Activities to Help Fine Tune Early Fine Motor Skills

Deanna Macioce, MS, OTR/L

Being back at school means that as therapists, teachers, and parents we start to pay a little closer attention to educational needs. We go from making sure our children are getting enough outside play during summer to what the needs are for them to breeze through their school day with ease. This includes attention and focus, handwriting and visual motor skills, as well as, social skills. From preschool through high school, much of a student's day involves utilizing their hands. Therefore, it is important to establish good fine motor and dexterity skills early on in order to set them up for success. Strong foundational hand skills help establish proper handwriting and scissor skills.

Some children naturally develop typical fine motor skills. Moving from a mass grasp to the ideal tripod pencil grasp through everyday play. However for many, especially those lower tone, sensory children this does not always happen. Without proper attention to developing these skills, it can have a long-term affect, making handwriting, coloring and scissor skills more difficult, especially in the realm of endurance to carry them out.  

Highlighting some activities and developmental needs will help to focus on how you can work on these with your child, especially the younger ones who are starting to piece together the fine motor puzzle.

Infancy offers a time of exploration. Pay attention to the toys that they are presented with, making sure the toys are of varying sizes. This will allow the child to develop different grasp patterns, strengthening the muscles of the hands. In addition, play with these toys in varying position, such as on the belly or sitting upright.   As a child begins to move by crawling always encourage crawling with opened hands to ensure proper weight bearing through the elbows, wrists, and hands. To strengthen palmer arches set up activities that allow them to crawl with objects in their hands. Such as crawling through a tunnel to obtain a puzzle piece and then crawling back through to place it into the board.

Moving through the toddler stage, grasp and fine motor development begin to take on the focus of using writing tools and scissors. Giving children the opportunity to play with manipulatives is key. From stacking blocks of varying sizes and shapes to negotiating different pieces into a shape sorter, many of the early hand skills are developed through play. Therefore, pulling out those traditional toys of puzzles, snap beads, lacing activities and blocks offers more opportunity for fine motor development than just the push-button toys. In addition, with supervision allow your child to explore with crayons and markers. And once again, utilizing ones of various sizes is beneficial. There is no need to throw away those broken crayons, using them while drawing and coloring helps to encourage the development of a triad grasp.

To help develop finger strength, activities using play dough, putty, and items such as Moon Sand provide opportunities for play, while improving fine motor skills. Hands working to knead and mold these substances encourage individual finger and grasp strength. Rolling out the dough and pinching both help improve palmar arches and pinch grasp. You can also work on these skills in the kitchen with cookie and bread baking. Finger strengthening and dexterity can naturally be addressed in day-to-day tasks, such as opening and closing small plastic containers and bags. By placing snacks and toys in these, children are naturally working on fine motor skills, and they are easy to take on the go.

In regards to grasp development, early on we look at how a child develops a pincer grasp (using the tips of the thumb and pointer finger together). As toddlers, presenting them with small objects to safely eat, such as Cheerios, Gerber Puffs, etc. helps to encourage them to use a pincer grasp. To assist in the process, you can gently hope their hand allowing them only use of the thumb and pointer finger. In addition, at this stage, it is important to pay attention to isolated index finger use. This means that as children are pointing at objects in a book, activating push button toys, etc. they are using a single pointer finger and not the entire hand.   As children grow older, you can help to encourage the use of the thumb and index finger only by placing a small object or cotton ball in the palm of their hand to hold during activities, such as writing, coloring or game playing. This helps them improve finger grasp strength and use the thumb and pointer finger on their own.

Providing activities that directly work on these skills are beneficial. Magna Doodle boards and Aquadoodle Mats allow them to work on grasping and holding different tools to perform drawing and pre-writing activities. In addition, crafts are an ideal way to pull in fine motor skills, from ripping small pieces of paper to glue onto a template, crumbling tissue paper, and using pincer grasps to obtain objects to glue such as macaroni and buttons. Another way to work on finger strengthening through ripping paper is by allowing your children to rip up your daily junk mail.

Playing and using large tweezers, strawberry hullers, or even kitchen tongs to obtain and move objects, such as blocks, pom poms, or beads and place into a bowl or egg carton container. In addition, there are games and toys on the market that provide these items, such as Operation.

So, it is never too late to fine tune your child's fine motor strength. It will be only make the daily tasks they face at school easier.

Homework Buddies

Deanna Macioce, MS, OTR/L

With school starting again, we are back to having to help our children muddle through the task of homework.  Although this can be unpleasant for many students, this becomes extremely difficult to tackle for a lot of children who suffer from Sensory Processing Disorder, ADHD, and other conditions.  These are the children that work so hard to  "keep it together" all day at school, that when they come home, sitting down to do homework is the last thing they want to do.  It is common to see these children, who sat and struggled to attend at school, come home with poor behavior, be anti-social, and resort to "down time" on their own. Whatever it is, parents fight this constant battle and want to get it done and out of the way "as soon as possible!  If not, then more fatigue and lack of focus sets in making it worse.  For some parents, this battle causes them to already start counting down the days until winter break!

Our bodies are made to move and children spend so much time sitting throughout the day at school, not allowing their brains and bodies to connect.  Many children are kinesthetic learners, so coming home from a day at school to sit down at the table once again to focus on schoolwork won't work. We are going to take a look at a few strategies that may help to lessen the homework battle.  Although, they will not all work for your child, here's to hoping that a few will help ease the pain.

1.  Break away from the "you don't do anything until your homework is done" mode of thinking.  Allow your child 20-30 minutes of outside playtime to ride their bike, shoot baskets, or even go to a playground.  When this isn't possible, work on some indoor ideas, such as a mini trampoline, doing some exercising, or running a few errands that encourage some walking.

2. When choosing after school snacks, try to make sure they are "feeding" your child properly for focus on attention.  It has been found sometimes that chewing gum, having crunchy or chewy snacks, or having a sucker help maintain attention when doing work.  Allow children these supports at home where it is easier to carry out than in the school environment.

3.  Have a space that works for your child.  Based on your child's needs, does it matter after sitting at school all day whether or not they are at a table or desk?  Allow them to work in prone or a small tent, whatever fits their needs.  However, make it a space that is free from a lot of distractions and more importantly, make sure they have a caddy with all supplies they are going to need.  Breaking their focus and attention to get up to obtain supplies makes it more difficult to keep them on task once you get them there.  Use tools such as weighted lap pads, ball chairs or seat discs as needed.

4.  Work with the school and teachers to try and "adapt" some of the homework.  Kids need to fit a mold when at school to complete work because they are part of a class.  Find out if your child's teacher will allow you to work on spelling or math facts by playing games, utilizing ball activities, etc. but then allow you to complete the worksheet if your child mastered the skills..  This is more difficult and time consuming on your end, but if you can provide evidence and get the school team on board, it will enhance your child's learning in the long run. In addition, be on top of the game.  For longer projects, upcoming tests or things that need a lot of attention, ask for extended deadlines, but not after the fact.  As a team, we all want our children to learn, so it is not always important when the assignment gets done or that it got done, but whether or not the child learned.

5.  Giving your child work breaks is crucial.  Their attention spans of true focus only last about 20 minutes on average.  So, break work up into chunks.  Allow them some time to get up and move, but reel them back in after about 10-15 minutes max until all the assignments are done.  Find what your child needs to re-group and provide it.

6.  Visual prompts are very helpful for many children.  Using a small dry erase board to list what needs to be done, showing them the breaks help them maintain focus once they get started.  Also, using a visual timer when they are doing independent work helps keep them on track.

