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.

Defining Health and Wellness in Children

It is easy to define health…it is the absence of illness.  It is not so easy to define “wellness”.  It presents in so many forms: emotional, physical, neurological, and cognitive, etc.  It means so many things. It is frustration tolerance.  It is coping skills. It is endurance and strength.  It is problem solving.  It is the ability to learn. It is the ability to learn from mistakes.  It is about understanding boundaries and creating reasonable boundaries.  It is about self-esteem, integrity, ethics and empathy. It is about relationships.

In short, wellness is about life well lived.

That is true of children and adults. But what about “wellness” that is unique to children. What does it look like and how do we teach children to seek it, use it and more important create it in their daily lives?

Children live in the here and now.  “Forever” can be the next ten minutes or a whole day. “Pleasure” is “I want it now!” Delaying gratification is an often-tortuous concept for young children. “Tomorrow” is light years away. Fun and happiness are interchangeable.  Children lack the insight that fun is passive (show up to movies, the park, the party) and happiness is active. Happiness is achievement; pride in a job well done, the mastering of a new skill (riding a bike), it is interactive and requires effort.

As parents we take our children to the doctor for yearly check-ups to check growth and development. But where can you go for wellness? That is more elusive and far less tangible.

In a society that wants to give our kids “what we didn’t have” we may inadvertently be robbing them of opportunities to learn how to make their own happiness. There are as it has been written, “blessings in a skinned knee”.  Being frustrated can teach problem resolution, being angry about something can teach emotional management, being overwhelmed can teach organization, losing can teach sportsmanship, getting an “F” can be a motivator for better study skills.  These are all necessary skills for living a competent responsible healthy life. These are essentials for wellness.

It is fun to go to Disney World, but one cannot live there.  No one can live a stress free life. All things do not always have a “happy ending” but lots of things can have the “right” ending.

As in baseball (my personal favorite sport), a swing and a miss can teach better aim, measured timing and get the batter that longed for grand slam.  Not every time at bat, but that time when everything “connects”—that is happiness and happiness is wellness.

Teaching your child that difficulty is not disaster it is an opportunity for them to grow and learn.  It is a chance for them to learn how to overcome those issues that are currently challenging for them.  It can teach your child compassion for others who are also experiencing a “tough time”.

And at the end of the day what is it we really want for our children?  We want them to be “good” people.  We want them to be independent. We want them to be part of a community of caring. We want them to chart their own course, follow their dreams and be proud of themselves. We want them to be successful people. We want them to know and appreciate the value of hard work well done.  We want them to always strive for happiness and to achieve a life of wellness.


Invariably life, as my overly wise daughter Jenny (at age 7/now 41) wrote on a bookmarker for me, “Life is not easy”. Who said it should be easy? However, done right, it can be well lived.

Understanding the difference between a developmental pediatrician’s evaluation, a psychological and an occupational therapy evaluation.

Taken from: Taken from:

Original Source:

Children’s Special Services, LLC

Developmental Pediatrician

…a developmental pediatrician plays a crucial role in the treatment of children with developmental and behavioral conditions.

The following is a short list of some common conditions which a developmental pediatrician may diagnose and treat.

▪    Learning Disorders – A wide range of conditions fall into this section of developmental conditions. Children who find writing, public speaking or math unusually difficult may benefit from a developmental pediatrician, as do children with dyslexia. In these cases, thedevelopmental pediatrician will diagnose the childand then provide further treatment, which often includes a referral to a specialist in a particular condition or an academic center which specializes in learning disorders.

▪    Developmental Delays – If a child has fallen behind his peers in basis skills, such as mobility, cognition, language or speech, a developmental pediatrician can be extremely helpful. They are trained to recognize these delays earlier than an MD with no specialized training, and therefore help children sooner. The earlier a child receives help with a developmental delay, the better the chances that he will quickly catch up to his peers. As with learning disorders, a developmental pediatrician has the option to treat the condition herself or to refer the child to another doctor or therapist who specializes in one particular delay, such as a speech therapist.

▪    Habit Disorders – Encompassing Tourette’s Syndrome as well as a variety of tic behaviors, habit disorders can be very disruptive. Not only are they confusing and frustrating for the child, but for the child’s family as well. When treated early in life, tic disorders can often be eliminated or minimized quite well.

