'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.