7.  Get creative on setting goals/motivation.  Earning video game time, a treat, or even to the point that each day they get so many pieces to a puzzle, Lego set, etc. working hard to complete the toy.

It is in known that for many utilizing these strategies come with a lot of constraints, siblings, work, and other activities.  Therefore, they cannot be done all the time, but when possible setting up a routine that works will offer your child success and take stress off of you.  Think about what can be done "on the go", such as when you are driving in the car or when you are waiting at a sibling's practice. Carry along the visual and oral supports. And work to integrate homework into the hectic after school schedule.  In the end the battle will lessen, and keep the stress lowered for you.

Building the Foundation for Learning

Deanna Macioce, MS, OTR/L

It seems as everywhere we turn there is discussion about our education system.  From standardized testing to the Common Core, there is so much focus on scoring and benchmarks that as parents, therapists, and even teachers we sometimes feel that our children are not really learning.  And this is true for all children, not just those with a diagnosis.  We tend to put so many demands and stressors on our children about learning from an adult perspective at such an early age, that we are, in fact, at times hurting their overall development.  Based on Piaget's Cognitive Theory, a child's brain learns and thinks differently than an adult's brain.

From an occupational therapy perspective, a child's 'work' is play.  Therefore, when a child's brain and body are developing, the biggest impact comes in the form of play.  Allowing children the opportunity to learn through the manipulation of objects and toys, using creativity and imagination, and performing self-initiated problem solving, sets the foundation for ongoing learning.   However, we are found to judge our early education centers and preschools on their overall "curriculum", often faulting the extra time given for self or explorative play.  We, as a society, want to see activities and lessons focusing on the learning of academic skills, such as colors, letter, and numbers.  With the advances of technology, we are often "wowed" by the environments that perform learning activities with iPads, computers and smartboards.  While these are all important and beneficial, they should not be seen as the foundation to learning.  Children who are given the opportunity to develop the proper cognitive foundation, will easily pick up the technology, and will not "fall behind" as we often hear.

In addition, from the sensorimotor standpoint, children need to move.  Movement plays a key role in strengthening the vestibular and proprioception systems, while also developing bilateral coordination, core stability, and balance.  And believe it or not, these are needed for a child to be a successful student.  Children are expected to sit and attend for long periods of time always being in the upright position.  And those who lack core stability, find it hard to maintain this position, and are found to be the fidgeting, slouching child.

Therefore, children need the to opportunity to play and learn through movement.  Unlike adult brains, they cannot sit for the three-hour lecture class, and take in information that comes only in the form of listening and writing.  When we allow their brains to develop early on in the proper developmental environment, we will be able to build strong critical thinkers and learners.  That means that lessening their recess and physical education time is not beneficial to the educational curriculum.

So, our job as parents, teachers, and therapists, is to work hard to find that balance.  Give our children the time to move and play, while reaching all those educational benchmarks.  As a therapist working on handwriting, move away from the tabletop and find other creative ways to achieve the same goals. Parents, instead of always using electronics as a form of down time, especially when children come home from school, encourage them to participate in 20-30 minutes of play or outside exploration before even asking them to focus on their homework. Do not over-schedule children with organized sports and extra-curricular activities.  And teachers, find ways for children to learn new concepts using their bodies, manipulatives, and allow children movement breaks, not just those on an IEP. This takes extra effort on all parties, but if the team works together we will be setting our children up for success.

Filling Our Sensory Buckets at the Beach

Deanna Macioce, MS, OTR/L

Summer has arrived, and we are often found filling our days with trips to the beach to soak up the sun, water, and sand.  Going to the beach is a great way to embrace summer. It offers so much fun for children of all ages, despite developmental needs, and much peace for adults.  When looking at the beach experience in terms of sensory inputs, we typically hone in on the tactile benefits that it offers. However, it provides the perfect landscape for meeting the proprioceptive/heavy work needs of any child.

As we sit back and watch the joy that comes on many of the faces of the children playing in the sand, we are taken back to our own childhood.  The laughing, giggling, and excitement reminds us of a time when we were able to let go of any inhibition of sitting in the sand, having it all over our bodies, and in our suits to just have a little bit of pure fun.  The best part of playing in the sand is definitely the end product of the castle that is built or the hole that is dug, but in working hard to achieve this our little ones' sensory systems are being fed buckets full of proprioceptive input.   As they dig through the sand with any type of shovel, or even the use of their hands, the resistance of the sand to fill their buckets or dig a moat provides a good amount of feedback.  And typically, those buckets need to be carried or dumped which helps to offer some great 'heavy work'.  Since this is pure fun, you can watch your child do this over and over again, unlike when Mom or Dad tries to achieve getting this input at home (with those 'great' sensory diet activities provided by their OT)!  Running to the shore to fill up buckets of water, or the wet sand (which build the best castles) intensifies the input our children receive.  So next time you want to help carry that bucket, take a step back and let those sensory systems be fed. For those who like to dig, digging a hole just the right size for some body burying in the sand, not only is a nice tactile experience, but it is a built-in weighted blanket!

And to beat the heat, or remove all that sand from our bodies, 'diving' right into the water is another great way to meet our proprioceptive needs. Swimming alone provides a full body experience.  Whether you are at the ocean or a lake, the swimming, bouncing, and just overall movement within in the water offers great benefits.  And when those waves come crashing in, our bodies get a rush of proprioceptive input.  Water play is especially ideal for our older children, so grab a ball or Frisbee, and play some catch in the water...with all the fun that is happening they will not even realize the 'work' their bodies are doing.  In addition, using a body board can also help those older children work through some motor planning needs.

Therefore, whether you are lucky enough to have a beach near your home, or you are packing up the family car for vacation, it is great to see that a trip to the beach is not only fun and relaxing, but also very beneficial for our sensory systems.  It is not just the heat that tires our children it out, it is all the excellent 'heavy work' they do while having fun!

'Steamrolling' Through Proprioceptive Input

Deanna Macioce, MS, OTR/L

As teachers, parents, and therapists, we learn more and more each day about sensory processing, especially in our everyday life.  We see how the world around us is always feeding our sensory systems, and how it effects our interactions with the environment and others. In turn, we begin to get a better understanding of what it means for our children, especially those who have Sensory Processing Disorder (SPD). We all love a good bear hug or that great deep pressure massage, right?  Well, that is not true for everyone however, we have found that providing activities that elicit proprioceptive input offers a realm of benefits.

Proprioception plays a major role in overall self-regulation for children who demonstrate difficulty with tactile input, focus, attention, and body awareness.  Understanding proprioception and the effect that it has on the body is sometimes very complex since it also affects the tactile and vestibular systems.   Having a functional proprioceptive system helps improve body awareness, postural control and stability, and motor planning.

So often we hear about trying to find ways to address proprioception with heavy work activities. With success, these activities will help our children motor plan with greater ease, understand where their bodies are in space, attend better, and demonstrate improved postural control.   These activities help with organizing and calming a child's sensory system. There are numerous activities that help provide proprioception, especially in our day-to-day routines.   Carrying a backpack, climbing at the playground, loading and unloading groceries, as well as participating in yard work, just to name a few.

Within the therapy setting, there are many pieces of equipment out there to assist with the various needs of children who demonstrate sensory processing concerns, but one that is very successful and versatile at providing the proprioceptive input so often desired is the Southpaw Steamroller.  The Steamroller is a great addition to any obstacle course, providing the necessary deep-pressure input for a calming effect. It also is an ideal place to have your child hang out to complete an activity such as a puzzle, reading a book, or doing a maze for continuous input. The Steamroller allows you to be creative because is easy to attach to a theme, such as making pancakes or going through a car wash.  Set out cars on one end and have a child go in and out of the Steamroller multiple times to take the cars through the car wash. In addition to providing deep pressure, it is an excellent way to address improving shoulder strength and stability, as well as motor planning.  As a child negotiates his or her way into the machine, they pull themselves out with their arms giving them just enough support to work on shoulder strength.