▪    Regulatory Disorders – Feeding issues, disciplinary problems, bed-wetting and sleep disorders fall into this area of research. A developmental pediatrician is trained to spot the signs of these disorders as well as to treat them, although, as with many issues, a referral to a specialist may be the best solution. These issues are often only symptoms of underlying psychological conditions, such as excessive stress, and so a child psychologist may be recommended. In many instances, however, a developmental pediatrician has the skills to deliver effective therapy, especially in mild to moderate cases.

Psychological assessment is a process of testing that uses a combination of techniques to help arrive at some hypotheses about a person and their behavior, personality and capabilities. Psychological assessment is also referred to as psychological testing, or performing a psychological battery on a person.

4 Components of Psychological Assessment

Norm-Referenced Tests

A standardized psychologicaltest is a task or set of tasks given under standard, set conditions. It is designed to assess some aspect of a person’s knowledge, skill or personality. A psychological test provides a scale of measurement for consistent individual differences regarding some psychological concept and serves to line up people according to that concept.


A formal clinical interview is often conducted with the individual before the start of any psychological assessment or testing. This interview can last anywhere from 30 to 60 minutes, and includes questions about the individual’s personal and childhood history, recent life experiences, work and school history, and family background.


Observations of the person being referred in their natural setting — especially if it’s a child — can provide additional valuable assessment information. In the case of a child, how do they behave in school settings, at home, and in the neighborhood? Does the teacher treat them differently than other children? How do their friends react to them?

Informal Assessment

“..a supplement to standardized norm-referenced tests… informal assessment procedures, as such as projective tests or even career-testing or teacher-made tests…. language samples from the child, test the child’s ability to profit from systematic cues, and evaluate the child’s reading skills under various conditions.

Definition of occupational therapy:

Occupational Therapy is the use of everyday tasks to assess the needs of the child inclusive but not limited to their physical, neurological/ (sensory), emotional, and developmental skills.

The occupational therapist uses both norn-referred standardized tests and informal clinical observations to ascertain the levels of both actual and potential functional capacities.

Testing components:

Standardized Tests:

 Visual Perceptual Skills-Testing:  Assesses the seven realms of perception with the motor component removed to look specifically and visual processing.*

This can include preliminary screening for Dyslexia and related visual issues.

Visual Motor Testing:

Evaluates the visual processing with the motor component to assess how what the child sees is translated into a specific motor response.**

This can include the testing for Dysgraphia and Dyscalculia as well as motor co-ordination.

Fine motor: in hand manipulative tests and dominance testing.

Sensory Assessments:

(gross motor abilities included)

Evaluates behavior inclusive of frustration and coping skills, Visual and auditory reactions and actions; Functional response patterns inclusive of tracking reaching, grasp and release motor patterns, diadokokinesia, range of motional strength, flexion and extension patterns, balance, muscle tone, equilibrium, stability and weight shift, reflex reactions, functional movement patterns inclusive of but limited to walking/running/etc., body image, activities of daily living/self cares, tactile processing, proprioception, stereonosis with vision occluded, position sense, and handwriting.

Evidence based practice:

Utilizing the results of the testing and current research the occupational therapist then designs a treatment plan specific to that child’s individual needs.


What to do when school gets out…4 short months from NOW!!

Think summer and you start thinking about keeping your child busy.  And you want the moments to count for something not just “time fillers”.

That is where Children’s Special Services, LLC can really be THE place to turn to . Learning coping skills, cooperation, social skills, organization, frustration tolerance, information processing, etc. while increasing sensory motor skills is WHAT WE DO!!

And we have been doing it for over 20 years.  Check out our website and go the calendar for May, June and July programs.

Our US Trademarked Handwriting WIN™ Write Incredibly Now™ Program is being implemented in over 15 states nationwide and our PLAY Your WAY sensory based Social Skills Program incorporates sensory and emotional regulatory skills in an interactive and fun environment.

All services are billed as therapy for possible insurance reimbursement.  All services are CPT and ICD coded so that services are within the reasonable and customary rates and regulations for occupational therapy within the state of GA.

Come check us out!!

Our Camps are:
Play YOUR WAY to Sensory Motor and Social:  A program of guided play to help the young child  ages 3-7 with fine and gross motor and sensory motor skills inclusive of but not limited to:

  • Sensory Modulation
  • Frustration tolerance
  • Following directions
  • Transitions
  • Noise tolerance
  • Tactile experiences
  • Memory
  • Sequencing
  • Body self awarenss
  • Drawing and Construction
  • Sharing
  • Group skills

WIN™ Program Write Incredibly NOW™  

Handwriting organization and sensory awareness rolled into 12 moving and exciting hours of increased competency—US Trademarked Write Incredibly Now ™ Program uses creative play to increase motor fluency.

