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Understanding Dysgraphia—it more than learning to write

Dysgraphiais commonly understood as a disorder of handwriting.  However it is more than that.  It impacts self-cares such as learning to tie shoes, buttoning, zipping, and includes all in hand manipulative task such as eating, etc.

It is not an issue that can be resolved by “tutoring”.  It will not self-resolve with age and maturity. It is brain-based and is simply stated the translation of a correct cognitive image into a purposeful and correct motor response.

In other words, what you “see” in your mind is what you produce in with your hands.

Although this often first becomes evident in school when the child cannot write legibly there were probably earlier signs that went un-noticed because the child was young (and the thought was “they will outgrow this”).

Without Occupational Therapy treatment children do not “outgrow” Dysgraphia. The visual sensory perceptual motor skills involved in remediating Dysgraphia are outlined below.  Getting these skills to work in harmony with each other is the art and science of occupational therapy intervention.

Perceptual Sensory Motor Factors Impacting Dysgraphia

Small muscle strength(this is not related to or about exercise or strengthening).

  • Fatigues easily /switches to sedentary tasks
  • Ability to sustain a grip/demonstrate resistance and co-contraction.
  • Isolation of individual finger movements

Visual motor

  • This includes visual tracking and the ability to follow an object, as it is moving.
  • Visual pursuits inclusive of copy skills should be consistent and not require a lot of verbal cueing.
  • Visual memory should be automatic

Grasp

  • The ability to competently hold a pencil/paint brush
  • Make smooth connected strokes
  • Use a functional pincer grasp (for writing)
  • Ability to sustain a stable hold on the object in the hand (utensil, toothbrush, pencil, etc.)

 Perceptual DiscriminationThere are 7 realms of perception: (note this is processing not acuity)

  • Discrimination: (discerning one object from another)
  • Form Constancy: (recognition of form in various sizes)
  • Visual Memory:(retention of a visual form)
  • Visual Spatial Relationships: (different orientations)
  • Visual Sequential memory: (specific items in order)
  • Figure-Ground: (overlay discrimination)
  • Visual Closure:(part-whole; visual completion)

It is very important to treat the processing beforeintroducing handwriting. Being mindful that handwriting, because it is so blatantly visible is often packaged with a lot of  (negative) emotionality.

Teaching Handwriting

Start with making the hands “happy”, fun game postures and a lot of gross motor.  Creating something functional and fun is often the secret of getting the child engaged particularly if you are working with a 4thgrader and up. Make the initial activities from start to finish no more than 30 minutes.  For kids with attention issues, you may want to break this up into 10-minute segments depending upon the child’s task tolerance.

Handwriting is rarely a ‘stand alone’ issue.  The factors that impact handwriting were developmentally in place before the child was required to write or draw.  Asking parents to remember their elementary child, as a toddler can be very helpful to the OTR in addressing associated concerns.  (some questions might be:)

  • Did they like to draw?
  • Were they able to sit and play with manipulative toys? At the dinner table?
  • Did they demonstrate impatience if they had to do something again? (Puzzles, etc.)
  • Did things drop out of their hands easily?
  • Did they like using scissors?

Using color codes helps with spatial visualization. TheHandwriting on the Wall® Program inclusive of the WIN® Workbook(go to YourTherapySource.com for sample pages) uses colors instead of directional instructions.  It is easier for the child to hear, ‘make a red line’ than to process ‘slant up to the dotted line and come back to the solid line’ and/or similar instructions that are used in more traditional handwriting programs.

The WIN® Write Incredibly Now® systemteaches 3 shapes for manuscript and 4 for cursive.  When the child can automatically make these shapes with their eyes closed then letters are introduced in groups  (not one at a time).

Utilizing games, crafts and multi-media engagement the shapes are presented not as letters but as ‘hand warm ups’.  This reduces performance related stress as well as a fear of failure often experienced in previous attempts to learn handwriting.

Early and current behavioral information is important

Using a task/motor checklist that both the parent fills out before the first OT session and that the OTR fills out after the first session can help the parent see things that perhaps were precursors to current issues and might have been ‘excused’ as “Jonny just being Jonny”.

Handwriting is not something that gets “fixed”

As Dr. Keith Berry states, “…because it is so visible, (as opposed to spoken language) poor handwriting often serves as a self-fulfilling prophesy of inadequacy …negatively impacting self-esteem …and is a factor in school drop-outs….”.