Whether you have direct access to the Steamroller or not, take the time to focus on proprioceptive input for our children this month with new ways to use the Steamroller or finding ways to provide it in those activities already happening naturally at home.

Pulling Together Your Team

Deanna Macioce, MS, OTR/L

Johnny hates to wear jeans, Kelly seems to be 'on the go' all the time, Michael covers his ears when he hears the lawn mower, and Melissa cries when her mom puts her on a swing. We have all heard about and seen these children, and for those who are experienced in working with Sensory Processing Disorder (SPD) these are common statements. However, for many, especially parents it is very difficult for them to understand and grasp the concept of the sensory system and the role it plays in our day-to-day life.

Many people feel that we all have sensory concerns, which is true, but it is when it gets in the way of our "functional" living that it becomes an issue. Sensory processing is used to describe how the nervous system receives information from the body's senses and then turns that information into a response. When discussing SPD, individuals who are affected by this present with disorganized or inappropriate responses, often times being described as 'behavioral'.   It is difficult for parents to truly discern what is sensory and what is age appropriate. For example, two-year-olds often try to gain control of situations, such as refusing to eat or dress when asked by a parent, but for a child with SPD, they often do not make the choice of how they respond. There is a reason they may not want to eat, whether it be texture or taste, and they may struggle with transitioning between short sleeve and long sleeve shirts due to tactile defensiveness.  

Many children who exhibit sensory processing concerns often have another diagnosis as well, such as Autism Spectrum Disorder, ADHD, or Down Syndrome, however for others, it is purely a stand alone diagnosis. It is these stand alone situations that are often the most difficult to identify, and for parents to understand. Children appear to be 'typical' but there is some reason that life is not going smoothly at home or school, or situations just seen too difficult for a child to cope with.

As professionals we often become frustrated when we feel parents are not "pulling their weight" at home, or that they are not taking the time to help carryout suggestions, however we need to realize that most parents are tired, overworked, and often just don't understand. In addition, we say we work as a "team" but then feel it is better not to have the parents be part of the therapy session or the activities in the classroom. How could we expect them to be "team" players when we are not educating, including, or encouraging them. And it does not go with out saying that it is known that not all parents strive to be participants. However, this does not mean they do not want the best for the child, we just need to find out at which level we need to interact and connect with them.

Therefore, using strategies such as pulling parents in for portions of sessions, using video, or even teaching sessions will help the parents to become more comfortable, have a better understanding, as well as see how things are performed in the school or therapy setting. Today's technology with smart phones, make it easy to take video and send snippets to parents. In addition, communication is key. So having some regular way of communicating whether at the end of session, via email, or log is very important. Once the parents are on board to be a team player, they will help with the facilitation of strategies at home and the child will make progress as a faster pace. Making it a win-win situation for everyone.

We need to realize that the number one players on any child's team are the parents. Whether a teacher or therapist, realizing that the importance of pulling the parents into treatment planning, and teaching is the most beneficial for the child involved.    They are the ones who are the constant in the child's life. Teachers change each year, therapists are seen in small doses and often are every-changing, so it is important to pull in the child's number one fan-their parent or caregiver!

'Weighing' In On the Use of Weighted Items in Therapy

Deanna Macioce, MS, OTR/L

With so much discussion in the realm of treatment for Sensory Processing Disorder (SPD), we find that there is little research to support many of the techniques, protocols, or methods used.  If you are an occupational therapist (OT) you find that you use the methodology you were taught, enhanced by the things you have learned from attending continuing education courses, picked up ideas from co-workers, or just used your creativity to find something that works through experience to address a sensory need for a child. And you find it to be effective by the changes noted in the child's underlying neurological system, so you use it.  This is seen with treatments such as listening programs, spinning and brushing protocols, and the use of weighted items. It is known that if two individuals demonstrate issues in the same sensory areas, their needs, behaviors, and treatments are going to be different.  That is why OTs are known for using their little "tricks" be make treatment be successful, regardless of the research. If you are a parent, caregiver, or teacher you have seen the effects of some of these treatment techniques making a difference in the life of your child who is now more regulated, able to tolerate a movement he or she once couldn't, attend better in school, or even sleep better at night.

In regards to the use of weighted items, such as vests, blankets, or other items, we find that there is little research, and sometimes it is less than convincing that these treatment tools are effective. However as therapists we know that for some children the use of weighted items has been beneficial for calming, improving body awareness, or increasing alertness.  We have seen children increase their focus in school, sit better during circle time, calm when frustrated and be able to move into the sleep cycle with ease. Therefore, we have continued to keep these items as part of our treating repertoire, knowing that they may not work the same on every child.  Since these positive changes have been noted, we are able to find items from vests, to blankets, to hats, and so on because the use of weighted items can be effective in children.

Most often weighted items are used in therapy to address proprioception.  This is the sensory system that "senses the position, location, orientation, and movement of the body muscles and joints. Proprioception provides us with the sense of the relative position of neighboring parts of the body and effort used to move body parts"  (STAR Center).   And when we see improvements to the proprioceptive system, we see changes in body awareness, focus and attention, and calming.  We know that performing tasks the require heavy work and resistance are beneficial to work on the proprioceptive system, and weighted items help us obtain this.

The use of weighted vests are commonly seen in schools to help children sit and attend during activity.  In addition, the "just right" input could help these children remain regulated during play, interacting with peers or with transitions.  They are also beneficial to use during movement activities to help improve body awareness and position in space.  Lap pads and neck wraps are used during sitting tasks and are great for desk work.  Just a bit of weighted input helps children stay focused and attend while giving them the proper input to help keep their bodies seated.  Blankets are best to use when addressing a calming state.  They also help during stationary tasks to provide input over the body or during tasks performed in prone, such as playing a game or completing a puzzle.  In addition, weighted blankets have been found to help children calm and regulate their bodies for sleep, and provide good input to help them remain in the sleep cycle. Southpaw has recently worked to improve their weighted hat.  Not only do we now offer a trendy hat that can be worn by either males or females, we have improved the shape and size of the weights allowing it to be better dispersed.  Therefore, it is easy for children to wear it in a variety of settings, with ease during movement, and appear to have a common item on, versus a vest, lap pad, or neck wrap.

With the use of weighted items, or any type of sensory treatment method/protocol it is important to consult an occupational therapist to help determine wearing procedures, timing, and the proper needs to be addressed.  This will help establish an effective wearing program meeting the child's needs, while avoiding the child accommodating to having it on which in turn lessens the effect of using a weighted item.  It is also important to establish the right amount of weight with your therapist.  Typically is will range from 3-10% of the child's body weight.  But this is dependent on the item being used, the need trying to be met, and the overall weight distribution.  Also, it should be noted that it is important to use weighted items proactively, rather than as a reaction to when a child begins to meltdown as an attempt to calm.

Despite the research weighted items can be beneficial in a child's sensory program.  Therefore, whether you are a teacher, parent or therapist, it may be time to re-visit these "weighty" tools!

Creatively Enjoying the 'Thaw'

Deanna Macioce, MS, OTR/L

With the thawing out from this 'Polar' winter coming soon, everyone is ready to be outside, burning energy.  Regardless of where you are in the country, this winter has been unlike any others.  And although just getting outside and being active would meet most needs, this month we are going to look at a few fun, creative ideas for outdoor play that meet a variety of therapeutic needs.  So, put on your coats and leave your boots at home...and let's have some fun!