Both manuscript and cursive taught.

**All camps billed as therapy for possible reimbursement for out of network expenses.

More information


Phone 770-394-9791

Twitter OTRLovesKids

Using Toys Creatively

Special Needs essentials blog/Deborah Gauzman

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

When thinking of playful engaging activities for “special needs” children it is important that know that everything can be adapted to meet the needs of any child within a play environment.

It is more important to think how than what.  A simple game of checkers can be made easier by putting string in the directions the player is allowed to move, pick up sticks can be arranged to follow a pattern on an underlying mat so that the game includes color and positional matching not to mention pincer grasp, dominoes can be color coded on their dots so that the game turns into multiple matching tasks not just one; and so forth.

Parents do not have to spend a lot of money in special needs catalogues looking for just the “right” toy or game when all games can be “right” if used creatively and with necessary adaptations.

When selecting special toys or equipment think about versatility and how many ways you can use the item.  Special Needs  “essentials” is just that, the “essentials” so think about the BEST pieces to buy that cover a range of opportunities for multiple functions.

For example a “chewy tube” can also be an in-hand manipulation toy; neon bracelets can be adapted pick-up sticks; hand held massagers can be part of a relay race game; and puppets designed for increasing hand skills can be used for imaginative play to increase social skills.

There is also the Old Fashioned concept of making a game or craft together.  Before all the left over Christmas wrapping paper is gone, make a sculpture with the paper, watered down school glue and some ModgePodge. Think about making toy storage boxes that the child will be invested in using by covering them with the left over wrapping paper and making it shiny with the ModgePodge. Parent and child will get a lot more out of this activity than the end product—they will be talking to each other and this is an excellent time to use and build vocabulary and social skills.

The most important thing to think about is ‘how can this activity enhance my child’s total developmental abilities: physical (hand skills and/or gross motor), neurological (thinking, reasoning and sensory) and perceptual (seeing and processing) skills.

Your options are endless and they are most likely to be already in your home rather than a fancy (and expensive) catalogue, or in a store near-by.

Susan N. Schriber Orloff, OTR/L is the author of the book. “Learning RE-Enabled” a guide for parents, teachers and therapists,(a National Education Association featured book) as well as the CEO/Exec. Director of Children’s Special Services, LLC an occupational therapy service for children with developmental and learning delays in Atlanta, GA.  She can be reached through her website at or at  On Twitter at OTRLovesKids, or her blog, or Facebook Susan N. Schriber Orloff, OTR/L, FAOTA Children’s Special Services, LLC page.

What is Perceptual Processing and Discrimination?

This question is often asked but not so easy a question to answer. The words “discriminating tastes”  bombard us on our TV’s, radios, iPads and billboards. Implying that if you ONLY do this  ONE thing you will be a discriminating connoisseur of ______________________________your whatever.

Such popular definitions can lead to Wishful thinking that can be all at once falsely uplifting, defeating, damaging, misleading, and often incorrect and for the layman, new parent, inexperienced care giver leaving in its wake a pile of misconceptions that leaves a parent truly trying to help her child but who is currently overwhelmed by an avalanche of theories and words that are pouring over the parent turning this barrage of information into a Mother’s Guilt Trip Tsumani.

So let’s pedal back to some very basic definitions of perception itself before with deal with the over-lay of perceptual interactions that eventually emerge as what is commonly referred to as “Processing”.

Without wanting to go too deep into the neurology of the eye the structures within the brain it touch, overlaps and influences lets think of perceptual processing as different instruments in an orchestra. Like an orchestra the perceptual system has its “players’ and functions and only when they all work in harmony do we get the real music of understanding.  (i.e. cognitive understanding)

First Chairs always go to the basic discriminators—theses guys let us all know we are here and more or less in the “seats” we should be in.

Continuing with the “Orchestra Metaphor” think of the brain as described below (an oversimplification, of course)–

Supporting the First Chairs Discriminators and the General Memory players.  These folks remember the most of the music but are really good at playing it immediately after hearing it.

The next section is for gets everyone in their right place and lets them know when they out of their proper place; visual spatial relationships. This section may have the least orderly section with chairs pointed all which ways, but this is the group that has to sound as ONE no matter which way their seats are turned and whether or not their seats turn, straight or backward. All there players have specific relationships with each other.