Handwriting is a symphony of skills that when left to flounder become triggers for child to reject learning altogether. There is also some research that suggests that Dysgraphia impacts attention and motivation for learning new skills.

This is often difficult for parents to understand because perhaps written skills came almost automatically for them.  This is not an issue of just trying harder. Children need to learn motor muscle fluency abilities.  Fluency is what we use daily when we look into the refrigerator and without looking at the pad and pencil in our hands, we write ‘milk, cheese, etc.’.

What we did was see the object, see the word, see the letters and see the letters as they were evolving…and we did this automatically because our brains were able to recruit all these neurological, physical, and cognitive skills. 

However for children with Dysgraphia, these skills do notcome automatically and that is where Occupational Therapy through the application of evidenced based graded sensory motor -guided engagement creates motor automaticity.  Once basic schemes within required skills are secure, the child can easily progress to writing and other fluid motor abilities.

To get a copy of the personal behaviors checklist please contact Susan Orloff OTR/L FAOTA through this website.

 

Does your child have to be PERFECT?

Susan N. Schriber Orloff, OTR/L FAOTA

“He’s just a little perfectionist, like me!” explains the parent when the teacher says that the child cannot be corrected easily. And with that it is blown off as something that either the child will “outgrow” or will learn as part of coping skills later in life.

Perfectionism is more complex than that. Normal perfectionism involves the striving for the accomplishment of a skill or task. This perfectionism is natural and innate in everybody. Healthy perfectionism is the motivation to acquire attainable goals. These children can make errors and still feel they are “OK” and be proud of their effort.

However, when perfectionism impacts life skills, learning, emotional stability and socialization it can be considered maladaptive. These children are hypersensitivity to “mistakes” and interpret them as “attacks” on their self-esteem. They exhibit an often-unquenchable need for admiration from others.

With healthy perfectionism the child can tolerate some mistakes and still feel good about trying. With unhealthy perfectionism the child demands of him/her self an extremely high level of performance in every situation. These children can find it as hard to take a compliment as they do a criticism. For these children the emphasis is on what was done wrong rather than what was done right.

Their feelings of well being are tied to their performances and so when they do well feelings of “superiority” can emerge particularly in group and/or classroom situations. These children have to be first in line, have to be chosen first for the team, often lose attention when the “spotlight” is not on them, rush to start work without waiting for directions (which is counter-productive to their desired outcomes), equate “first done” with “smarter”/”better”, and tend to think that their work will never be good “enough” so why try.

These behaviors are frustrating for both the teacher and the child. The teacher sees the child as sabotaging his own work and “tuned out” and the child is using avoidance to detach himself from what is seen to them as a stressful situation.

It is important to understand that these children do not feel safe. They have generalized feelings of inadequacy to be all consuming for them. Irrespective of the realities of a given situation, their over-riding emotion is a hypersensitivity to (even the potential of) a negative evaluation of themselves. Often theses children are poor risk takers and will only enter into novel situations when assured of success.

The sooner these behaviors are addressed the more effective the remediation. Left unaddressed, these behaviors in children can evolve into more severe manifestations as the child matures.

The Diagnostic Statistical Manual of Mental Disorders-5 places “perfectionism” as a characteristic within the realm of related anxiety and depressive disorders.

Anxiety is not just the purview of the adult world.   Children experience anxiety as well. Recognizing this can prevent its exacerbation and serve as an initial calming force for the child. Letting the child know they do not have to retreat, hide behind an exterior of false bravado or become defensive.

Occupational Therapy with its focus on function, organization, processing and graded self-regulation is the ideal treatment modality for helping these children. Here are some goals that might be included in a treatment plan for children experiencing “perfectionism”:

  1. Recognize their accomplishments through graded successful task experiences creating more realistic and secure self-esteem
  2. Teach self-regulation techniques specific to when a child is experiencing anxiety and/or stress so that they can recognize what is happening instead of retreating from the tasks
  3. Provide realistic task situations to foster prioritizing
  4. Predict outcomes with a variety of alternative choices in order to choose the best one
  5. Differentiate a “criticism” from a suggestion on how to improve results of a given task
  6. Revise original choices, learn self-correction and express appropriate pride in what was accomplished
  7. Employ graded risk-taking to increase participation with tasks that do not have an assured outcomes
  8. Formulate techniques and methods that allow the child to enter into novel tasks more readily
  9. Create methods to inventory tasks and their component parts for both problem-solving and self-evaluation
  10. Design routines that facilitate the ability to follow specific directions and sequences.

