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Activities of daily living, fine motor skills and sensory strategies for children with Down Syndrome
Sydney Martin, MS OTR Children’s Hospital Colorado
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Outline
• Medical Characteristics • Fine motor skills • Activities of daily living for Children & Adults • Visual Supports for Daily Living • Sensory Integration • Modulation, Behavior & Self-regulation • Sensory Diet • Questions and Answers
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Characteristics • Hypotonia
§ Joint Laxity
• Hand Characteristics § Smaller hands § Single Simean Crease § Wrist Bones § Clinodactyly (Curved 5th finger)
• Medical § Cardiac § Susceptibility to infections § Hearing loss
• Cognitive § Developmental Delays § Attention difficulties 3
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Occupational Therapy Domain Areas of Practice
• Sensory and self regulation • Social skills and emotional regulation • Fine motor, visual motor skills • Attending, listening and processing • Self-help, including eating, dressing, grooming, bathing,
toileting and chores • Cognitive functions
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Fine motor skills • Postural Control • Trunk and shoulder stability • Reach, grasp and release • Play • Dexterity skills for school, daily living skills • Assistive technology • Pre-Writing & Writing • Vocational skills
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Developmental Considerations Postural skills
Trunk Control Shoulder stability (fine motor/dexterity)
Play
Language Self-Care
Social interaction
Engagement in purposeful activities
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Postural Skills • Trunk Control • Stability • Stability with gross motor tasks • Rotation • Facilitation of reach and grasp • Shoulder Stability
§ Strengthening activities • Shoulder • Placing weight on arms and hands in play • Promoting arch development • Fine motor skills • Motivation during play • Fun Activities
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Reach, Grasp & Release • Reach
§ Requires shoulder stability § Motivation to reach & play
• Grasp § Pinch § Thumb control-opposition § Wrist movement § Finger control & coordination § Types of grasp
• Palmar • Pronated • Tripod • Pincer (Pinch)
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Dexterity Skills • Finger Coordination
§ Moving fingers individually § Poking, pointing § Holding pencil § Scissors
• Wrist § Turning hand over § Sensory play § Self help skills § Dressing & Fasteners § Opening lids
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Bilateral Coordination • Scissor Skills • Pre-Scissor skills
§ Tearing paper § Squeeze or loop scissors § snipping
• Scissor Skills § Cutting Straight line § Move to curved lines § Shapes § Hand Strength- spray bottle, squeeze activities
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Printing & Pencil Grasp • Pre-Printing
§ Markers & Crayons § Sensory play-sand, clay,
shave cream § Use Stickers to target and
connect the lines § Printing § Vertical surface/wall or
Chalkboard § Vertical & horizontal
Orientation § Left to Right § Sensory play with writing § Shoulder stability § Start & Stop
§ www.HWTears.com
§ www.TVTeacher.com
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Assistive Technology • Touch screen programs • Trackballs- offer better control • Joy Sticks • Track pads • Key guards • Alternative keyboards
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Developmental Considerations Praxis
Initiation, Planning, & Sequencing
Imitation (motor and oral-motor)
Play
Language Self-Care
Social interaction
Engagement in purposeful activities
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Teaching Strategies for Activities of Daily Living
• Intensive Toilet Training • Chaining • Picture Activity Schedules • Video Modeling • Practice and repetition • Daily Living Social Stories
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Independence in Self Care and Adaptive Skills
• Wiping at the toilet • Brushing Teeth • Brushing Hair • Showering • Dressing
• Making a snack • Doing the laundry • Washing dishes • Setting the table • Getting bag ready
for school
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Chaining • Chaining is a very useful basic teaching procedure that
you can use for these kinds of skills • Chain
§ Multi-step actions where all steps have to occur in the correct sequence to finish the task correctly
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Chaining Interventions
Backward Chaining
Forward Chaining
TASK ANALYSIS
Chaining
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Importance of a chain
• Each completed step serves as a cue for the next relevant action § If the chain is interrupted you may lose some steps
in the sequence
• Examples of Chains § Tying shoes, making a sandwich, starting a car
• Before a chain is taught you have to identify every step using a TASK ANALYSIS
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Teaching a step in the chain
§ Present initial instruction (e.g., “Put on your shirt.”) • Present the steps instruction (e.g.,“Place
shirt over your head.”) • Use prompts if needed • Use reinforcement for correct responses as
needed • Fade prompts • When behavior occurs without prompts,
move to the next step
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Linking Steps Together: Backward Chaining
• All steps are completed for the client, except for the last, then second to last, etc. § 1-2-3-4-5 (therapist) 6 (client) … mastery § Example: the shirt and one arm is placed into
the shirt– Child has to put other arm in. § Reduce prompts as you go for mastery
• Use when there is a natural reinforcer at the end of the chain– I’m Dressed!