Scavenger Hunts- These can be done in a variety of ways to address different skills.  First, you can give the child a list of things to find, such as an animal, something that is a particular color or shape, and an item in nature.  Once it is found they can mark it off the list or to address handwriting skills, have them write what they found. Using a small clipboard to hold the list will also provide a writing surface for them, while helping to address bilateral skills.  Or, if your child has a camera, have them use the camera to take a picture of the item that has been spotted.  This is particularly fun for toddlers who have the "kid tough" cameras.   These activities allow children to get outside while strengthening their visual and direction following skills.

To incorporate movement you can set up the hunt so that clues need to be found.  This is ideal for older children.  Once a clue is found, it could instruct the child to move in a particular manner to the next spot.  For example, bear walking, walking backwards, skipping, etc. This not only helps children to problem solve finding the next clue, it helps with motor planning and spatial awareness skills while adding in some vestibular and proprioceptive input.

Obstacle Course- For those children who get bored easily with riding their scooters and bikes, or just need a little bit more help getting their bodies moving, turn your backyard into a fun and challenging obstacle course.  Use boxes to jump over, crawl or jump through hula hoops, do animal walks, perform side jumps.  What ever you can do to get them moving.  Obstacle courses are a great way to provide vestibular and proprioceptive input while addressing motor planning, core strengthening, bilateral coordination, balance and direction following skills.  For higher functioning individuals, you can work on speed and agility by timing the trials.

Basketball- Basketball playing can take place in the drive or at the park, wherever a hoop is found.  In addition, it can be an individual activity or performed with one or more peers.  Basketball by itself is an excellent therapeutic activity.  It pulls in bilateral coordination, hand-eye coordination, upper extremity stability and overall strength and endurance when just working on shooting baskets.   For individuals who demonstrate difficulty interacting with peers or overall conversation, playing a game of HORSE where each child has to ask the other a question before shooting is both fun and beneficial.  It gives these children a chance to work on initiating conversation, but not so focused on it because of the distraction of anticipating "making the shot"!

Sidewalk Chalk-  A favorite by children of all ages allows you to have an open canvas with your creativity and activities.   Children can work on their handwriting skills by writing words, letters, or forming shapes for pre-writing.  And due to the typical positioning when using sidewalk chalk, shoulder stability is often strengthened during these tasks.  So, taking a tedious of activity of writing outside to see a change in motivation to perform the task.

With school still in session for a few more months, you can add movement while using sidewalk chalk by writing sight/power words or various numbers randomly over the ground, leaving space between them.  Then children can move to the word when it is called out and catch a ball.  With numbers, giving a math problem with the child to solve in their head and then hop, twirl, or walk to the answer.  Spelling can also be worked on in the fresh air in this manner too.  Just write the letters out on the ground and then children have to move to each letter to spell the word- an excellent idea for your kinesthetic learner!

So on those brisk, but sunny days take some time to get some fresh air before the Spring rains hit!

T-ing Up Activities

Deanna Macioce, MS, OTR/L

Regardless if you are a teacher or a therapist, you find that as you plan activities in the clinic or classroom you often focus in on just one or two benefits to the task at hand.  For example, what is the skill being addressed, what will a child learn or what will they improve or focus on?  Often times, the one component that is very key and overlooked is positioning.  For example, we tend to think that children should always have their work placed on the desk in the middle, but for some children with visual perceptual issues, a simple shift in positioning can make a world of difference.  In addition, we think that most seating arrangements should work for all children regardless of height or comfort, strength or stability, and we tend to perform most therapeutic tasks in standing or sitting at a table or desk. However, you may find that just a slight change of using a T-stool, therapy ball or Southpaw's new Togo seat can increase the benefits by addressing core strengthening, balance and vestibular input.  Therefore, seating and position are important!

Therapy balls are commonplace in most therapy settings, and more and more schools have them available for seating options.  Therapy balls come in a variety of sizes and can be inflated differently offering various amounts of vestibular input.  When used for sitting and positioning, balls offer just enough movement and bounce to increase alertness, addressing focus and attention.  They help improve trunk stability and balance when used dynamically during activities.  Having a child sit upright on a therapy ball that allows the child to comfortably place her feet on the floor and participate in Zoomball allows you to address balance, trunk strengthening, and weight shifting with additional vestibular input.  So now, an ideal activity for bilateral coordination, shoulder stability, and visual attention just got better!

Anyone who has ever heard Carol Kranowitz (author of The Out-of-Sync Child) speak, knows that early on, once seeing the benefits of t-stools, had all of her preschool children sitting on them during circle time.  T-stools are a very beneficial piece of equipment that are often overlooked.  They are great because anyone of any size can use a properly fitted one.  T-stools hone in on really activating the core trunk muscles increasing a child's balance.  Because they require so much stability and weight bearing through the legs, when you add an activity with them, such as a bean bag toss where the child has to obtain the bean bags off the ground and toss at a target, the challenge and benefits are numerous.  They are also ideal for sitting with increased focus and attention, much like Carol has her preschoolers doing.  They do not allow for much slouching and slacking, and a slight wrong shift of weight can cause a child to tip. 

Southpaw's new Togo seat offers the benefits of both a therapy ball and t-stool in one.  It is great at addressing core strengthening and balance with a little bit of vestibular input improving focus and attention.  In addition, the seat also comes in two different seat bases, allowing a slight difference in support.   In a classroom, the Togo seat offers the ability to keep the wiggly child paying attention to the teacher with a slight bit of movement that is now distracting to the whole class, and takes up less space then a therapy ball.

So before you finish your plan on your next activity, see how you can increase the benefits with these fun pieces of equipment.

‘Coordinating’ Through the Snow

Deanna Macioce, MS, OTR/L

Snow:  you love it or hate it, and if you are one of those that fall in the grey area, it is best to find a way to embrace it.  Often times we find that for those who live in snowy regions, the winter months put a damper on their physical fitness and therapeutic activity.  However, snow offers many benefits, especially to our older children. That is why it is a great reason to take advantage of the snowy conditions while they are here.  Although play in the snow offers an array of sensory experiences, coordination skills are going to be highlighted because with improved core stability, balance and bilateral coordination, a better proprioceptive system and body awareness are developed. 

Embracing the weather means children can participate in activities such as snowshoe walking, sled riding, and skiing, both cross-country and downhill.  All activities that cannot be done without one thing: SNOW!

Snowshoe walking can be done with children as young as 3-years-old.  By placing on the snowshoes, individuals walk through the conditions requiring an increased amount of balance and strength due to using a more exaggerated gait.  By making crunchy footprints in the snow, children get to take a trip down a path, lifting high each leg and keeping themselves balanced through weight shifting.  It puts a nice twist on something most do every day; walk.

Sled riding is often looked upon as a vestibular activity, which it offers great benefits in this area.  However, when focusing on coordination we see that the sled riding is more then just a rush down a high hill.  Climbing the hill to get to the top involves core strengthening to make it up the incline.  It also addresses those tight hamstrings that many children have.  And the sled needs to make its way to the top as well, so by pulling the sled behind, children get to work on weight shifting with an object.  Balance and core stability are enhanced as children need to maintain their bodies in an upright position while rushing down the hill.

Cross-country skiing offers the biggest challenge when it comes to coordination, mainly in the process of getting the skis on and maneuvering the body to move.  Once situated the bilateral gliding of the legs is a whole body coordination activity.   Both the arms and legs have to move in sequence in order to allow the child to glide across the snow-covered ground with ease. In using the poles (which are optional, and may be cumbersome for younger children or those with decreased coordination skills) stability is provided for increased balance, but they also help encourage the increase use of the arms.  