 

Understanding that there are not hard and fast rules for remediating perfectionistic behaviors and that there is no cookbook or GPS for navigating through these emotional waters. However, here are some ideas for parents and others within the community including teachers.

  1. Make task expectations very specific: A first them B and you will be done, etc.
  2. Goals should be short term and easy initially with gradually increased complexity
  3. Make sure the child understands the process and recognize him/her for following the steps
  4. Do not emphasize the outcome—focus on the process, required steps/ sequences to be followed, etc.
  5. Pace performance—these children tend to “go fast” make it rewarding to see how slowly they can go—try this first with a familiar task
  6. Create and/or play games that are completely by chance with no strategy and practice “losing”
  7. Talk about “good” mistakes (post-it notes, Penicillin, etc.)
  8. Have fun—watch bloopers on YouTube and laugh together about the “mistakes” that individual(s) made
  9. Practice with something your child will have to work at—in other words practice practicing –do the task together –avoid competition –novel things music, voice-overs to commercials (there is an app for that), etc.
  10. Demonstrate what is needed to be done
  11. Emphasize “your best” and not “perfect”—your best can be excellent and still not be perfect–talk about YOUR mistakes children tend to think their parents are “perfect”
  12. Discuss the worst possible result of not being totally right (perfect)
  13. Snacks—important tension breakers and help keep energy up
  14. Take breaks

 

But most of all, as we encourage relaxation in our children we need to practice what we preach. Parents and other adults in this child’s life need to relax as well. We only get one day at a time so pushing harder cannot make change come faster.

Behaviors Students May Have Who Experience Memory Difficulties and Related Learning Issues:

Susan N. Schriber Orloff, OTR/L  FAOTA

Your child may feel very different from what you think you or their teachers are seeing.  Use this checklist to help you ferret out what is actually happening.

Behaviors Students May Have Who Experience Memory Difficulties and Related Learning Issues:
(1)             Poor organization

(2)             Habitually tardy to turn in assignments

(3)             Loses books, reports, etc

(4)             Anxious

(5)             Overwhelm easily

(6)             Freezes up

(7)             Sloppy

(8)             Incomplete assignments / too brief

(9)             Works without signs of personal investment

(10)          Doesn’t follow instructions

(11)          Overdependence on aid

(12)          Very easily distracted

 

This Causes the Teachers to Assume that the Student is:

 

1)     Lazy

2)     Arrogant

3)     Disrespectful

4)     Uncaring

5)     Not Working To Potential

6)     Inattentive

7)     Excuse-Prone

8)     Rule-Breaker / Rule-Tester

9)     Uncooperative

10)   Just needs to try harder

 

What Students with Memory Difficulties are Probably Feeling

 

1)      Inadequate

2)      Awkward

3)      Unpopular

4)      Defensive

5)      Alone

6)      Confused

7)      Like “everyone” is always staring at them

8)      Angry

9)      Depressed

10)   Feeling unsafe-emotionally and physically

 

 

 

Sensory Self-Soothing and the Pre-school Child: Thumb sucking and other behaviors

Susan N. Schriber Orloff, OTR/L, FAOTA

Small children often suck their thumbs, mouth their fingers, suck the edge of the shirts, bite their nails, twist and/ or pull their hair…and this list goes on.

For children newborn through one-year thumb sucking, fingers in mouth, etc. is both developmentally and sensory appropriate.

Predominant current pediatric and child dentistry advice tells parents not to worry. “They will out grow it.” is the standard response. And they do for the most part.

We rarely see an adult sucking their thumb, or do any of the mannerisms noted above. But we do know adults, who constantly are cracking their knuckles, clicking the top of ballpoint pens, unconsciously bob their knee up and down, tap pencils to a desk, crack gum. All of these are sensory self-calming techniques and we do them sub-consciously and use them as mini-stress breaks.

However there are some medically sound reasons to address these behaviors. Thumb sucking can distort the teeth requiring orthodonture and in sever cases jaw realignment. Prolonged sucking on items can extend drooling beyond the chronological age when it should have been extinguished. Oral stimulation can replace the desire to eat and negatively impact adequate nutritional intake.