Our next section has a lot of similar instruments some larger, some smaller but all making similar and/harmonious sounds this included reading their music and those of the other guys so that they can stay on track with the other players.  In visual perceptual terms these are your Visual Form Constancy players.

Then comes Percussion loud when the need to be, soft when required that put the accent marks on well placed melodies while all the other music is going on, these players are your Visual Figure Ground Players.

But last but not least a real orchestra needs a conductor and that is your Visual Closure System.  Just like the conductor can hear the slightest from the back as clearly as he does with those from the front, the Visual Closure System organizes what is only partially seen and brings it forth as a full and integral player for our everyday “orchestra” call LIFE.

And it happens in nano-seconds, automatically as if it is on “auto-pilot.  That is for most of us.

When these systems are not working  (for whatever reason research as not as yet clearly defined) the child experiences life out of sync, discordant and at variance with their environment which may include peers, Teachers, therapists, etc. producing and child that may outwardly appear to be argumentative, have poor impulse control, conflicted, harsh to self and others all the while displaying a self that is inharmonious to both self and others.

Think of yourself with really good table manners invited to eat dinner, elegantly laid out and served on the main deck of a cruiser crossing the over to the Outer Banks of North Carolina.; a 2-hour almost always a smooth as glass  trip …….but…..expected rough currents appear the plates shift the food spills and after initial shock and dither the repair mode sets in.

Imagine time after time knowing how the music should sound, being invited to the best seat at the best table and then never getting there because “something happens’.  For little children the “something that happens” is all too often incorrectly absorbed as their fault and so they try with their limited repertoire of management behaviors to try to “fix it” and it gets worse and their self-esteem plummets producing an array of behaviors from isolation to acting out.

While indeed sensory integration is a huge part of out lives, there are other related systems that must be regarded as well. Independently and in conjunction within our neuro-muscular cognitive neighborhood called our body.  We all are the sum of many parts that create the whole of our unique selves.

Children are no different. Their impulse behaviors may not be as mature, their ability to delay gratification may be more frail, they may have all their emotions right on top and for the most part, their “honesty button” is always on.  Subtle is on their vocabulary list and “wait” is a concept readily used, often selecting more reactionary behaviors.

With computers giving us “popcorn brains” and fast food getting even faster, it is no wonder that we gravitate to fast answers as well. However with developing children with sensory motor perceptual growing constantly going on sometimes a slower more careful look both by observing and testing can give the best result for formulating a protocol that will help your child express their potential, ease into learning, and most of all develop a healthy curiosity that stimulates a life-long habit of wanting to learn.

The following checklist is provided for parents and teachers to begin the conversation IT IS NOT A DIAGNOISTIC TOOL. If more that 2 items in each are noted a full occupational screening is advised. Check items “yes” or “no” ONLY  (“well he does do this sometimes would be counted as a “no”) Remember we are looking for mastery, skills done without assistance and with proper form.

It can be used in part with a formal screening or as a checklist for teachers and related educational professionals.



