Presenter: Amy Carroll, OTR/L

LEAP Occupational Therapy

Carroll.amyp@gmail.com

OTICON 2012, Goa, India

16 January 2012

About Amy Carroll

OTR/L

NBCOT

25+ years experience working in public schools

(government schools)

20+ years experience as private practitioner

Advanced training in Sensory Integration &

Interactive Metronome

O.T. Doctorate student at Thomas Jefferson

University in Philadelphia, U.S.

Presentation Overview

Occupational Therapy in School Settings

Guidelines for my practice (AOTA & U.S. Law)

O.T. Role in U.S. Schools

OT Process in schools

Intervention for Children with Learning Disabilities

Evaluations

Common Issues

Specific Intervention Activities & Tools

Guides to my practice

Adapted from: American Occupational Therapy Association, 2008

O.T. DOMAIN

Occupation

Performance Skills

Performance Patterns

Client Factors

Activity Demands

Environment & Context

AOTA Practice Framework: O.T. Domain

Guide to Practice:

U.S. Law Related to Special Ed. and School-Based O.T.

1960s

1970s

1980s: 1990:s

Source: Pape & Ryba, 2004

Individuals with Disabilities Education

Act

OT: a “related service” within special education

Education for the

Handicapped Act

2004

General structures for service:

Clinical vs. School-Based

In clinic, hospital, private

practice

Sensory Integration (SI)

Neuro-developmental

treatment (NDT)

Listening Programs

• In school: classroom, gym, cafeteria, etc.

• Sensory Regulation

• Principles of NDT

• Develop. Activities

• Practical tools and techniques

• Assistive technology

Clinical:

(treat, remediate)

Schools

(access, benefit, participate)

Response to Intervention: 3 Tiers

U.S. School-Based O.T. Process

Team Meeting

Individual Education Plan

(IEP)

Monitor &

Report

Evaluation

Re-Evaluation

Referral

Discharge

Intervention

Tools & Techniques

U.S. School-Based O.T. Process

Team Meeting

Individual Education Plan

(IEP)

Monitor &

Report

Evaluation

Re-Evaluation

Referral

Discharge

Intervention

Students with Learning Disabilities:

Common Areas of Concern for Referrals

• Handwriting

• Work completion

• Fine-motor skills

• Lack of Self-Regulation

• Poor Attention

• Behavior Management Issues

• Disorganization

• Social Skills and social participation

• Academic Issues (reading, math, etc.)

• Transitions from school to the work world

Students with Learning Disabilities:

Evaluation Process

Understand referral

Discuss with teachers, parents, or school psychologist

Gather relevant background information

Observe child in various natural school settings

Consider potential problem and root cause

Administer assessment tools

Students with Learning Disabilities:

Primary Assessment Tools (1 of 3)

Occupational Profiles/ Inventories:

Canadian Occupational Performance Measure

School Function Assessment

Handwriting Assessment

Evaluation Tool of Children’s Handwriting

The Print Tool

WOLD Sentence Copying Test

Students with Learning Disabilities:

Primary Assessment Tools (2 of 3)

Visual Perception

Motor-Free Visual Perception Test 3

Test of Visual Perceptual Skills, Revised

Visual Motor/Visual Perception

Beery VMI 5th edition

The Developmental Test of Visual Perception 2

Students with Learning Disabilities:

Primary Assessment Tools (3 of 3)

• Fine Motor / Visual Motor

• Bruininks- Oseretsky Test of Motor Proficiency 2

• PDMS-2: Peabody Developmental Motor Scales,

Second Edition

• Sensory Processing / Sensory Modulation

• Sensory Profile

• Sensory Profile School Companion

• Adolescent/Adult Sensory Profile

• Sensory Processing Measure

The Student’s Educational Team

Student

Para-Educators

Teachers

Parents Therapist(s)

Administrator

Stability and motor control posture, shoulder, wrist, grasp

Bilateral integration

Visual skills

Sensory regulation/modulation

Praxis

Organization

Students with L.D.:

Common Issues Requiring Intervention

Stability and Control: Posture

Stable posture is important for desk work

Hips: 90°

Knees: 90°

Ankles: 90°

90 – 90 SITTING POSTURE

Posture Intervention: Key Concepts

Do seatwork after ―heavy work‖ (gym, playground,

etc.) and movement experiences

Work for brief periods, and in different positions

• Sit at desk, bean bag chair, on a therapy ball

• Standing at the blackboard or an easel

• Prone with pillow under chest

• short periods initially (i.e. 5 min)

Posture Intervention: Activities

Lazy 8’s

Prone over a ball

Parachute

Scooter

Mini-

Trampoline

Posture Intervention: Common Tools

Desk top slant boards

Recommended slant = 20°

3-inch binder is an inexpensive substitute

Move-n-Sit / Wedge Cushion

Encourages upright sitting posture

Allows for subtle movement

Therapy ball

Stability and Control: Shoulder

Shoulder stability is needed for fine-motor

control

Signs of decreased shoulder stability:

Shoulder hiking

Scapula winging

Arms and wrists not grounded when writing

Shoulder Intervention

Key Concepts

Same as many postural intervention activities

Use activities requiring heavy work in the shoulder area

Animal walks, wheelbarrow walking, etc.