In adults these are habituated unconscious motor patterns. In children these are coping mechanisms. They are NEW patterns that have not had the time to have neural pathways. Initially they are just “habits”.

In very young children who start to do a specific repeated motor patterns addressing these quickly can often deter them from becoming imprinted and embedded. In young children these actions can have social consequences. A peer may not want to h old hands with a child with a saliva-wet hand. Kids taking turns on technology might complain to the teacher “Jonny left the keyboard messy”. At lunchtime the child who uses his/her mouth for self -soothing often replaces the (thumb/shirt/pencil top/etc.) stimulus with food. This is the child that seems to be stuffing everything in at once or who is the “messy eater” that others prefer not to sit next to.

Beyond identification it might be helpful to understand what is going on within the sensory motor network that drives the child to choose these patterns. These behaviors start because they are gratifying and serve a life enhancing experience.

In a study with premature infants it was observed that thumb sucking stopped the baby’s crying, decreased agitation and increased the resumption of normal bodily rhythms inclusive of swallowing and eating.

 

Another study surprisingly found that early (0-14 months) thumb suckers achieved higher and faster independent social maturity than their non-thumb sucking peers because the knew if they got stressed they could rely on themselves and not have to run to Mom for comfort. They had their comfort right with them. However the plus of thumb sucking steeply decreased as theses babies approached and became toddlers. That is when the social and physical negative ramifications begin to emotionally and socially impact the child.

Prolonged thumb sucking and other oral stimulatory actions are considered in these older children to be neurologically tied to sensory processing issues.

Our mouths are our first tactile discriminatory pathways. We use our mouths to eat, suck-soothe and touch. Tied to our olfactory (smell) receptors it allows us to taste, differentiate mommy from daddy, grounds us spatially and helps us develop our initial primary sense of security.

Conclusively and without question we all, child and adult, need and seek motor patterns that help us cope when under stress. At work adults can get up from their desks and get a snack, visit a co-worker, go for a short walk. These behaviors totally discouraged in most academic settings.

Susan Heller, PhD wrote in an article for Psychology Today that unchecked habituation of these behaviors can potentially evolve into other addictive behaviors throughout the life span. She continues that altering these behaviors is a mixture of self-motivation and increased self-awareness. Dr. Heller suggests reading with your child the book, David Decides About Thumb sucking.

With sensory issues redirection replace and redirect (the behaviors) is the course of least resistance. Going “cold turkey” will be a source of stress for you and your child. In fact it may even exacerbate the very behavior you are trying to eliminate.

A great starting place is to investigate using CHEWELERY. These fun items are available through ARK Therapeutics, amazon.com, and can be found in therapy catalogues. They are fun colorful and excellent oral stimulatory “substitutes”. The “CHEWELERY” come in necklaces for boys and girls (sports themes, gender neutral and princess options), bracelets, fidgets and more.

It is important to keep in mind that sensory issues rarely stand alone and like dominoes that are standing on edge lined up in a row, one system has impact on others as well. Occupational Therapy can evaluate your child’s sensory stability often circumventing developmental functional deficits that may evidence themselves as age/grade task demands increase. Developmental issues a do not self-resolve. Children do not outgrow them although unaddressed they often morph into other behaviors that can impede academic and social success.

What we touch, hear, smell, see and taste is what we understand, what we relate to, what we remember and process and what we alert to. Simply put it allows us to correctly and efficiently navigate our world. Only a registered and certified Occupational Therapist can competently evaluate your child’s sensory integrity and, if needed, give you a personally customized plan designed specifically for your child.

 

Dysgraphia: More than Just Handwriting

Dysgaphia is commonly understood as a disorder of handwriting. However it is more than that. It impacts self-cares such as learning to tie shoes, buttoning, zipping, and any in hand manipulative task such as eating, etc.

It is not an issue that can be resolved by “tutoring”. It is brain-based and is simply stated the translation of a cognitive image into a purposeful and correct motor response.

In other words, what you “see” in your mind is what you produce in with your hands.

Although this often first becomes evident in school when the child cannot write legibly there were probably earlier signs that went un-noticed because the child was young (and the thought was “they will outgrow this”).

Without Occupational Therapy treatment children do not “outgrow” Dysgraphia. The visual sensory perceptual motor skills involved in remediating Dysgraphia are outlined below. Getting these skills to work in harmony with each other is the art and science of occupational therapy intervention.