Down-hill skiing and snow boarding are activities that require a larger amount of skill and coordination. Therefore, children can participate despite their weakness.  They require balance, bilateral use of arms and legs, and weight shifting the body appropriately to avoid a fall. Many places offer these activities in an adapted program.

Being outside and getting some exercise is an added bonus to these activities. And being that children can only participate in them with snow, why not add them into their therapeutic programs.  So, bundle up and have some fun!

How to Stack Up on Play

Deanna Macioce, MS, OTR/L

We find more and more that we are moving away from traditional play with our children. The fun and exciting things that have entered our world of play in the form of technology is amazing, however by partaking less in the toys that require imagination, manipulation, and self-generated play our children are growing up with weakened developmental skills. Typically these days, if it doesn’t light up, talk back to you, play music or require the downloading of an ‘app’, it is not the ‘coolest’ toy or activity. But if we took some time to encourage play with blocks, stacking and building toys, we would not only be improving a child’s fine motor skills, visual motor/perceptual skills, imagination, and attention, we would be giving them a new opportunity to fun. In addition, research suggests that children who engage more in block play tend to perform better in the areas of math and science. Parenting Science (http://www.parentingscience.com/toy-blocks.html)

Blocks come in a variety of shapes and sizes, and it is not only to give companies a reason to market more products. From a therapeutic prospective, the differences enhance various developmental skills while adding some fun. There are cardboard blocks, wooden blocks, Lincoln Logs®, LEGOS®, Duplo blocks®, and many others. As well as, the creative shapes and designs found in building toys, such as those offered by Southpaw; the Better Builder Series, and Totter Tower. And we cannot forget the simplicity of those common household items such as boxes, soup cans, and plastic cups. There are so many ways to incorporate stacking and building into your child’s play, no matter what age or skill level.

Blocks and other building toys play a huge role in fine motor development, especially looking at grasps and hand arch development. Starting with the large cardboard blocks, moving down to the 1-inch wooden blocks and then those similar in size to LEGO® blocks, children progress from a gross grasp to a refined pincer or 3-tip grasp. A well-developed grasp is beneficial in all daily tasks, including eating, performing handwriting activities and manipulating fasteners, such as zippers and buttons.

Breaking apart the task of stacking in more detail, we find that these activities also help with developing improved shoulder, elbow and wrist stability. When children have stronger stability at the shoulder, we find that they are able to perform fine motor tasks such as handwriting, scissor activities, and tool use with increased refinement and endurance.

Visual motor skills are enhanced with building activities. Whether copying a design, stacking or creating a self-generated design, building pulls in 3-dimensional work addressing depth perception. As children continue to develop these skills, moving from plain blocks onto more complex building with LEGOS® or K’nex® systems where they have to follow a book of directions are beneficial.

The nice thing about incorporating more stacking and building into play is that it easily can be done almost anywhere or with anything. Stacking the boxes from the grocery bags (or as my children build vehicles to ride in with the extra large items from the local warehouse store) or building with the jelly packets on the table at the restaurant; building can happen anywhere. Stacking and building have no age limits and the possibilities to creativity are endless. Remember that children learn by example, so if we take a break from those technological toys and spend some time being creative, they will join in with us. Now as we begin the holiday shopping, make sure we add a little ‘building’ to the list!

"Fall"ing into Calmness

Deanna Macioce, MS, OTR/L

In the last month or so, most people have experienced a ‘season’ of change with the start up of school.  Whether you are a parent, teacher, or therapist, the Fall not only brings a change in weather, but a change in routine, expectations/demands, and behavior.  It is not uncommon for children to be over-tired and worked, resulting in increased agitation, increased arousal level, and overall disorganization of his or her sensory system.  Therefore, we are going to provide some fun Fall activities to help decrease arousal levels and hyperactivity, as well as increase attention and self-regulation. 

The cool, brisk air of the season provides a natural calming component.  Therefore, getting out to play, ride a bike, or take a hike to gather up leaves and acorns for a craft helps use up the extra energy after school.  For ideal success in lowering the arousal level, complete the high-energy activities first, followed by something more calming, such as wheelbarrow walking across the lawn. 

One of the best things about Fall, is the beauty of the changing leaves, however it goes without saying that those leaves bring about a lot of extra work.   Raking leaves is beneficial for all children and they sell rakes in about every shape and size.  The pulling motion provides bilateral coordination, but is an excellent way to get a nice dose of heavy work.  And the hard work is always capped off with a great jump into the leave; also a nice tactile experience in itself.  Although leaves appear to be light, when in a pile they provide a good amount of weight, so complete the whole task by having your child scoop up the leaves with both arms and dump them into a wheelbarrow.   And do not forget that pushing the wheelbarrow is another natural activity that provides therapeutic benefit.

Pumpkins are not just for decoration these days.  They are a nice way to increase the fun to your activities, providing a great amount of ‘heavy work’.  Have your child carry them from one end of the yard to the other in a race, load up a wagon to push or pull them around the yard, or use them to set up an obstacle that they have to wheelbarrow walk, skip, or do an animal walk around (ie. crab, bear, etc).   Arrange some bales of hay for them to set the pumpkins up on. This is a great way to get some extra lifting while strengthening the shoulders.  In addition, the bales of hay are fun to for them to climb and jump off, providing some nice overall proprioceptive input.  Pumpkins can be used for a fun bowling activity, providing a bit more of a challenge then using a ball.

Have a daily costume party by having your child pretend to be a mummy.  Lay them on an outstretched blanket and then roll them up tightly, as you would to be a hot dog or burrito, and you have an instant mummy .  Or use body socks to have her walk around as a monster.

For the older child, have him decorate a large pumpkin using hammer and nails (with adult supervision).  This is great for attention, focus, bilateral fine motor skills, and using the hammer to complete his design provides a nice amount of proprioceptive input
   
If you have the child who calms with fidgeting or tactile input, filling a large bin with popcorn kernels to run her hands through or to find small objects is both fun and exciting.  Get creative (and work on school work) by hiding foam shaped objects, such as leaves, pumpkins, ghosts, with letters or sight words on them so that they have to find them and then read them to you.

For those creative people, there are a ton of crafts and art activities that complete the Fall and Halloween seasons.  So, once you have done the calming activities and your child is regulated, pull out the materials to do some fun crafts to work on fine motor skills.  Utilizing tools such as bingo dobbers, corks, glitter glue sticks or medicine droppers for painting Fall scenes are both great for strengthening the fingers and hands, but also require a bit of ‘heavy work’.  Increase the calming effect by using a weighted lap pad, vest or other material.

Therefore, beauty of the season can help bring some ‘calmness’ to your life.  It goes without saying, that initially this is a tough time of year for all children with the increased amount of changes, as well as the amount of attention that is required to get through their days.  So take a few minutes to help your child get to the right level of “organization” to  have fun and be successful.

Utilizing Social Stories™ in Preparing for Back to School

Deanna Macioce, MS, OTR/L

For years authors have been writing books to help children through new situations.  For example, The Berenstain Bears collection, as well as many others, has a book for every type of situation; going to the dentist, the arrival of the new baby, and practically every holiday.  If you walk up and down an isle in the Children's section of any bookstore today, you will find an array of books featuring the first day of school, whether it be preschool, kindergarten, or just another year.  But when we take a look at our children with significant social difficulties or anxiety to new situations, we realize that sometimes those "off the shelf" books do not really hit home for them, especially if they take things very literally. That is where Social Stories™ become helpful when preparing with the transition of back to school.  They can be helpful in guiding children for riding the bus, participating in recess, eating lunch in the cafeteria, sitting during circle time, etc.