Chair pushups

Prone on elbows (lying on stomach)

Writing on the chalkboard –vertical surface

Common Tools

Slant board

Desktop easel

Stability and Control: Wrist

Wrist should be in slightly extended or

neutral position

Good wrist position supports mature grasp

Stable wrist position necessary for speed &

precision

Flexed wrist position is not functional

(Benbow, 2000)

Wrist Intervention: Key Concepts

Use vertical work surfaces

chalkboard or easels

Slant board

Lean forearm and wrist against the blackboard

Keep activity at the child’s eye level

Paper position affects wrist position

Paper parallel (~ 30° angle) to the writing forearm's natural position

Beginner printers can start with the paper on a horizontal plane

(Sources: Pape &Ryba, 2004 and Olsen, 1994)

Wrist Intervention: Common Tools

6-inch piece of masking tape slanted 30°

For consistency and spatial organization

Slant Board

Encourages proper wrist position

Stability and Control: Hand (Grasp)

Typical children use static or dynamic tripod or quadripod grasp by age 5

By age 6 or 7, most children can write or draw using the intrinsic muscle movements of the fingers

Hands stabilized to allow refined finger movement, rather than wrist / arm movements

Mature Tripod Quadripod

Common Incorrect Grasps

Tower Grips

Thumb Wrap Index tucked, Trap Grasp

Trap Grasp

Fisted Grasp Extended Finger Grasp

Extended Finger,

Ungrounded Forearm

Grasp Intervention: Key Concepts

Look for the open circle web space to quickly identify the quality of a grasp

Allow preschool children to explore

Different patterns of grasping

Different drawing & writing tools

Encourage achievement of milestones to develop hand

Arches

Wrist extension

Skilled vs. stable sides of hand (A-OK grasp)

Finger muscle movement

(Case-Smith & Pehoski, 1992; Benbow 2000; Olsen, 2003)

Grasp Intervention: Training Activities

Tweezers Coins

Color-forms Coin Activities Pegs

Putty

Kitchen Gadgets

Grasp Intervention: Grip Pressure

Focus on:

Stability and control more proximally

Fine motor control and quality of the grip

Intervention Activities:

Open non-dominant hand on the desk

Squeeze a ball in non-dominant hand

Line-up dominoes

Pick-up fragile objects with fingers or tweezers

Drop a specific number of drops from an eyedropper

(Case-Smith & Pehoski, 1992; Benbow 2000; Olsen, 2003)

Grasp Intervention: Gripper Tools

The Pencil Grip

Stetro Grip

Handiwriter

The Pencil Grip

Handiwriter

Bilateral Integration: Dominance

• Most children have dominance before school age

• If no dominance in preschool or kindergarten:

• Hold a bit on pencil paper tasks

• Observe to see a pattern emerging

• If no preference emerges by age 7, some specialists suggest encouraging right hand dominance (most common). I have always allowed the dominance to emerge.

• If dominance issues exist, the teacher should expect the child to be less skilled for a time

( Benbow 2000; Olsen, 2003)

Bilateral Integration: Helping Hand

Non-Dominant hand = helping hand

Helping hand- essential for many school

activities especially proper handwriting

Stabilizes the paper

An open helping hand often promotes a more

relaxed grasp

(Olsen, 1994)

Bilateral Integration: Common Tools

Dino-Ruler

Bow-Tie Board

Googly-Eyes

Clipboard

Googly - Eyes

Bilateral Integration: Activities

Coin Flips

Etch-a-Sketch Toy Putty

Geo-Board

Specialized Games

Handwriting

Bilateral Integration: Activities

Lazy-Eights

Mini-Tramp

Parachute

Jump Rope

Suspended Ball

Crazy Clock

Scooter

4 Key Aspects of Vision

• Acuity (addressed by Dr.)