__Problems taking on/off coat

__Cannot tie shoes

__Cannot manipulate buttons, snaps, zippers


__Needs reminders to keep track of belongings

__Rejects certain fabrics

__Always wears socks, resists bare feet

__Habituates wearing 1-2 specific outfits



__Poor motor learning (new skills)

__Mixed and/or no hand preference

__Poor handwriting

__Frustrated with fine motor tasks

__Difficulty copying from desk/board

__Writing “floats” off the writing line

__Poor gross motor (Running, jumping, skipping)

__Looses place when reading or copying

__Poor grasp (awkward use of pencil/crayon)

__Poor writing pressure

__Works unusually slowly

__Cannot make numbers in a column

__Cannot color inside the lines as needed

__Poor reproduction of shapes/forms/


__Reverse letters or numbers when reading or writing

__mix up his/her right and left sides



__Difficulty staying focused



__Overly dependent on teacher/parent

__Forgets homework/bookbag, etc.

__Poor sequencing skills

__Sloppy desk/notebook

__Easily distracted

__Gets easily into a “white noise space: so he startles with unexpected noises.

__Difficulty initiating tasks

__Difficulty transitioning from one skill/task to another

__Needs instructions repeated

__Gets confused easily

__Habitually late coming in from activities

__Difficulty skimming page for information

__Poor spelling

__Refuses to get hands dirty

__Gets upset if too many papers, toys in personal area

__Cannot stay with task for any long period of time



__Not many or few friends

__Complains that “someone hit” them

__Difficulty with cooperative tasks

__Multiple somatic (physical) complaints

__Poor eye contact when speaking to peers, adults, new acquaintances (circle one)

__Limited or absent awareness of ambient social cues (i.e. facial expressions, etc.)

__Needs teacher to soothe so that child can nap

___Stays to the fringes of the group instead of interacting with peers

__Talks or gestures to peers while eating

__Shares toys is able to give up a toy easily and go on to another one with minimal disruption

__Withdraws when an unfamiliar person enters area/class/playground etc.

__Messy eater

__Hesitant to interact with peers

__Problems lining up with classmates

__Difficulty discerning personal space

__Poor expression of thought, ideas, and feelings

__Overly sensitive to corrective remarks (criticisms)

__Avoid talking out in class, and/or participating in discussions

__Easily frustrated

__Speaks but only to 1-2 people otherwise very quiet or not speaking at all

–We work well briefly however gives up when first “mistake’ is made

__Not understand jokes

__Waits to watch the actions of peers before entering into an activity

__Has a hard time accepting “no” from teacher

__Has to have his name said many times before a reaction is elicited

__Difficulty reading body language or facial expressions

__Refuses utensils


The checklist was designed and created by Susan N. Schriber Orloff, OTR/L, FAOTA  from various sources and may be use with written permission and source recognition only .It is the intellectual property of Children’s Special Services, LLC

Toe-Walking: What does it mean and is it important?

Comprehensive studies (conducted in Sweden on over 1,400 children) suggest that early toe-walkers outgrow their desire to do so and that it is not an indicator of mental or cognitive disorders.

However these studies do also indicate that the incidence of toe walking is higher in children with autism, muscular dystrophy and cerebral palsy than with typical children. But clearly NOT all toe walkers have associated neurological issues.

Children who toe walk past the age of 3 are at risk of developing shortened heel cords, balance issues, muscle stiffness, and associated pain in the legs and feet. It has also been associated with muscle co-ordination issues and can inhibit participation in sports, etc.

Toe walking is technically called an “equinas gait”.  Typical gait is with a heel/toe strike with reciprocal alternating movements.  The coming down on the ball of the foot is referred to a “plantar flexion”. The inability to have normal gait can impact gross motor movements (inclusive of range of motion of ankle and foot) as the child grows impacting not just the feet and legs but the back muscles as well.  Left unaddressed the child can develop contractures that would eventually render typical walking impossible.

In severe cases children have had to have surgery to release their heel chords and/or wear a brace (at night during sleep or an orthotic in their shoes) to stretch out the shortened muscles. Treatment is usually dependent upon how this impacts the child’s daily life.  If the child is excessively falling, demonstrates difficulty running and/or tires easily with gross motor activities then a medical consult is suggested.

While it is difficult to construct a specific correlation, toe walking has been observed in some children with sensory integrative dysfunction. This information is inconclusive because it is unclear whether these children had sensory-based mobility issues first or if they developed them because of the toe walking.  In either scenario, occupational therapy interventions can assist the child with ITW develop more secure proprioceptive and kinesthetic abilities to increase spatial body awareness and adaptive safety/play skills.

In an article by Brian Hoppestad, PT, MS, EdD in Physical Therapy and Rehabilitative Medicine (Vol. 24.Issue 22 Page 16) he states that, “…children with ITW* present with other developmental problems, principally language delays; and to a lesser extent, fine- and gross-motor deficits and visuo-motor impairments.3 Engstrom et al. estimated the prevalence of toe-walking in the general population. Of the children in the study cohort, 2.79% were previous toe-walkers, and 2.09% continued to toe-walk at 5.5 years of age. Children with a diagnosis of developmental delay or neuropsychiatric disorder had a prevalence of toe-walking of 41.2% (both inactive and active toe-walkers)…”

(*ITW; idiopathic toe walkers)

Current antidotal reports suggest that toe walking may impact skeletal maturation inclusive of potential joint deterioration. ITW should now be regarded as not as benign as previously thought. However most articles are case studies and not statistical so definitive answers are not available at this time.

Clearly ITW impacts a child’s posture as well as related mobility/stability patterns both necessary for attention and learning. Recent studies report however, that even with interventions some residual gait issues may persist into adulthood.