• Use when task termination is a reinforcer
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Forward Chaining
• Teach the steps in a forward manner, 1 at a time § 1 (reinforcer)… mastery § 1-2 (reinforcer)… mastery § 1-2-3 (reinforcer)… mastery, etc.
• Use when the client can perform each of the steps
• Use when the initial steps are easiest
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Nail Trimming • Always after or during bath time when the nails are soft • Don’t use the word “cut” use the word “trim” • Provide heavy work activity before • Video the family trimming their nails & have child watch • Introduce nail trimmers to cut onto paper first in play • Slowly introduce nail trimming to your child when they
are calm • Break the activity into steps • Take breaks and offer a pleasurable activity during nail
trimming.
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Haircuts • Take Child to watch the hairdresser • Complete heavy work activities before • Use a towel and clip instead of cape • Take along an extra shirt to change into • Visual distraction- computer or IPAD • Sit on parents lap • Reward with positive reinforcement • Consider having a hair dresser come to your home if
necessary
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Schedules
Visual Schedule
Picture
Written
Tech Based
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Why use activity & Visual schedules? • To increase behavior that has been learned but is not
occurring independently § Pre-teach a skill § Improve Independence
• To reduce problem behavior during transitions
• To teach new sequences of behavior and learn new skills
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Prerequisite Skills
• Ability to discriminate pictures from backgrounds
• Identify matching with 3D objects
• Identity matching with picture to object
• Tolerance of manual guidance
• Ability to manipulate materials
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Visual organizers • Visual Schedules
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Picture Exchange Communication System-PECS
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Routine-based Strategies Work systems
The individual work system answers four questions 1. What work? 2. How much work? 3. How do I know when I am
finished? 4. What happens next?
http://www.teacch.com/
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First this – Then that…
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Visual Schedule First - then
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Ready/Not Ready • Teach child to indicate if they are “ready” or “not
ready” • Associate “not ready” with a means to get “ready”
§ then move them into getting ready § finally, engage in task at hand because they are “ready”!