Perceptual Sensory Motor Factors Impacting Dysgraphia

Small muscle strength (this is not related to or about exercise or strengthening).

  • It is neurological and relates to muscle tone.
  • Ability to sustain a grip/demonstrate resistance and co-contraction.
  • Isolation of individual finger movements

Visual motor

  • This includes visual tracking/scanning and the ability to follow an object, as it is moving.
  • Visual pursuits inclusive of copy skills should be consistent and not require a lot of verbal cueing.
  • Visual memory should be automatic

Grasp

  • The ability to competently hold a pencil/paint brush
  • Make smooth connected strokes
  • Use a functional pincer grasp (for writing)
  • Ability to sustain a stable hold on the object in the hand (utensil, toothbrush, pencil, etc.)

 

Perceptual Discrimination

There are 7 realms of perception:

  • Discrimination: (discerning one object from another)
  • Form Constancy: (recognition of form in various sizes)
  • Visual Memory: (retention of a visual form)
  • Visual Spatial Relationships: (different orientations)
  • Visual Sequential memory: (specific items in order)
  • Figure-Ground: (overlay discrimination)
  • Visual Closure: (part-whole; visual completion)

OPPOSITIONAL DEFIANT DISORDER-understanding and treating

Oppositional Defiant Disorder Basics*

Children with oppositional defiant disorder (ODD) display extreme resistance to authority, conflict with parents, outbursts of temper and spitefulness with those close to them such as family and/ or those perceived and stationary helping persons. In other words, persons with whom they are sure that the display of outbursts will not have long lasting consequences. There may be a fear of peers (who can shame the ODD child) or those seen as having more power such as teachers, school authorities, etc.

 

ODD: What Is It?

Oppositional defiant disorder (ODD) is a persistent behavioral pattern of angry or irritable mood; argumentative, defiant behavior towards authority figures; and vindictiveness. In some children with ODD, these behaviors are only in evidence in one setting—usually at home. In more severe cases they occur in multiple settings. For a diagnosis of ODD, the frequency and intensity of these behaviors must be outside the typical range for a child’s developmental level, gender and culture.

ODD: Diagnosis

To distinguish symptoms of ODD from normal childhood or adolescent rebellion, professionals depend on a detailed history of behaviors in various situations. For children younger then 5, the behaviors should occur on most days for at least 6 months; for those who are 5 or older, they should occur once a week for 6 months. Since children with ODD may show symptoms only in one setting—usually at home—and are more likely to be defiant in interactions with adults and peers they know well, the symptoms may not be in evidence in the clinician’s office.

ODD: Risk For Other Disorders

ODD is often diagnosed alongside ADHD. Children with ODD often have co-occurring mood disorders like depression, anxiety disorders, or learning or communication disorders. Professionals warn that ODD that goes untreated early in life is often linked to more severe disorders later, including conduct disorder and substance use disorder.

ODD: Treatment

ODD is treatable, usually with behavioral therapy or a combination of behavioral intervention and medication. Behavioral therapy must be employed consistently and across all environments: home, school, community.

Psychotherapeutic: A popular evidence-based treatment is a type of behavior therapy called parent-child interaction therapy. The parent and child work together through a set of exercises while a therapist coaches parents through an ear bud. Parents learn to increase positive interactions with the child and to set consistent consequences for undesirable behavior. Children learn to rein in behavior and enjoy a more supportive relationship with parents.

Pharmacological: Medicines are not specifically indicated for ODD. However, as many children with ODD have co-occurring conditions such as ADHD, they may be on medications for those other disorders. In addition, some children are so troubled by their own aggression, and their difficulties managing their painfully low frustration tolerance, that a clinician may recommend medication—to help them control those responses and benefit more from behavioral therapy.

 

STEPS TO HELP WITH RAGE

  • Diffuse: do not try to address everything at once pick one issue and combine it with something that is easier to do
  • Distract: Put issue/task aside and go onto something familiar
  • De-escalate: limit talking do not get “sucked into fighting/answering” when child is in an aggravated state. “Do this (familiar and or pleasant activity) I will be back” think of it as “hit and run”. DO NOT try to coax child out of rage. DO NOT try to negotiate, offer rewards, etc.

Teach coping skills when child is calm. Learn “triggers” and prepare child that we are going to practice coping with those triggers when they “don’t matter”, i.e. base calm.

