an uncluttered interface, silent operation and optional audible alert this timer works great in almost any setting. Time Timers come in three, eight and 12 inch sizes, perfect for the classroom, in your home or on the go.
Price: $30-$40
Purchase at:

2. Time Tracker & Time Tracker Mini

Time Tracker TimerTime Tracker is a great visual tool for children with special needs. Following along the lines of a traffic light, Time Tracker uses colors to notify a child that his or her time is almost up. Time Tracker features volume control, a pause feature and quick programming of the lights and sound effects.
Price: $26
Purchase at:

3. Time Tracker Mini

Time Tracker MiniThe Time Tracker Mini is a smaller more simple version of the Time Tracker. The Time Tracker Mini is half the size of the original Time Tracker (4.75 inches tall) and operates easily with just 2 dials. Alarm times on the Mini can be set from 5  minutes to 2 hours, in 5-minute increments.
Price: $15
Purchase at:

Talking Timer4. Talking Timer

The Lux Talking Timer offers the flexibility  to be used as either a precise clock or as a count up/count down timer. A clear spoken voice will announce the time of day or how much time remains until the count down elapses. You can set a timer for up to 23 hours and decide if you would like an audible alarm or not.
Price: $17
Purchase at:

Amco Color Alert Timer5. Amco Color Alert Timer

While this timer was designed with the kitchen in mind, it can also be used for your child with special needs. The Amco Color Alert Timer is useful if you are looking for an inexpensive timer or looking for the added bonus of kitchen use. The timer is a 60 minute timer, that blinks yellow with 10 minutes left and red with one minute left.
Price: $17
Purchase at:

Above from an article on friendshipcircle blog.  Check it out!

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Do You Have a Child That Hates to Lose?

Does this look familiar?

Does this look familiar?

We play a lot of games here at APT, and there are frequently some pretty sad or frustrated faces when a game is lost.  We play games for a variety of reasons including building social awareness, improving self regulation (skills such as handling frustration, managing expectations) auditory or visual skill building, fine motor skill enhancement and so on.  Kids who hate to lose are often called “sore losers,” but it can be taken to the extreme.  Kids will throw tantrums, name-call (to themselves or others), cry, hit or even stop talking.

We suggest first trying to avoid the problem by teaching them how to be good sports.  Parents magazine suggested a couple of the following and also some tried and true methods from the therapists here are included:

  • Play by the rules.  You are your child’s best teacher and you shouldn’t let them win on purpose.  If the game is too hard for them, scale down.  Shake hands whoever the victor is at the end of the game.
  • Encourage self competition.  This means letting your child set their own goals.  If they were able to ride their bike up 1/4 of the hill, maybe their goal can be half the hill next time.  They don’t have to play games all the time to learn some aspects of healthy competition.
  • Encourage “improving” over “winning.”  The game that keeps score may be more difficult for a child to handle than activities that don’t.  Martial arts, dancing and fort building are not scored, but you can show improvement in each.
  • Poor sportsmanship is not okay.  Bragging when they have won or “freaking out” when they have lost:  neither is being a good sport.  Model for your children how to be a good sport.  At the beginning of a game, do a cheer for the opposite team.  Always make sure to say “good game.”  Don’t gloat when you win.  Point out what the other team did well, even if they lost.
  • Acknowledge the effort.  Let them know how hard you see that they tried.  Ask them if they’d like some help getting better at something.
  • Don’t set the bar too high.  If your child is 5, don’t pick out a board game for ages 7 and up. There is a reason for age parameters.  Try to stick to them.
  • Set a new strategy.  When they say “I’m never playing this dumb game again!, ”  you can try to help them become better at the game you were playing.  Ask them what they could have done differently.
  • “How would you feel?”  Ask them how they would feel if a friend quit in the middle of a game that your child was winning.  Ask them these questions when it is no longer game playing time, when the heat of the competition has worn off.
  • Set them up for success.  For our kids, things like lighting, noise and seating can make a huge difference in how well they are able to play.
  • Have a sense of humor!!  When kids get a “skip a turn” card or make a wrong move, they can pick a silly word to say that will express their frustration.  We use words like “Oh Fiddlesticks!” or “Oh Pickles!” Silliness takes the seriousness out of play.  You can also leave the game as it is and go out and throw a ball outside.  Come back later.

For some kids, the emotion of winning or losing may just be too much for now.  On those occasions, play a game where they are part of a team or choose an activity that is non-competitive like an art or science project.

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Executive Function: What does it mean?

The skills that make up executive functioning are strong indicators of future life success.

The skills that make up executive functioning are strong indicators of future life success.

Executive Functioning is the latest buzzword that parents have been hearing lately.  EF is made up of many smaller skills that make up the bigger picture.  In the illustration above, from a recent Parents magazine article, you can see how these skills are imperative to being able to get along with other kids, follow through with an idea, become familiar with rules and expectations, self monitor behavior and stay focused on the task at hand.  Phew!  Takes a lot of energy.  Some kids have difficulty with these skills for a variety of reasons including having a diagnosis of autism or ADHD or even dyslexia.  Children (and adults) who don’t have a formal diagnosis can still struggle with EF, and it’s the therapist’s and parent’s work to help bridge the gap.