• Ocular- Motor

• Visual- Perception

• Visual-Motor Integration

Note on Visual-Motor Integration:

Diagonal lines develop later than vertical and horizontal

Developmental sequence for design copying:

l — 0 + \ /

Visual Intervention: Techniques

Remove clutter to eliminate competing visual stimuli

Highlight writing baseline, or important part of a ditto

Reversals:

Gray block paper or rectangle

Letter formation patterns

Spacing between letters:

Exaggerate space between words

The big nothing

Finger in the space (often difficult)

Encourage consistent letter formation habits

(Some ideas from Olsen, 1994)

Visual Intervention: Techniques

Vertical and horizontal skills develop earlier than

diagonal skills

Sometimes children do better when they learn

cursive

continuous movement

more developed foundation skills

fresh start

Visual skills develop through movement

Visual Intervention: Activities

•Visual skills develop in concert with movement

Visual Motor Intervention:

Chalkboard Activities

Circle Drawings Square Drawings

Visual Motor Intervention:

Chalkboard Activities

Tangle Roller Coaster

Bubble Gum Machine (Adapted from Chalkboard Fun, Sena, 1996)

Paint the Fence

Train Tracks Fire-fighters

Wallpaper

(Adapted from Chalkboard Fun, Sena, 1996)

Visual Motor Intervention: Chalkboard

Activities

(Olsen, 2003)

Visual Motor Intervention: Activities

Sign-In Activity

Visual Intervention: Tools

Vertical Surfaces

Slant boards

Adapted Paper

Highlighted Ruler

BEST!

B- Bump the baseline

E- Easy to read letters

S- Spacing

T- Tall letters tall… small letters small

!- Punctuation! (Carroll, 2003)

2 lined paper

“Best” Cue Card Shaded Paper

Stop-Go Paper

Highlight Ruler

Sensory Regulation / Modulation

States of Alertness / States of Arousal

Too High, Too Low, or Just Right

―Just Right‖ = settled and focused for learning

Sensory regulation strategies = ―Sensory Diet‖

Many times less stimulation is needed

Allow quiet time-maybe a book or music in a bean bag

Cubby or cave with comforting items

Also Important to consider:

Establish routines

Warn of changes in routine

(Williams & Shellenberger, 1996)

Sensory Regulation Strategies & Tools

Sensory regulation strategies = “Sensory Diet”

―As needed‖ or at scheduled times

Older children learn when and how to use strategies

Heavy Work (see posture activities)

Pushing & pulling activities

Jumping & hopscotch, animal walks, obstacle course

Squeezing foam ball , putty, clay

Thumb-Wrestling

―Spiders on a mirror‖ / resistive toys

Deep Pressure

Compression clothing / lycra clothing

Hot dog, massage, brushing

Sensory Regulation Strategies & Tools

Heavy Oral Activities

Sucking or mints or sour hard candy.

Chewy candy (licorice, gummy bears), dried fruit, gum

Sipping from water bottles.

Movement / Physical Activities

Swings and scooter board, obstacle course

Move’n Sit cushions

Varying positions

Sitting on a ball or small rocker

―Fidget‖ tools (plastic coils, squeeze balls, silly putty)

Sensory Regulation: Common Tools

Tennis Balls on Chair

Body Sock

Lap Buddy

Theraband on Chair

Bean Bag Break Area Move-n-Sit Cushion

Rocker Chair

Crash Pad

Praxis: Key Concepts

Praxis = The ability to plan and execute new or novel motor sequences

Children with poor praxis commonly display:

Difficulty establishing routines

Difficulty with self care tasks (open locker combination, managing belongings)

Labored handwriting

Difficulty or reluctance in gym and recess

Requires more time to complete tasks

Can be resistant to new activities

Praxis: Interventions

Tactile and Proprioceptive activities (heavy work)

Obstacle courses

Play on playground equipment

Scooter board activities

Working with clay or putty, resistive mediums

Multi-step projects

Crafts

Constructional toys (Lego's etc.)

Praxis: Tools & Techniques

Break down instruction into steps

Repeat directions and provide additional visual cues

Demonstrate

Desk Map

Teach student to ―self talk‖ through a task

Checklists for routines

Social stories for routines

Multisensory handwriting instruction for stroke sequences

Consider early keyboarding

Practice self care fasteners

Lunch packages: parents can cut small hole to help child open

Pre-teach gross motor activities

(input from Pape & Ryba, 2004)

Organization: Intervention

Establish routines for where items are stored

Provide sensory cues for transitions - visual, tactile, sound

Teach transition cycle:

Set-up

Do Clean-

up

Plan

(Carroll, 2003)

Organization: Common Tools

Color coded folders or labels

Accordion Files

Copy lid in desk drawer

Trapper keepers

Allow an extra space to store items

Locker : organize books into a.m. and p.m.