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Sensory Integration
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Pyramid of Learning
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Sensory Integration • Sensory integration is a neurological process • Theory that describes the relationship and association
between behavior and neurological processes • “The neurological process that organizes sensation from
one’s own body and from the environment and makes it possible to use the body effectively within the environment.” (Ayres, 1979)
• The ability to receive, interpret and organize sensory information (i.e. Self Regulation)
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A Model for Understanding Sensory Modulation
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Sensory Integration-Based on Ayres
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Frick, Wilbarger
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Ayres’ Model of Praxis
Ideation
Planning
Execution Ayres Model of Praxis
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Dunn’s Model of Sensory Processing
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Sensation seeking
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POOR REGISTRATION
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Sensory avoiding
Lane, C. 2011
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Sensory Modulation • Taking in sensory information • Processing sensory information • Functioning within an Optimal Range
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Disruption with Sensory Modulation
• Observe behavioral difficulties • Sensory avoidance • Irritability • Sensation seeking • Poor coping and self-regulation
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S.T.E.P.S.I. • Model of Sensory Integration designed by Stackhouse &
Wilbarger
• S ensation • T ask • E nvironment • P redictability • S elf Monitoring • I nteraction
Copyrighted to Stackhouse and Wilbarger
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Goal of OT with SI Treatment • Purposeful activity and Goal oriented responses • Facilitation of the adaptive response • Based on integration of sensory and motor input • Self-regulation • Motor planning • Improving the child’s organization of neural and sensory
information to adapt effectively to their environment
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Classical SI – Bottom UP • The use of sensation through the adaptive response produces sensory integration, the basis of praxis & motor planning
• Qualities of sensation include focused work on foundation of disorder § Vestibular § Tactile § Proprioception
Adaptive Response
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How We Treat Sensory Issues • Careful analysis of the problem • Sensory Diet & Sensory Based Activities • Classroom, Home and Community based Program instructions & suggestions
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Sensory Systems
• Vestibular (movement) • Tactile • Proprioception (heavy work) • Auditory • Olfactory • Visual
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Sensory Diet Components • Proprioceptive & Tactile discrimination activities • Movement (Vestibular) input • Mouth activities: Organizing & Self-Regulation • Auditory input: Music, listening programs • Effective strategies for transitioning • Reducing behavioral outbursts • Help with shifting • Task and environment modification
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Self-Regulation is the Key • “Self-regulation is the ability to attain, change, or
maintain an appropriate level of alertness for a task or situation.” (Williams & Shellenberger 1996).
• Self Regulation helps us to adapt to our environment • Coping skills and Calming skills
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Movement
Information to muscles and joints
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Alertness Strategies
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The Sensory Diet Concept • Originated by Patricia Wilbarger, M.A., OTR
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Sensory Diet Components
• Routines for transitions • Family lifestyle and preferences assessed and
modified • Can be used during new learning • Task/activity modification • Environmental modifications
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The Key is Building a Daily Schedule Event/Time
Sensory Diet Activity
Transition Other Support
Wake -Up
AM Lunch Early PM
Dinner Bed-time
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Sensory Based Strategies Movement: Modalities
§ What sensory receptors are stimulated?
§ What areas of the brain are activated?
§ How does it effect arousal & alertness?
§ How does it support function?
• Intensity • Frequency • Duration • Rhythmicity
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The Relationship of Arousal to Attention, Learning and
Performance GOOD
ADAPTIVE RESPONSE --------------------------------------------------------------------------- (Attention, Learning, Performance) POOR __________________________________________________________
LOW ⇑ OPTIMAL RANGE ⇑ HIGH OF AROUSAL
After Hebb, 1949
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Arousal-Relaxation Cycle Builds Self-Regulation
Child
experiences a “need”
Child feels upset
Adult satisfies need
Child Feels Content/organized
behavior
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Sensory Strategies
• Sensory Play • Tactile • Heavy Work • Movement (Vestibular) • Auditory (music) • Oral Proprioceptive • Visual
• Cozy corner • Headphones • Therapy ball • Movement Activities
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Ziggurat Model
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Aspy, Grossman, 2008
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Education and Advocacy • Education
§ School & community personnel § Explaining learning strategies § Explaining behavioral differences
• Advocacy § Educating about Down Syndrome conditions § Teaching strategies for success § Promoting success across all environments
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Resources • “Fine Motor Skills for Children with Down Syndrome” by
Maryanne Bruni, BScOT • The Sensory-Sensitive Child: by Smith & Gouze • “How Does Your Engine Run” www.thealertprogram.com • www.texasautism.com Ziggurat Model • www.southpawenterprises.com • www.therapro.com • www.Therapyfunzone.com • www.sensorycomfort.com • www.softclothing.net
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Thank you for your Attention! Contact Information: Syd Martin MS, OTR Children’s Colorado Hospital Email: [email protected]