 

REFERRAL Suggestion:

Dr. Michelle L. Green, PhD

Address18 Lenox Pointe NE # B, Atlanta, GA 30324

Phone(404) 840-4403

 

*Sources: Child Mind Institute

Scott. D. Walls, MA, LIPC, CCMHC—PSEI Institute

Compiled by: Susan N. Schriber Orloff, OTR/L, FAOTA

Children’s Special Services, LLC, ATL., GA

www.childrens-services.com

 

Tic Disorders in Children

Tic disorders can be simple or complex.  Simple tic disorders can be eye blinking or facial grimaces. Complex ones are usually involving motor groups and produce tapping, echolalic speech, multiple motor habituated movements, etc.

Statistically tics are more frequent in boys than girls.  The common age for onset is about 5-6 years of age.  Tics are known to “peak” between ages 8-12 and then decrease during adolescence.  Very few (although some)  tic disorders persist into adulthood.

50% of the children have a diagnosis of ADD/ADHD, the remaining group may have an Oppositional Defiant Disorders, OCD, etc., and others have a mixed bag of some or no pre-existing conditions.

Often tics are a result of an (early) hyper-sensitivity to touch and/or vestibular stimuli.  Sensory integrative therapy can help the child cope with sensory discomforts.

Tics are considered a release from an “urge” and can be brought on by anxiety, either social or academic or both.    Tics can resolve independently but that is usually a waxing and waning process that is consistent and not a “sure thing”.

Occupational Therapy may initially increase tic responses because the therapy focuses on the tics and the child becomes even more aware of the actions relating to the tic.  However as coping skills are increased this diminishes over time and assists with tic resolution.

Additionally Cognitive Behavior Intellectual Therapy (CBIT) can help by helping the child recognize the triggers for the tic episodes and then use relaxation to reduce their onset and/or duration.

Relaxation exercises are useful and this can include deep breathing exercises, at home yoga techniques, music etc.

Social anxiety may trigger tics as the child is feeling the urge to do a specific motor action but is afraid of demonstrating this in the presence of peers for fear of their reactions.

Occupational Therapy is most helpful in teaching the child a new behavior to replace the tic with one that is both relaxing and socially acceptable.  OT can help the child replacethe tic , not control them since trying to control them may increase their frequency.  In OT the child is taught techniques that will help habituate positive sensory accommodations and reactions that decrease stress reactions and the need to utilize “tic actions”.

The OT can help the child learn relaxation and decrease stress with motor activities and actions as well as teaching some techniques that are “below the radar” such as the use of fidgets, muscles tightening and relaxing, etc.

It is also important to consider other resources and a full psychosocial assessment may provide additional valuable information.

Susan N. Schriber Orloff, OTR/L FAOTA

SELF-Regulation and the Autistic Child

Hypothetical Situation* (names not actual names)

“Joey”* participates in a self-contained classroom in his public school.  He has done very well.  Over the past 12 months his verbal skills have dramatically.  He now speaks in full sentences and expresses his needs, thoughts and feelings.  His echolalic speech has dramatically decreased.  He is no longer speaking in cartoon conversations, etc.

Joey no longer needs to be in constant movement. He is following directions and can sit a table to complete a 3 step fine motor task for up to 30 minutes.

Concerns still remain when with spontaneous (non-task related) actions. Recently he was rehearsing a church program that was being led by older teenage boys and he was jumping around and could not “stay still” even though he was reminded by the leaders to do so and also by his mother.

There are other situations similar to this that are a concern to his mother and to some degree cause a level of embarrassment when these incidents occur.

The Immediate questions for the family is how to control him and how to limit these unusual behaviors. Questions also arise as to if these behaviors should be tolerated as “sensory based” or are they just “mis-behavior”?

What is sensory what is not

Almost everything we do as human beings is sensory: we feel, we speak, we smell, we touch and when we do we react to those experiences.

What makes the Autistic child different is that they do not have a filter through which to decide how to plan what to do when.

These children do not have the intuitive ability to follow a motor emotional cue to redirect their actions.

These reactions are sensory.  Occupational Therapy teaches self-regulation as well as standard motor emotional response patterns that help meliorate and qualitatively enhance the child’s repertoire of socially acceptable behaviors.

However, in novel situations such as having to follow specific directions in a typical group of peers, these learned behaviors cannot easily be recruited because the situation is so different from those within the child’s familiar expectations.