Desk Map: diagram of where things go

Map of where classrooms are-color coded

Consistent format with class work

QUESTIONS?

References (1 of 4)

American Occupational Therapy Association. (2008). FAQ-Response-To-

Intervention. Retrieved 12 13, 2011, from AOTA:

http://www.aota.org/Practitioners/PracticeAreas/Pediatrics/Browse/S

chool/Copy%20of%20FAQ-Response-to-Intervention.aspx?FT=.pdf

American Occupational Therapy Association. (2011). Occupational

Therapy in early Childhood and School-Based Settings. Retrieved

December 20, 2011, from AOTA: American Occupational Therapy

Association:

http://www.aota.org/Practitioners/PracticeAreas/Pediatrics/Highlight

s/40881.aspx?FT=.pdf

American Occupational Therapy Association. (2010). Occupational

Therapy in School Settings. Retrieved January 2, 2012, from AOTA: The

American Occupational Therapy Association:

http://www.aota.org/Practitioners/PracticeAreas/Pediatrics/Fact-

Sheets-on-the-Role-of-OT/School.aspx?FT=.pdf

References (2 of 4)

American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy , 62, 625-683.

Amundson, S. J. (1995). Evaluation Tool of Children's Handwriting: ETCH examiners manual. Homer, Alaska: O.T. Kids.

Ayres, A. J. (1988). Sensory integration and praxis tests. Los Angelos: Western Psychological Services.

Beery, K. E., & Beery, N. A. (2004). Beery VMI administration, scoring, and teaching manual (5th ed.). Minneapolis: NCS Pearson, Inc.

Brown, C. E., & Dunn, W. (2002). Adolescent/Adult Sensory Profile: User's manual. San Antonio: Pearson.

Bruininks, R. H. (2005). Bruininks-Oseretsky Test of Motor Proficiency (2nd ed.). Circle Pines, MN: AGS Publishing.

Case-Smith, J., & Pehoski, C. (1992). Development of hand skills in children. Rockville: AOTA.

Colarusso, R. P., & D., H. D. (2003). Motor-Free Visual Perception Test (3rd ed.). Novato, CA: Academic Therapy Publications.

Coster, W., Deeney, T. H., & Haley, S. (1998). School Function Assessment. San Antonio : The Psychological Corporation.

References: (3 of 4)

Dunn, W. (1999). Sensory Profile. U.S.: The Psychological Corporation.

Dunn, W. (2006). Sensory Profile School Companion: User's manual. USA: PsychCorp.

Fewell, M. R. Peabody Developmental Motor Scales (2nd Edition).

Gardner, M. F. (1996). Test of Visual-Perceptual Skills (n-m) Revised manual. Hydesville, CA: Psychological and Educational Publications.

Hammill, D. D., Pearson, N. A., & Voress, J. K. (1993). Developmental Test of Visual Perception, second edition. Austin: pro-ed.

Kuhaneck, H. M., Henry, D. A., & Gleenon, T. J. (2007). Sensory processing measure. Los Angeles: Western Psychological Services.

Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajkp, H., & Pollock, N. (1994). Canadian Occupational Performance Measure (second ed.). Toronto: CAOT.

Olsen, J. Z. (1994). Handwriting Without Tears, workshop

Olsen, J. Z. (2003). Pre-K teacher's guide. Cabin John, MD.: Handwriting Without Tears, Jan Z. Olsen.

References:(4 of 4)

Olsen, J. Z. (2009). The Printing Tool. MD.: Handwriting without tears, Jan Z. Olsen.

Pape, L., & Ryba, K. (2004). Roles of occupational therapy in the school setting. In L. Pape, & K. Ryba, Practical considerations for school-based occupational therapists (pp. 1-30). Bethesda: American Occupational Therapy Association, Inc.

Reynolds, C. R., Pearson, N. A., & Voress, J. K. (2002). DTVP-A Developmental Test of Visual Perception: Adolescent and Adult examiner's manual. Austin: pro-ed.

Richards, R. M. (1988). Classroom visual activities. Novato, CA: Academic Therapy Publications.

Sena, L. (1996). Chalk-Board fun. Bisbee, AZ: Imaginart Press.

Williams, M. S., & Shellenberger, S. (1996). How does your engine run?: A leader's guide to the alert program for self regulation. Albuquerque: TherapyWorks, Inc.

Wold, R. (1970). Screening tests to be used by the classroom teacher. Novato, CA: Academic Therapy Publications.