Carol Gray was the first to devise the concept of social stories in the early 1990s.  Based on her work with social stories, she states, "A Social Story™ describes a situation, skill, or concept in terms of relevant social cues, perspectives, and common responses in a specifically defined style and format. The goal of a Social Story™ is to share accurate social information in a patient and reassuring manner that is easily understood by its audience. Half of all Social Stories™ developed should affirm something that an individual does well. Although the goal of a Social Story™ should never be to change the individual's behavior, that individual's improved understanding of events and expectations may lead to more effective responses."   Therefore, it is important that a story not be used in a uniform situation for a group of children, rather it should be developed and used on an individual basis.  To develop a useful and accurate social story, the individual's needs, behaviors and responses need to be assessed so that it can truly depict the difficulty the child is having. (www.thegraycenter.org).

Social stories stem from a Speech/Language background, but are used within all realms of therapy and education.  However, very often many parents and professionals are fully aware that the concept exists and their success. The Gray Center website offers a lot of hints, suggestions, and instructions for developing an effective social story.  In addition, it provides some sample stories used in some common situations.

Often times we find professionals have simply just developed stories about new situations that do not focus on the social aspects, but introduces the child to them and what to expect.  These can be just as useful and effective.  In addition, it has been found that some parents/professionals have even taken one of those books "off the shelf" books of a child's favorite character and inserted the child's picture and name into the book, increasing the interest for the child. Just as we work together as a team to develop sensory diets, we also need to work as a team to effectively help our children deal with the changes of school.  Whether it be their first year, or just a new year with new schedules, teachers and friends, it is our role to help them make it through the initial hump. Most children on the Autism Spectrum, and those with sensory or anxiety issues benefit from some help in preparing for everything the new school year has to offer.

So, as we pack the book bags with all the supplies, fill the closets with the new wardrobe, let us not forget about the importance of building up their confidence and decreasing their anxiety as we start off another school year.

Filling Up on the Right Tools for Success

Deanna Macioce, MS, OTR/L

It goes without saying that you would not try to take a road trip across country without having your car fueled, the proper amount of oil, or working brakes.  Or you would not go backpacking across Europe without hiking boots, a backpack, and the daily essentials.  So, let’s look at things on a smaller scale, why do we not prepare our children with the proper tools and “fuel” to get through the day.  Too many times, especially in the school environment we hear that “there isn’t enough funds for sensory equipment” or “sensory needs are not very important at school”.  BUT THEY ARE.  In essence we are setting our children up to fail, or even more, have to work harder by not having proper sensory diets developed and in place for staff and parents to carryout. 

Children with sensory processing disorder, those on the Autism Spectrum, or children who struggle with attention and self-regulation, need to have the right tools in order to be successful.  That starts with the right sensory diet.   When developed properly and strategically, a sensory diet is more than just a few suggested activities for your child. It should be individualized and developed with your child’s needs, routine, environment, and resources taken into consideration.  Therefore, it requires a team approach, gathering input from all members. 

Too often we find that sensory diets are not developed, let alone carried out.  And there are many reasons behind this.  Whether it be not enough time to develop it, staff or family not having the time or knowledge to implement it, or a child’s lack of interest, there seems to be a reason of why it does not happen.  But if we work together as a team, we will find that it can be done, it should be done, and in return we are helping a child be more success, learn with greater ease, and tolerate the day much easier (for the child, parents, and staff).

First, team members should help complete a behavioral analysis throughout the child’s day.  This will help establish both the routine, and begin looking at his or her needs.  From there, the occupational therapist can help establish some strategies and activities that need to be utilized. In working with the staff and parents, the therapist can determine what will work based on time and other factors during that portion of the day.  For example, it cannot be expected that Mom will be able to do a 10 minute one-on-one task in the morning when she is trying to get three children breakfast, pack lunches, do the send off to school, as well as getting herself ready for work.  Once the strategies and tasks are determined, the therapist can then develop the diet, providing proper instructions, materials and pictures as needed.  In addition, all members of the team need to be trained on their portion of the diet.  For example, it Johnny will need to have an oral protocol completed before lunch, just providing a NUK brush to the aide will not do the trick.  If a team member is confused or feels as if he or she does not know what to do, they will be less likely to carry out the task.  Although time consuming, training and instruction needs to be completed.  Once the diet is developed, everyone is trained and on board, it is time to implement.   Ongoing assessment and changes need to be done based on needs and behaviors.  The occupational therapist should be in charge of making sure new team members are trained, behaviors and needs are assessed and to make changes to the diet as need be. 

And you do not have to have the sensory room complete with equipment to develop an effective diet.  Sometimes that requires extra time transitioning a child in and out of the classroom.  Spark a little creativity…there are plenty of resources both in books and online to help develop activities that are easy to naturally bake in to what is already happening at that point in the day.  Teachers and staff need to be willing to share realistically what can be done in the school environment, but also need to be flexible based on what the child’s needs are.  Remember, the team is only trying to help the child tolerate the day, changes in routines, and be more successful!

So, as we round the corner and begin our back to school shopping and preparations, let’s take the time to fully develop our child’s sensory diet.  Without it, is like sending your child to school “out of gas”!

Water, Water, Water... Everywhere!

Deanna Macioce, MS, OTR/L

Playing in water is a fun part of summer play and a great way to beat the heat on those hot summer days.  For most, it is the type of play that is not allowed in the house, so now is the time to incorporate these activities that offer an array of therapeutic benefit into your sensory diet.

Let’s start with the one that offers some of the most therapeutic benefit-swimming.  Swimming is a great way to provide proprioceptive input and helps with overall body awareness.  Even if your child is not yet able to swim, just providing play in the water is beneficial. So, get a bucket and let them scoop and dump the water while hanging out in the pool.  The activity of actual swimming offers great core strengthening and motor planning.  Moving through the various swim strokes addresses bilateral coordination, as well as reciprocated body movements.  Getting in a pool this summer will be therapeutically beneficial to any child, and a lot of fun.

Just as there are sensory bucket activities with beans, rice, and others items to help incorporate tactile play, there is no reason why water cannot be one of those items.  Water tables and bucket playing offers a tactile media for kids to have a splash in. Increase the fun by having the child scrub cars at the car wash or bath their dolls using shaving cream and then rinsing off in the water table.  Let this summer be the perfect time to get messy!

To address those fine and visual motor needs, have your child use water squirters or shooters for target playing.  From water guns and blasters, to the small hand squirters, everyone’s needs can be met.  Set up a target range, or use a beanbag toss board to have children work on hand-eye coordination by aiming the water at the particular target. For improving fine motor strength, use water guns of various sizes for trigger pulling.  In addition, this activity will help with increasing finger flexion and hand strength needed most for tasks such as handwriting and scissor use.   Using the smaller character or animal squirters are ideal for your younger children or those with a more immature grasp to address grasp and finger strength.

And you can always include stroke, letter, and shape making with water play.  Fill up a bucket and using a paintbrush, have children draw and copy strokes.  Tracing can be provided by drawing the shapes or letters on the cement with sidewalk chalk, and then allowing the child erase it with the paint brush.  With this activity, you can work on shoulder, elbow and wrist stability by having them pretend to “paint” a wall, house, etc. in the vertical position, and you may even get some cleaning done in the process.

Cooling off in a sprinkler or at the spray park allows children some gross motor playtime, with a different tactile experience.  Based on the set up the sprinkler, this activity is an ideal way to work on direction following and motor planning.  In addition, it is these activities allow for peer interaction.

So no matter how you choose to cool off this summer, make water play a way to improve your child’s sensory diet with activities that you cannot do during those cold winter months!

