1. Presenter: Amy Carroll, OTR/L
LEAP Occupational Therapy
Carroll.amyp@gmail.com
OTICON 2012, Goa, India
16 January 2012

2. About Amy Carroll
 OTR/L
 NBCOT
 25+ years experience working in public schools
(government schools)
 20+ years experience as private practitioner
 Advanced training in Sensory Integration &
Interactive Metronome
 O.T. Doctorate student at Thomas Jefferson
University in Philadelphia, U.S.

3. Presentation Overview
 Occupational Therapy in School Settings
 Guidelines for my practice (AOTA & U.S. Law)
 O.T. Role in U.S. Schools
 OT Process in schools
 Intervention for Children with Learning Disabilities
 Evaluations
 Common Issues
 Specific Intervention Activities & Tools

4. Guides to my practice

5. Adapted from: AmericanOccupational
Therapy Association, 2008
O.T.
DOMAIN
Occupation
Performance
Skills
Performance
Patterns
Client
Factors
Activity
Demands
Environment
& Context
AOTA Practice Framework: O.T. Domain

6. Guide to Practice:
U.S. Law Related to Special Ed. and School-Based O.T.
1960s
1970s
1980s:
1990:s
Source: Pape & Ryba, 2004
Individuals with
Disabilities
Education
Act
OT: a “related service” within special education
Education
for the
Handicapped
Act
2004

7. General structures for service:
Clinical vs. School-Based
 In clinic, hospital, private
practice
 Sensory Integration (SI)
 Neuro-developmental
treatment (NDT)
 Listening Programs
• In school: classroom,
gym, cafeteria, etc.
• Sensory Regulation
• Principles of NDT
• Develop. Activities
• Practical tools and
techniques
• Assistive technology
Clinical:
(treat, remediate)
Schools
(access, benefit, participate)

8. Response to Intervention: 3 Tiers

9. U.S. School-Based O.T. Process
Team
Meeting
Individual
Education Plan
(IEP)
Monitor
&
Report
Evaluation
Re-
Evaluation
Referral
Discharge
Intervention

10. Tools & Techniques

11. U.S. School-Based O.T. Process
Team
Meeting
Individual
Education Plan
(IEP)
Monitor
&
Report
Evaluation
Re-
Evaluation
Referral
Discharge
Intervention

12. Students with Learning Disabilities:
Common Areas of Concern for Referrals
• Handwriting
• Work completion
• Fine-motor skills
• Lack of Self-Regulation
• Poor Attention
• Behavior Management Issues
• Disorganization
• Social Skills and social participation
• Academic Issues (reading, math, etc.)
• Transitions from school to the work world

13. Students with Learning Disabilities:
Evaluation Process
 Understand referral
 Discuss with teachers, parents, or school psychologist
 Gather relevant background information
 Observe child in various natural school settings
 Consider potential problem and root cause
 Administer assessment tools

14. Students with Learning Disabilities:
Primary Assessment Tools (1 of 3)
 Occupational Profiles/ Inventories:
 Canadian Occupational Performance Measure
 School Function Assessment
 Handwriting Assessment
 Evaluation Tool of Children’s Handwriting
 The Print Tool
 WOLD Sentence Copying Test

15. Students with Learning Disabilities:
Primary Assessment Tools (2 of 3)
 Visual Perception
 Motor-Free Visual Perception Test 3
 Test of Visual Perceptual Skills, Revised
 Visual Motor/Visual Perception
 Beery VMI 5th edition
 The Developmental Test of Visual Perception 2

16. Students with Learning Disabilities:
Primary Assessment Tools (3 of 3)
• Fine Motor / Visual Motor
• Bruininks- Oseretsky Test of Motor Proficiency 2
• PDMS-2: Peabody Developmental Motor Scales,
Second Edition
• Sensory Processing / Sensory Modulation
• Sensory Profile
• Sensory Profile School Companion
• Adolescent/Adult Sensory Profile
• Sensory Processing Measure

17. The Student’s Educational Team
Student
Para-Educators
Teachers
Parents Therapist(s)
Administrator

18.  Stability and motor control
 posture, shoulder, wrist, grasp
 Bilateral integration
 Visual skills
 Sensory regulation/modulation
 Praxis
 Organization
Students with L.D.:
Common Issues Requiring Intervention

19. Stability and Control: Posture
 Stable posture is important for desk work
Hips: 90°
Knees: 90°
Ankles: 90°
90 – 90 SITTING
POSTURE