When your child is in preschool, their brains are developing executive functioning simply by playing with other kids.  For young kids, EF is learned and integrated when kids are able to “use their words” or utilize language when dealing with a problem.  If they have a problem which they can’t solve, they get adult help.  Or they figure out that the game the other kids are playing looks just as fun as the one that was just snatched up by an unwelcoming group.  When a child acts out under these conditions or alternately retreats, then they made need some assistance developing EF skills.

“Executive Functioning is the brain wrestling with it’s emotions.” –  Walter Gilliam, PhD.  Yale University

When a child is mastering executive functioning, they are simultaneously learning to deal with emotions which can make for an explosive mix.  Because studies suggest that self regulation can be a better indicator of future success than SAT’s, it’s worthwhile to invest time in some proactive strategies.  The following ideas are some which have been taken from a variety of sources, but check with your healthcare provider if you have questions.

Choose a school that emphasizes executive function in their curriculum

Look for words like “child centered” and “play based” when selecting a school.  For older kids, look for teachers that see themselves less as dictators and more as facilitators of the process.  Good schools know that emotions and behavior are part of learning just as numbers and facts are.

Tell stories

Kids who listen to stories, make up their own or even listen to an audiobook aren’t relying on visual material.  They have to rely on their memory and how they feel about the story to hold it in mind and keep engaged.

Be a good role model

Ask questions when you don’t understand, talk out loud when attempting to solve a problem.  Go to yoga when you are stressed, then come home and say how the silence helped you figure something out.

Point out an accomplishment

Let your child know when you see them controlling their impulses.  Your preschooler is about to throw the remote when she is told she can’t watch her favorite show.  But instead, she puts it down and starts playing something else.  Tell her she made a good choice.

Patience is a virtue…

When your child learns to wait, something often tough to do in our culture, they are also stopping themselves from doing something else that could be negative.  Like, stomping their feet, yelling or running away.  Modeling patience is helpful too.  Remember that the next time you are stuck in traffic…

Discipline and perseverence

We can learn these skills by doing them.  Over and over and over again.  Just like that episode of Sesame Street that they watched a thousand times.  Younger kids love repetition.  Older kids need a bit more novelty, but repetition is needed nonetheless.

Executive Function isn’t really anything new, although it’s experiencing a resurgence in the media right now.  Ask your OT if there’s anything particular to your child that you can do at home.

photo from Parents Magazine




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“Auditory Processing:” What does it mean?

Auditory processing is more than just hearing.

Auditory processing is more than just hearing.

What does “auditory” mean?  Is that the same as “hearing”?

Auditory simply means related to hearing.  The inner ear has two major organs that contribute to our sense of sound.  Very simply speaking, the cochlea is responsible for defining the sound that is heard (like a car horn) and the vestibule is responsible for the sound making its way to the brain so that the brain can produce a movement based response (get out of the way).  The vestibular system, also housed in the inner ear with it’s partner the hearing system,  helps us achieve more complex responses like balance.  It’s a complex symphony that results in coordinated movement in response to sound.  The music of this symphony is auditory processing.


Kids who have a healthy and functioning auditory system…

* are able to turn their heads toward you when their name is called.

*are able to filter out sounds which they don’t need to pay attention to like the refrigerator turning on, or a baby crying in church or their brother kicking a chair during dinner.  Those noises are background.

*can follow directions that are given verbally from you or a teacher without problem.

*can catch the vast majority of words spoken to them without missing a word.

*aren’t distracted by sounds which may be familiar or unfamiliar

*know what to do when they hear a certain sound like the bell to change classes.


Kids who have problems with auditory processing…

*may miss small parts of direction, which can affect how they respond.

*may be hyposensitive, which means they are underresponsive, or aren’t able to clue into important sounds around them.  They may talk to themselves a lot or make a lot of sounds.  They may not accurately respond to a direction because they may not have heard it accurately.

*may be hypersensitve, which means that they are overstimulated by noisy environments.  They may seem controlling or avoid these types of environments.  They may cover their ears, or act like they want to run away.  Sounds may seem actually painful to them.

*may seem very distracted and unable to follow your directions.


Ways you can help…

Sing songs with them.  Read with them and ask questions about what they have read.

Use verbal cues like “Are you ready?”

You may find it helpful to say something a different way.  After asking a child to pick up his shoes a couple times, you might want to say:  “your shoes belong in the closet.”

For older kids, voice recorders on smart phones can help them remember details from classes.  Younger kids can also benefit from visual components like videos.

Outlines, study guides, personal organizers can all help.

Noise cancelling headphones can be helpful.

Therapeutic Listening- as prescribed by your OT.

Talk to your occupational therapist about the specifics related to your unique circumstances and your child.  We can help find ways to reduce their frustration- and yours.

Other websites to check out:

The American Speech-Language Association– a detailed article about auditory processing.

This website has ideas from parents.

These videos are descriptions of brain pathways related to the senses.

Ideas for the classroom.

Nice blog written by therapist related to auditory processing.




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Cathy Holway visits APT!