Products in Motion: Southpaw's Cocoon Swing

Dr. Catherine Hoyt OTD, OTR/L

In pediatric occupational therapy, we focus on participation in skills and activities appropriate for the age and developmental level of the child. We also have to consider what is important to our client; which in pediatrics is the child as well as the family.  Addressing the child's needs and the family's goals can sometimes be a challenge. The appropriate equipment can help us to foster adaptive responses to engage the child in play, the main occupation of children.

For one 4 year old child, John, his family really wanted him to be able to play with children his age doing typical pre-kindergarten activities such as finger painting, swinging, listening to music, attending large parties and eating treats. John is a happy, energetic and bright little boy, but some of these experiences caused him a lot of anxiety and he would say things like "I'm afraid I won't like it" or "I'm scared".   John was scared of going into any space that was at all dark or restrained his movement in any way.

We used the Cocoon Swing because it provided an experience where he was able to challenge himself while still feeling safe. The swing let him sit comfortably and have a bit of reduced lighting while still being able to see out.  The Cocoon Swing also let him experience a bit of pressure from the fabric of the swing but still have the flexibility to move his body.  The Cocoon Swing was a little scary to him at first, but he was able to manage that anxiety because it provides the just right amount of comfort by being able to see through the fabric and out the top. It also provided the deep pressure around his body, which was calming to him. It helped John develop the capacity to challenge his fears knowing that he is able to overcome them.  John continues to face challenging activities and he is still learning,  but this swing has helped us move forward in therapy.

Bike Riding: Stacking the Blocks to Success

Deanna Macioce, MS, OTR/L

Whether you are driving through your neighborhood, the local park, or down a busy avenue, you will almost always catch someone riding a bike.  Bike riding is a universal activity that is enjoyed by people both big and small.  We tend to think that it is a rite of passage during childhood, moving from training wheels to the ultimate two-wheeler, and often hear the phrase, "it is as easy as riding a bike".  However, that is not the case at all.  Bike riding is one of the most complex activities to master, and for our children with sensory processing difficulties and special needs, it appears to be as challenging as climbing Mount Everest.  May is National Bike Month, and with summer sneaking around the corner, it is the perfect time to focus on this. 

If we take a look at the 'building blocks' to bike riding we see that it involves much more than just progression, growth and development.  Bike riding entails balance, bilateral coordination, trunk and shoulder stability and visual skills, as well as the cognitive abilities to discern safety and direction following. Therefore, we need to be cautious and aware of where the break down of skills are for our children before we just plop them on the seat and tell them to "go".  And we need to ensure their comfort level so that we keep them feeling safe and not losing their confidence. 

Improving a child's core stability, including trunk and shoulder control will help enhance his or her overall balance, which is required for successful bike riding.  This is where many of those therapy ball activities come into play, both in upright sitting and the prone position.  In addition, utilizing the bolster or disk swing helps with improving trunk control, while offering a bit of movement.  Increasing the challenge to the task by including a hand-eye coordination activity is always beneficial for incorporating the necessary visual skills for success.  T-stool and scooter board activities, as well as wheelbarrow and animal walks are just a few other ways to help improve this 'building block'.

When looking at balance, performing activities on a balance board or disk can be beneficial.  Especially those that require a good amount of weight shifting, such as obtaining bean bags from the floor and then having the child toss them into a target.  Performing activities that encourage one-foot balance and utilizing balance beams are quick and easy ways to address this 'building block'.

Bilateral coordination can be addressed with a variety of activities, but those that encourage reciprocated movement are ideal, such as climbing a rock wall, ladder, or rope pulls.  In addition, the Pedal Walker is a great way to help children get the feel and movement pattern needed for pedaling a bike.  Cross-crawls, jumping jacks, and reciprocated jumps are quick and easy and can be done in any environment.

Visual skills often are the ones that tend to impede success.  It is not easy to steer a bike while looking at the ground, as well as visual skills are apparent for balance.  Strengthening them can be incorporated into almost an activity.  As mentioned above, those that require hand-eye coordination while the rest of the body is doing something are most beneficial.  Activities that entail keeping the head upright should be utilized, including target throwing and ball catching.

With just a few suggestions to help improve the 'building block' skills, once these components are strengthened, it is time to work on removing those training wheels.  It goes without saying, but it is always important to make sure that the safety gear is on, including helmet and pads, both elbow and knee.  It is important to show your child how to stop the bike, using his or her feet to regain balance and control.  And do not be afraid to let them feel what it is like to fall.  This will take away some of the fear when it happens, because, it will! Starting off in a grassy area is ideal, and sometimes using a spot with a slight slope will give them both natural movement and encourage them to learn how to use the breaking system. 

Bike riding is not just a physical activity that offers movement and exercise it also allows individuals mobility to get around, socialization with peers, and the ability to explore.  Therefore, finding other options to help your child get the bike riding experience, such as a specialized tricycle, the Southpaw Hand Cycle, or a youth trailer cycle that attaches to the back of an adult's bike, such as the WeeRide Co-Pilot, may be beneficial.

So, now is the time to stack those building blocks, helping our children to get out there and enjoy the fun of bike riding....Happy Trails!

The Changing Face of Autism

Deanna Macioce, MS, OTR/L

1 in 250…Those were the statistics when I started life as an occupational therapist.  Autism was something that we touched upon during school, but not much different than Cerebral Palsy or Down Syndrome.  And now the numbers are reported at 1 in 50. I have been a pediatric OT treating in a variety of areas, homes, schools, clinic based, and in the community for over 10 years.  However, the face of Autism has changed and intensified during these years.  And based on these numbers, it should not be a surprise that Autism has actually shaped and developed me as a therapist and a person; just as it has our schools, daycares, and so many community programs.

I still remember the first child on my caseload that had the Autism diagnosis. As a new graduate, there was so much that intrigued me and I wanted to learn everything that I could about the child and the diagnosis.  I was thirsting for the knowledge and ready to eat it up.  And although there were many resources, the information often was still vague, and there was not the mass quantity that there is available today.   Websites and organizations such as Autism Speaks, were not yet developed, as well as the knowledge and technology were definitely not where they are today.

In addition, I often reflect on the first parents I worked with trying to figure out why their child seemed “different”.  For one family, it was a child at almost 3 years old that showed no interest in opening up any present at Christmas, or knew the exact route Mom needed to take home from daycare; a daycare that never worked with a child on the spectrum.  For another family, it was a daughter who had a toy room filled with toys, but never interacted to engage in play with any of them.  For me, these were difficult situations, but growing ones.  A major challenge then was that these parents never heard of the word Autism.  They had no clue what characteristics would put their child on the spectrum.  Autism then was not known like it was today.  Therefore, it made the process a bit more difficult and definitely longer.  Today, it appears that we almost all know someone who loves a child with Autism, as well as medical staff, teachers, and daycare workers are all being educated and informed in order to better understand and care for our children.

Today, with increased knowledge and learning about Autism, the signs and symptoms have changed and have become more specific.  The Autism Speaks website (www.autismspeaks.org) list the “red flags” for the possibility of being at risk:

•    No big smiles or other warm, joyful expressions by six months or thereafter
•    No back-and-forth sharing of sounds, smiles or other facial expressions by nine months
•    No babbling by 12 months
•    No back-and-forth gestures such as pointing, showing, reaching or waving by 12 months
•    No words by 16 months
•    No meaningful, two-word phrases (not including imitating or repeating) by 24 months
•    Any loss of speech, babbling or social skills at any age

It also offers parents and caregivers the opportunity to complete a screening, the Modified Checklist for Autism in Toddlers (M-Chat), which is a great way for parents to take a quick look at some developmental skills that should be occurring, and indicate whether or not their child is meeting them.  Because, as parents, sometimes we are not fully aware of what is expected of a child at a certain developmental stage.