Toe-walking can also change the child’s visual field and visual scanning abilities. As they tilt forward this may force their eyes to move “up” so that they are looking from the “top” of their eye sockets and this could impact reading, writing and motor navigation. It could also factor into potential headaches and sensory organization concerns.

At this time there are no definitive “cures”, causes and/or treatments.  Additional ITW research studies are needed to answer these questions.

Narcolepsy in Children

Narcolepsy is usually found in adults and although it is rare in children there are significant occurrences that studies have been published on it  from both the prestigious Cleveland Clinic and the Hospital of University of Pennsylvania.

The basic definition is that it is excessive sleepiness and that it can occur at any time throughout the day. It can interrupt regular sleep patterns as well as impact a child’s ability to learn and play.  It is thought to involve the areas of the brain that control sleep.  The Hypothalamus, the area of the brain that is our “stop and think” center also controls both wakefulness and sleep.  Over simplified, in conjunction with the brainstem (think about this being the base of your head and top of your neck)  and the back of the Hypothalamus keeps us awake (activating the “up center in the brainstem) and the front of the Hypothalamus puts us to sleep.

Sleep is not a passive process the brain is very actively  “thinking—cortex” inclusive of executive functions, memory and creative thought (think dreams that seem real).

Narcolepsy carries a DSM-5 code of 347.00 (Diagnostic Statistical Manual of Mental Disorders and an ICD-10 code of G47.419 (International Classification of Disease).

All of the above information is to affirm that the behaviors associated with narcolepsy, while they may seem intentional are not.  If fact these behaviors are so disruptive to the saccadic life rhythms that left untreated they can be associated with anxiety and depression.

There is no cure for narcolepsy but there is treatment that includes medication, behavior modification, education and activity regulation.

In school aged children the provision of scheduled nap times even in teens can be essential for the child to maintain critical learning abilities. Conversely forcing such a child to “stay awake” can cause frustration and negative behavioral reactions.

Narcolepsy should be classified under “other health impaired” for IEP purposes and specific accommodations and modifications should be made for these children. Suggestions for addressing narcolepsy during the school day are:

  1. Provide time for the child to take one or two short (15-20 minutes) naps during the day
  2. Make sure teachers are aware of the condition so that this behavior is not mistaken for laziness or lack of interest
  3. Avoid activities that could be a danger to health such as swimming, except when child is in an affirmed state of wakefulness
  4. Establish and maintain a set schedule so that the child’s wake/sleep rhythms can be addressed
  5. Avoid boring and repetitive tasks –diversity is key to sustaining wakeful interest
  6. Provide extra time for tasks and tests’ inclusive of short breaks during class and/or tests.
  7. Have teacher share with student “missed material” via email, slides, powerpoint, etc.
  8. Providing audio versions of textbooks may also be helpful
  9. Use of “SmartPens” that can record and write so that taking notes is facilitated during “down times”
  10. Make sure the child stays active in class, let them sit in the back so they can get up as needed, sit on a sitball that gives sensory feedback, chew gum, etc.
  11. Take and exercise break after a test for about 15-20 minutes
  12. Studying and discussing assignments with a “work buddy” also increases alert behaviors.

At home:

  1. Keep the rooms cool
  2. Do homework while standing (maybe near the kitchen countertop)
  3. Limit after school activities
  4. Take a short nap when the child gets home from school
  5. Have a regular sleep schedule


Broughton RJ, Guberman A, Roberts J. Comparison of the psychosocial effects of epilepsy and narcolepsy/cataplexy: a controlled study. Epilepsia 1984; 25:423–33.

Why do kids MOVE so much?? Deciphering the ADD vs. Sensory Dilemma

Little 4- year old “Sally” is in constant movement, hard for her to sit still in circle time, cannot wait in line, seems to “bump” into friends, interrupts and grabs things a lot. She seems to be a bundle of immediate gratification; a whirlwind of activity always on the go.

What is driving Sally to be on the move? What it is NOT is bad manners!!

Children like Sally are typically always on the go because they do not have a body sense of where they are in space so they are constantly moving to find that space—somewhere.

What is body in space?  It is a sensory processing awareness skill that literally lets us all know “what end is up”.  Think of yourself as living in a gravity free zone all the time and not knowing if you are right side up or upside down.

Life for these children is a constant searching for a sensory anchor that they see but cannot catch onto.  Often these children become very anxious and manifest that anxiety by using extraordinary loud voices, overtly seeming to be aggressive and ignoring the “rules”.  None of this is usually the case.