For the Autistic child following verbal directions is difficult because they cannot visualize what is being asked of them.  In larger unfamiliar groups, being given verbal directions, particularly “reprimands” is almost intolerable for the Autistic child. They do not have the emotional resources as to how to alter their behaviors to “do it right” and they do not completely comprehend what it is they are doing wrong.

These sensory inputs: everyone around the child (personal space), the sound of singing (noxious to a child with auditory sensitivities), visual spatial processing (where to stand), proprioception /body awareness (how to be still) become muddled for this impacted child.  And the more he is told to stop, the more sensory agitated he becomes so he gets to the point where is cannot stop.

To the uneducated he looks like BUT IS NOT a misbehaving child. This is why it is important to explain to the “leaders” in these situations that Joey may need a little more “TLC” than the other children.

Things to do that may help

  1. Instead of the (usual) putting the out of sync child in the back, place Joey in the front so that the stimuli of others around him is reduced.
  2. Have him wear a weighted jacket so that he can feel him body more securely
  3. Put on sound reducing head phones so he can “hear” but muted so that he is not over reacting to the extraneous noises
  4. Rehearse the songs (or play or __) at home before he gets to the rehearsal and/or the program
  5. Gently remove him from the situation and (in private) give him deep pressure massages to the neck and back for about 2 minutes.
  6. Let him do jumping jacks if he is expressing the need to move.

Things to understand

  1. Joey is doing his best
  2. This is not about parenting
  3. The “annoyance” of others is their problem not yours
  4. Take self judgment out of the picture—you know your child and you are doing your best.
  5. This is not intentional on the child’s part it is reactionary and in part sensory and learned behaviors: (the child learned in situation “A” to do “B” but in novel situations he is at a loss. It is the treatment of Occupational Therapy to diversify his reaction repertoire.

How to pick a really GREAT pediatric OT

I did not write this but I thought this was a great piece of information to share!!  
 
Get more information on Facebook, Twitter and on our website https://childrens-services.com/
HAPPY NEW YEAR,  Susan!!
By Sabina Anna Rebis, M.D.

Pediatric OTs should:

Lay the groundwork from the beginning.
At the first visit, expect more questions than answers. “A parent will fill out a sensory questionnaire and provide a developmental history for the therapist,” says Meghan Corridan, an occupational therapist in New York City who treats children with a variety of disabilities and delays. A child will then undergo a session where he may be observed while cutting, grasping, or playing at a table. “While working at the table, the child is also assessed for attention span, frustration tolerance, and language skills,” Corridan says. Motor skills may be assessed in a therapeutic gym using swings, therapy balls, and other equipment.
Make visits consistent and address expectations.
The number and length of therapy sessions per week vary, depending on the developmental delay. “For children with isolated handwriting or fine-motor difficulties, we can work together for up to six months to a year,” Corridan says. Children with more extensive developmental delays or disabilities may be treated until they outgrow a therapeutic gym, usually around age 8 or 9. Corridan sees children with mild delays once or twice a week; those with disabilities usually have three sessions per week.
Have an eagle eye for improvement.
Occupational therapists hone in on even the subtlest signs of improvement and advance activities appropriately, teaching parents what to look for and how do the same at home. “Parents notice that the kids are able to do certain activities for longer amounts of time and are having an easier time keeping up with their siblings or peers. Schools may notice that a child’s attention is improving or that they have a better grasp on writing instruments,” Corridan says.
    Minimize frustration.
    “Frustration is a very important thing to keep under control; if a child gets frustrated during therapy — which is inevitable — he will begin to avoid activities,” Corridan explains. She’s always watching for signs of frustration and jumps in to provide suggestions before the child has a chance to throw in the towel. “I can tell that a child is making progress with his frustration tolerance when he begins to ask for help without my prompting it.”
    Make work feel like play.
    Adding one extra challenge to an activity is the fundamental idea behind keeping kids motivated. “In the therapeutic gym, I am sometimes able to ‘hide’ the work by adding it into an obstacle course,” Corridan says. She also uses technology to her advantage: “The introduction of the iPad to my therapy sessions has been a huge motivation to my kids. There are so many great apps that work on fine motor skills, handwriting, and visual perceptual skills. I find that the kids who sometimes avoid all those activities are far more likely to do them when on the iPad.”
    Get parents involved without overwhelming them.
    “I keep parents in the loop and provide them with activities to do at home,” Corridan says. “These might be strengthening activities like drawing on an easel, or doing wheelbarrow walking with their child at home.” But she doesn’t rely too heavily on parents, believing that it’s important not to turn a parent into an occupational therapist at home: “Parents should still be the parents and not the therapist.”