As an OT, my theoretic knowledge to treat these children is rooted in sensory integration or Sensory Processing Disorder (SPD). The SPD and STAR Center website states, “more than 75% of children with autistic spectrum disorders (ASD) have significant symptoms of SPD. However, the reverse is not true. Most children with SPD do not have an autistic spectrum disorder” (www.spdfoundation.net).  They also note that by “addressing sensory features (it) is foundational to improving the social and communication problems of children with Autism.”   This is why OTs, with many others help make of the team of people ideal to work with these children.

I like to look at who the child is, and not the “label” he or she carries when developing a treatment plan.  So, therefore it is important to look at where the family is and what their needs are at that point in time at home, in the school, and with whatever community interaction the child has. In my years of treating, I have addressed the concerns and developmental needs of toddlers and young children, however spanning over 10 years much of my focus has now been on school-aged children up through young adults, changing the needs and focus for both these children and the families.

For me, Autism has been part of my “job”, but it has also been a journey.  For the past 5 years, I can honestly say that Autism has shown itself more than 90% of the time on my caseload.  And although I am not a parent of a child on the spectrum, I am a person who has been touched by this diagnosis.  I have walked this journey with many parents and caregivers, and am so thankful for all that they taught me.  As an individual and therapist, I have learned to listen and support these families.  Truly understanding what their concerns are and what they need to function as a family. I know I am only a “stop” on their journey and there are many more that they will make, but while they are “visiting” me, I hope to use my knowledge, skills, and therapeutic use of self to make a difference.    

Returning to the Roots of OT

Deanna Macioce, MS, OTR/L

The history of treatment in the profession of occupational therapy found itself rooted in the use of crafts.   Therapists used a variety of crafts to help improve the fine motor, visual motor, coordination, and mental capabilities, as well as others of individuals.  They were a way to assist in improving an individual’s ability to perform their “daily occupations”.  However, due to the demands of insurance companies and the increased focus of “functional activities” you no longer see crafts being using in traditional therapy settings such as hospitals, clinics, and nursing homes.  Crafts were an ideal way to perform task analysis and devise a treatment activity that would address an individual’s need based on a variety of problem areas rather than just one specific activity. 

In the area of pediatrics, occupational therapists focus on the “functional” activities of children.  This includes, play, self-care, behavioral, and educational concerns.  Therefore, it can be easier to justify the use of crafts.

Just as in the ‘old’ days, crafts can cover a wide range of skills and can be adapted to address the various needs of children, while still focusing on their functional activities. The same craft can typically be graded, even if only in positioning and set up, to address most children on a therapist’s caseload.  From sensory needs, fine motor and visual motor skills to bilateral coordination, sequencing, and attention skills, crafts can do it all.

 Tactile sensory skills can be addressed with finger painting, doing hand and foot print crafts, and using glue, as well as using stickers, foam pieces or sequence. 

Both fine motor and dexterity skills can be address by gluing small objects such as marshmallows, dried pasta or pieces to complete a paper lion.  Increase the challenge by having the child use tongs to obtain the objects if grip and strength are part of the treatment plan.  Ripping small squares off a strip of paper to glue onto a template such as a heart, balloon or pumpkin helps to improve the use of the pincer grasp while encouraging bilateral hand skills needed for higher functioning activities.   In addition, the use of crayons, markers, and paint brushes for drawing and coloring help improve hand-eye coordination and visual motor skills, as wells grasp and hand endurance.

Scissor skills can be addressed initially to make snips for grass, a lion’s mane, or the petals on a flower.  Then moving to lines, shapes, and templates.  In addition, changing the type of paper used, such as construction paper versus card stock.

Attention, sequencing, and modeling skills can be addressed through the presentation of the craft and how the directions are delivered.  For some, you may provide just the model and the pieces, and have them form it, while others you may have directions just written out.  Doing the necessary sensory preparation for regulation and organization makes these activities even more fully encompassing of a treatment plan.

So, as we move into to April celebrating Occupational Therapy Month, it is a great time to go back to our roots encouraging the use of crafts in our treatments.  Not to mention it is fun, creative and they make great keepsakes. 

Why use Vibro-acoustics as part of your MSE treatment?

Linda Messbauer,  OTR/L

First, Vibro-acoustics is a process using two sensory systems in the body; the auditory and the touch system.  The response to the music through the auditory system is pleasurable based on the individual’s tastes and preferences in music or that which is meaningful to them.  But it is the touch system that plays a major role in response to the vibration and the one that will be discussed here.  Think about it, the skin is really the largest organ in the body with more receptors than any other sensory system.  Skin is the boundary between “Me” and “Not Me” and the “container” for all function, whether that be our organs or skeletal system. It provides our physical connection to the world and serves to keep us comfortable and safe.

One postage stamp size piece of skin contains:  9’ of blood vessels, 30 hairs, 300 sweat glands, 4 oil glands, 13 yards of nerves,  9,000 nerve endings, 6 cold sensors, 36 heat sensors, 75 pressure sensors and 600 pain sensors*¹…WOW

One of the sensory receptors is the Pacinian Corpuscles which is a type of mechanoreceptor. It is located in connective tissue of bone, body wall and body cavity. Depending on its location it can be cutaneous (skin), proprioceptive (pressure & movement) or visceral (organs).  It is sensitive to vibration and pressure; it transmits vibration to the brain to allow perception of distant events and is also part of tactile discrimination for feeling smoothness and textures.  It is considered “rapid adapting” meaning its firing potential is generated when force is first applied, and then becomes unresponsive to steady pressure.

Why is this important to know? Well, when using it to affect change of the human reaction to stimuli, we need to be cognizant of keeping variation or novelty occurring to keep the receptor firing. When vibro-acoustic equipment is utilized the music provides the novelty and variation to promote the firing of the receptor. And when the person moves, for example taps their foot to the beat, they receive more input. We know that when two sensory inputs are simultaneously combined the brain gets more than the summation of the two inputs. It also gets secondary and tertiary areas of the brain involved.  “Voila” as the French say, we are getting more potential synapses and possible neuroplasticity and this of course, is what we want. It also feels good to most people.

So why incorporate Vibro-acoustic equipment into your MSE? Using Vibro-acoustic equipment  increases the potential for changing the Brain and as a result, our behavior or response.

Studies have also shown that Vibro-acoustics contributes to:

• Reduce stress
• Facilitate the Relaxation Response
• Decrease pain
• Relax muscular hyper-tonicity
• Increase communication potential
• Increase  social engagement
• Promote muscle tone
• Increase range of motion

As with any form of new experience it should always be voluntary. With individuals who cannot verbalize their likes or dislikes, it is imperative to keenly observe their response. In my experience a facial expression in less than 3 seconds will tell you they don’t like it or it is too much. This has occurred only a very few times but, the aim here is to promote joy and fun and this equipment certainly does that.

Some precautionary information:

Always know your client; some contraindications include individuals with pacemakers, thrombus, active bleeding disorders, extreme low blood pressure, severe PDST or psychotic episodes. When in doubt, always consult a physician.

1* Credited to Patricia Wilbarger, M.Ed, OTR, FAOTA

References: Music and Spatial-Temporal Relationships, Rausher, FH, et al., Neurological Research, 19, 2-8

                        Molecular mechanisms of mechanotransduction in mammalian sensory neurons, Nature Reviews Neuroscience 2011 March

                        Somatosensory Systems, Neuroscience Online, UTA.tmc.edu