However, herein lies the conundrum: these children need boundaries and structure and at the same time they have difficulty processing directions because of their internal chaos.

To understand these children one must first understand that it is their neurology that is driving them.  Inside everyone’s head going from the outer ear way in is something called our Vestibular System. It registers movement, touch, pain and body righting and mediates and processes most of all our sensations.  When this is not fully communicating with the rest of our body several things can occur.  

Some people experience tinnitus (a ringing in the ear that does not stop), positional disorientation (being dizzy when moving so children keep moving to try to stop the reaction or resist moving at all), inability to visually focus at the midline of the body (“look at me”; “keep your eyes on your paper”, etc.), poor balance etc.  In addition their ability to accurately motor plan in both fine and gross motor arenas can be impacted.

It is important to keep in mind that not all children in constant movement are ADD/ADHD.  Sensory impaired children also exhibit this need to move and have no attention issues.

So what can teachers do to address this child’s needs and to reduce classroom chaos?  (a partial list of suggestions)

  •        Have sensory centers in the room, things to touch, smell, manipulate, ride on, etc.
  •         Set a timer so that the child knows that when they feel the need to go to sensory center they have a specific time to be in there—limits help provide structure that these children have a difficult time understanding.
  •       Body charts –each time they use a good voice, keep their hands to themselves, sit nicely in circle time, etc. they get to put a “dot” on the body part they controlled and the object is to get a dot in each part everyday. (using Velcro dots makes these body charts re-useable and you can even use a photograph for the face so the child relates the dots not just to self control but personally to themselves as well).
  •        Go crazy times” in the classroom –“OK when the bell rings move ______(fast/slow/up/down, etc.) and when the bell rings again, stop”. Use these movements “breaks” throughout the day they do not have to last more than a minute!
  •       Use hula hoops to give visuals for “personal space” in circle time—smaller hula hoops are perfect for this and every child sits inside their hoop.  Inside their hoop can be a squishy pad to sit on, or a doll to hold or a fidget as well to help sustain attention.


What can parents do at home to help their constantly moving bundle of love?  Much the same as what the teachers do in school just adapted to the home environment. But a huge suggestion is to turn off, tune off and tone down the noise in the house. Electronics, the TV, computers are always good “babysitters” but children today are not learning to amuse themselves because the gadgets do it for them.

Research has unequivocally proven that children and adults who spend a lot of time with electronics actually experience a form of “mental addiction” to these devices. Additionally, research has shown that we are developing something called the “popcorn brain”—it has to happen fast and change even faster to keep our attention.

In an article by Dr. Elizabeth Cohen further describes this phenomenon. “…according to a recent article by Elizabeth Cohen, Senior Medical Correspondent for CNN, we can forget how to read human emotions when we are always communicating online.  In addition, constant stimulation can activate dopamine cells in a part of the brain responsible for pleasure.  Repeated, long-term stimulation can actually alter the structure of the brain …Cohen spoke to David Levy, (a professor with the Information School at the University of Washington) who said that a “popcorn brain” is a brain so accustomed to the constant stimulation of electronic multi-tasking that it’s difficult to live life offline, where the pace is much slower.”

Life is movement and moving is part of life. Life is also knowing when to go and when to stop. Some of children need a little more help than others in learning the when and how of this. Learning to use our sensory system to make sense of our world is a life long process starting with learning where we are and where we want to go.

Mitochondrial Disease: Preschool through High School

There are many myths about Mitochondrial Disease and that leads to complicated incorrect misunderstandings.  Although it is thought of a primarily a childhood disorder, it can actually occur at any age. 

Previously it was thought that it was only the mother that passed the gene onto the child, but it is now known that there are many genetic hereditary patterns that contribute to the DNA mutations inside cell patterns.  Mental retardation, seizures and related developmental issues do not always occur with Mitochondrial Disease, and there are many children with typical cognitive abilities.  

There is current on-going research suggesting a connection between HIV positive parents and Mitochondrial Disease in their newborns.

Diagnosis is a complicated process that may or may not include a muscle biopsy.  And at this time, there is not one test that determines the diagnosis.  Just as there is not one test, there is not one protocol for treatment.  And there is a huge gap of misunderstanding between “incurable” and “untreatable”.

There is on-going research connecting some children with Autism to Mitochondrial Disease.  This study is population based and so far it has found that this occurs only in a minority of cases.