    Transitioning from homeschool to high school

    Case Study: *(names changed)

    Jack is a 14 year-old teen who is transitioning from homeschool to public high school. He has been homeschooled since mid-fourth grade when school got “difficult” and kids got “mean”.  He has a diagnosis of Tourette’s Syndrome that is manifested by intermittent body movements and a speech processing delay.

    Although he has not been diagnosed, his behavior suggests high functioning autism.  He is very ritualistic, displays rigid thinking, poor eye contact, cannot make inferences and has difficulty understanding simple “jokes”.  With his fixed sense of “right and wrong” and “fairness”, he has little tolerance for “gray areas” and /or “maybes”.

    Initially seen in OT for fine motor issues, Jack is now able to write legibly in cursive and paraphrase articles from the newspaper etc.

    He prefers to memorize rather than reason out tasks and has difficulty with organization and sequencing.  When “stumped” he sits and waits for the OT to help him as he does at home with his mother/teacher.

    He has returned to OT to learn basic high school survival skills inclusive of but not limited to note takings, task organization and social awareness of self and others.

    Current concerns

    The differences between homeschool and high school are huge.  At home he does not need “ask” for help because his needs are anticipated in school he will need to raise his hand and ask for help.

    At home he gets immediate feedback as to whether he is right or wrong and gets redirected. At school he may have to wait days to get a test and or homework back.

    He likes to try things first to see if he can do and then he will ask for help. Often in school there are no instant “replays”.

    It is difficult for him to reason out what he needs to ask and/or how to ask it. He is used to immediate intervention. In school with often 27+ children in a room learning to wait and move on while you are waiting is a necessary skill.

    At home mom “waits” for him to write his responses, in school the pace is much faster.

    At home mom can offer “cues” as needed, at school this is not usually an option.

    Many of the kids he will meet will have been together since elementary school. And although there is novelty to being the “new kid” social adaptation and learning how to go with the flow are essential school/social survival skills.

    Occupational Therapy Interventions (partial list of ideas)

    Create motivation: easier said than done but help to delineate the difference between fun and happiness.  With fun being equated with a movie or an amusement park experience (all you have to do is “show up”) and happiness being equal to learning and achieving something.   Get the teen to name something he has done that is “fun” and something that he has conquered as “happiness”.

    Teach how to ask the question: Provide novel experiences that he has not done before (pedaling a foot bike, etc.) and get the teen to think through the process of learning what he/she already knew and what they had to learn.

    Make a process booklet for reference: outline in booklet form what are the elements of getting a task done (i.e., establishing what comes first, how to know when you are done, how to proof-read, create priorities, etc.)  Let the teen talk and the OT write and then review it (with them with them using their own words) for understanding.

    Role play classroom situations:  inclusive of note taking and the elements of how to get down the main ideas; capturing key words, working in a group or with (an assigned) peer. What do you do if you do not like the person?

    Practice task problem solving: use visuals—what happens when the teacher want “X” and you are sure it is “Y”.  Taking correction is a very big part of this.  Reasoning and keeping things in perspective, not making a “fix this” into an “indictment” of yourself and/or self-worth.  Learning the art of compromise.

    Mind shakers:  things to do that can help you “get back” when you go “blank”; repeat in your mind the words you are hearing, write the last word you recall, blink hard and fast 2-3 times, etc.

    Facilitate study habits:  when appropriate have the teen learn something as if they had to teach it to someone else.  The best way to learn something is to teach it.  Practice cross referencing notes with textbooks or online information and write write write write it down!! Research has shown that our immediate memory lasts just under 10 seconds for full recall.

    Experience using inferential thinking:  Use scripts from plays or movies (there are plenty of them online from old radio shows, etc.) and have the teen say in their own words what they think might happen next and why.

    Teach debate techniques:  substantiating what you say with actual facts instead of feelings to support your argument/reasoning.  This will help with thought organization and sequential thinking.

     

    Transitioning from the slower individualized pace of homeschool to the often “hard knocks” of high school can put that teen on a sharp learning curve, but with careful preparation and “behavioral tricks” in his “back pocket” it can be done—and furthermore it can even be fun.