Mandy learns about and receives cranio-sacral therapy from our guest instructor, Cathy Holway of The Neurovascular Institute.

Mandy learns about and receives cranio-sacral therapy from our guest instructor, Cathy Holway of The Neurovascular Institute.

In early December, some APT and other therapists joined us to welcome Cathy Holway from the Neurovascular Institute to learn about cranio-sacral therapy.  Cathy is a doctor of physical therapy who received her training from the Upledger Institute, then later created her own form of work, Sacred Spaces, which has evolved into the Neurovascular Institute.   From her website:  the curriculum continues to synthesize outstanding, science-based medical education with the art and spirit of healing.  We spent the weekend practicing on each other, getting immersed in neuroanatomy and neurophysiology and brainstorming how to use the treatment with our kiddos.

Cathy tells us that touch rewires the brain.

Cathy tells us that touch rewires the brain.

When touch is used to access the brain, as in cranio-sacral therapy (CST), the goal is to help a client (child or adult) to move in the world with less effort and to engage with the world in a more positive way.  In a typical session of about 30 minutes to an hour, the therapist moves along the client’s body “holding” in certain ways and areas to provide a release to the neurophysiology of the tissues.  As the practitioner, we learned that our presence, touch and breath has a profound influence on the effectiveness of CST.   For most of our kids, this would mean activating the parasympathetic nervous system to help calm and relax the child.

If you’d like to learn more about CST to see if it might be right for your child, speak to your OT or visit Dr. Cathy’s website where you will find a wealth of information.

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What is “Vestibular Processing” anyway?

Spinning is super fun!

Spinning is super fun!

The following is excepted from North Shore Pediatric Therapy:


The vestibular system detects movement and gravitational pull, and it provides information regarding the position of our head in space and acceleration and deceleration of movement. It is the first sensory system to fully develop in uteroandis located in the inner ear. The vestibular system has strong neurological connections in the brain and is a major organizer of varied sensory input. This system is considered the most influential sensory system and has tremendous impact on one’sability to function daily. Directly or indirectly, the vestibular system influences nearly everything we do. It is the unifying system in our brain that modifies and coordinates information received from other systems, and it functions like a traffic cop, telling each sensation where and when it should go or stop.  


This system affects aspects of physical function like posture, balance, movement, coordination, attention, arousal level, impulsivity and behavior. The vestibular system works with tactile, auditory, and visual information to give us our perception of space and our position and orientation within that space. Children affected by poor vestibular processing may be perceived as inattentive, lazy, overly anxious, or seeking attention. They may have trouble reading or doing simple arithmetic. Functioning at school, going out into the community, performing routine daily tasks, or just getting out of bed in the morning may be difficult for children with vestibular difficulties.


Poor vestibular processing (or vestibular dysfunction) can occur for a variety of reasons; often, however,children develop a vestibular disorder for no known reason. Possible causes for vestibular dysfunction include: premature birth and a fairly long period of incubation after birth, exposure to excessive movement or invasive sounds as a fetus or infant, neglect (little handling and moving) during infancy, repeated ear infections or severe ear infections, maternal drug or alcohol abuse during pregnancy, or general developmental delay and immature development of the nervous system.


Symptoms and functional difficulties of poor vestibular processing include:

  • Over-arousal or under-arousal
  • Excessive movement
  • Avoiding movement at all costs
  • Difficulty maintaining attention
  • Motion sickness (car, boat, airplane), dizziness or nausea caused by watching things move
  • Excessive spinning or excessive watching of things spin
  • Inability to read or write in cursive
  • Decreased auditory processing
  • Inability to sustain listening without moving or rocking
  • Problems with balance (static or moving) and/or vertigo
  • Difficulty walking on uneven ground, and difficulty navigating stairs
  • Head banging
  • History of traumatic brain injury, shaken child syndrome, ear cuffing, etc.


The vestibular system primes the entire nervous system to function effectively by sending messages to the higher centers of the brain. When the influences of vestibular stimuli fail to reach their destinations, they cannot adequately contribute to sensory integration. One result of depressed processing in the vestibular system is hypotonicity (low muscle tone); when this system is not integrating information as it should and muscle tone is decreased, it is difficult to initiate movement or to maintain muscle tension during movement, resulting in significant difficulties in fine/gross and oral motor coordination.

The vestibular system also tells us where we are in relation to the ground, giving us a confidence that if we jump, swing, or somersault, we know we will hit the ground on our way down. Thisknowledge is called “gravitational security,”and with this basic sense of stability, children develop emotional security.

A child with dysfunctional vestibular processing, who does not possess “gravitational security,” tends to be inflexible, fearful and controlling due to the fact that he lacks control over the world around him and how he moves through it. This child often suffers from social problems as well, as he feels vulnerable to unpredictable situations caused by those around him.

Our Approach at APT:

At APT, we treat vestibular dysfunction in a variety of ways.  The most obvious are all the swings, climbing apparatus and tunnels you see around.  But we also address vestibular dysfunction by using auditory interventions, primarily therapeutic listening.   We don’t treat it in isolation either.  Most of the activities we utilize integrate many layers of sensory skills and we work toward what is best for your child.   Please ask us if you have questions!

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