What adds to the confusion about treatment is that each child can manifest the disorder very differently.  However the link between all of these children is the fact that learning how to play, a natural avocation of children, while conserving energy needs to be taught.  Teaching healthy play habits is where occupational therapy can make a significant contribution.

It is also crucial that this therapy/education process involve not just the parents but the siblings as well.  Including everyone in the process allows for the typical sisters and brothers to engage with their family as a contributor and not a by-stander.  This also may prevent their feelings of jealousy and rejection.

When you receive the diagnosis is very important.  If your child was diagnosed early and received services under (each state may have a different title) the Babies Can’t Wait 0-3 programs than entering into the public school with special services may at least, initially be an easier process.

However many times this is not diagnosed early especially in cases where the symptoms are mild and do not manifest themselves until the child is in more task-demanding situations.

There are basically two avenues for a “Mito” child to receive services, for the child entering public education there is the IEP (Individual Educational Plan through the IDEA part C).  However state regulations can retain your child under the IFSP (Individual Family Service Plan) until age 5 when most children start kindergarten.

These are two very different systems and are not related to one another. IFSP focus is on the family interactions and what they can do to help the child. The IEP is onlyeducationally based.  The IEP covers the child from ages 3-21.

The IFSP takes into consideration the needs and concerns of the family, and the IEP do not. These are two very different laws, and it is essential that families know the difference between State and Federal Laws.

Keeping records of milestones is very important when seeking services.  Dates of attainment of walking, sitting, standing, toileting, talking, swallowing, etc. not only are important to the pediatrician but the school in making the decision for appropriate services.

As your child progresses into elementary school you may begin to observe increased fatigue (as the school day is longer and more stressful with less “breaks), visual issues may appear and problems with reading may be noticed at this time, and increased occurrences of muscle cramping may be seen.  At this time the parents may also want to integrate benefits available to the child through the 504 (ADA law) for accommodations and modifications within the educational setting.

Provisions under the 504 are particularly important to children as they enter Middle School. Middle School is wracked with enough issues inclusive of but not limited to social expectations, increased homework and more writing writing writing! Not to mention the carrying of books from class to class.  At this time some children may opt for the use of a wheelchair to help conserve energy during the school day. 

Under the 504 parents can ask for modifications in scheduling, timing of tasks and assignment due dates, classroom settings, presentation of information and testing (such as an answer booklet instead of a worksheet), etc.

During middle school it is not too early to think about High School graduation. The type of diploma your child gets impacts post-secondary options. Be sure to ask about this very early on in middle school and again at the first high school IEP meeting.

An alternative to all this is home-schooling. This is a very personal decision and many factors need to be considered. Are your child’s needs being met in the public school setting, is health at risk during such a long school day, your child’s emotional status, etc.  However if your child is receiving related support services in the public school, you need to ask if these services will continue in the home-school setting. Some states send certified teachers into the home and other states leave that to the parent.  Related services may be provided but the parent would have to take the child to the public school, while others send the special services person to the home. All of this should be part of the parents’ investigation before a decision for homeschooling is made.

It is also important to know that under the IDEA (IEP) Plan, the mandate is for the “least restrictive environment”. That makes the priority of placement and services very rigid. The first option is always placement in a regular classroom. Then the following is suggested: placement in a regular classroom with modifications; resource room assistance; separate classroom for children with special needs and last a residential or day program placement.

Throughout this process the occupational therapist is key in making sure that milestones and educational outcomes are met.  Working with the teachers and the families the OT addresses issues of energy conservation, balance, mobility, technical support, strength, balance, coordination, sensory modulation, play skills and activities of daily living.  These are skills that will be needed not just in school but throughout the life span.  The occupational therapist can also help with the establishment of daily exercise plans to do both in school and at home.

Because the Federal mandate of the public school is to “normalize” educational settings, parents may need to ask for occupational therapy to be part of their IIFSP/EP Plan.

Obtaining services is often a complicated process and parents can learn more about this process and occupational therapy in the book, “Learning Re-Enabled” 2nd edition, available through and other booksellers.

Susan N. Schriber Orloff, OTR/L, FAOTA is the author of the book. “Learning RE-Enabled” a guide for parents, teachers and therapists,(a National Education Association featured book) as well as the WIN™ Write Incredibly Now™ Program (available through YourTherapy’  She is also the CEO/Exec. Director of Children’s Special Services, LLC an occupational therapy service for children with developmental and learning delays in Atlanta, GA.  She can be reached through her website at or at