20. Posture Intervention: Key Concepts
Do seatwork after ―heavy work‖ (gym, playground,
etc.) and movement experiences
Work for brief periods, and in different positions
• Sit at desk, bean bag chair, on a therapy ball
• Standing at the blackboard or an easel
• Prone with pillow under chest
• short periods initially (i.e. 5 min)

21. Posture Intervention: Activities
Lazy 8’s
Prone over a ball
Parachute
Scooter
Mini-
Trampoline

22. Posture Intervention: Common Tools
 Desk top slant boards
 Recommended slant = 20°
 3-inch binder is an inexpensive substitute
 Move-n-Sit / Wedge Cushion
 Encourages upright sitting posture
 Allows for subtle movement
 Therapy ball

23. Stability and Control: Shoulder
 Shoulder stability is needed for fine-motor
control
 Signs of decreased shoulder stability:
Shoulder hiking
Scapula winging
Arms and wrists not grounded when writing

24. Shoulder Intervention
Key Concepts
 Same as many postural intervention activities
 Use activities requiring heavy work in the shoulder
area
 Animal walks, wheelbarrow walking, etc.
 Chair pushups
 Prone on elbows (lying on stomach)
 Writing on the chalkboard –vertical surface
Common Tools
 Slant board
 Desktop easel

25. Stability and Control: Wrist
 Wrist should be in slightly extended or
neutral position
 Good wrist position supports mature grasp
 Stable wrist position necessary for speed &
precision
 Flexed wrist position is not functional
(Benbow, 2000)

26. Wrist Intervention: Key Concepts
 Use vertical work surfaces
 chalkboard or easels
 Slant board
 Lean forearm and wrist against the blackboard
 Keep activity at the child’s eye level
 Paper position affects wrist position
 Paper parallel (~ 30° angle) to the writing forearm's
natural position
 Beginner printers can start with the paper on a
horizontal plane
(Sources: Pape &Ryba, 2004 and Olsen, 1994)

27. Wrist Intervention: Common Tools
 6-inch piece of masking tape slanted 30°
 For consistency and spatial organization
 Slant Board
 Encourages proper wrist position

28. Stability and Control: Hand (Grasp)
 Typical children use static or dynamic tripod or
quadripod grasp by age 5
 By age 6 or 7, most children can write or draw
using the intrinsic muscle movements of the fingers
 Hands stabilized to allow refined finger movement,
rather than wrist / arm movements
MatureTripod Quadripod

29. Common Incorrect Grasps
Tower
Grips
ThumbWrap Index tucked,
Trap Grasp
Trap Grasp
FistedGrasp Extended Finger Grasp
Extended
Finger,
Ungrounded
Forearm

30. Grasp Intervention: Key Concepts
 Look for the open circle web space to quickly identify the
quality of a grasp
 Allow preschool children to explore
 Different patterns of grasping
 Different drawing & writing tools
 Encourage achievement of milestones to develop hand
 Arches
 Wrist extension
 Skilled vs. stable sides of hand (A-OK grasp)
 Finger muscle movement
(Case-Smith & Pehoski, 1992; Benbow 2000; Olsen, 2003)

31. Grasp Intervention: Training Activities
Tweezers
Coins
Color-formsCoinActivitiesPegs
Putty
KitchenGadgets

32. Grasp Intervention: Grip Pressure
 Focus on:
 Stability and control more proximally
 Fine motor control and quality of the grip
 Intervention Activities:
 Open non-dominant hand on the desk
 Squeeze a ball in non-dominant hand
 Line-up dominoes
 Pick-up fragile objects with fingers or tweezers
 Drop a specific number of drops from an eyedropper
(Case-Smith & Pehoski, 1992; Benbow 2000; Olsen, 2003)

33. Grasp Intervention: Gripper Tools
The
Pencil
Grip
Stetro Grip
Handiwriter
The PencilGrip
Handiwriter

34. Bilateral Integration: Dominance
• Most children have dominance before school age
• If no dominance in preschool or kindergarten:
• Hold a bit on pencil paper tasks
• Observe to see a pattern emerging
• If no preference emerges by age 7, some specialists
suggest encouraging right hand dominance (most
common). I have always allowed the dominance to
emerge.
• If dominance issues exist, the teacher should expect the
child to be less skilled for a time
( Benbow 2000; Olsen, 2003)

35. Bilateral Integration: Helping Hand
 Non-Dominant hand = helping hand
 Helping hand- essential for many school
 activities especially proper handwriting
 Stabilizes the paper
 An open helping hand often promotes a more
relaxed grasp
(Olsen, 1994)

36. Bilateral Integration: Common Tools
Dino-Ruler
Bow-Tie Board
Googly-Eyes
Clipboard
Googly - Eyes

37. Bilateral Integration: Activities
Coin Flips
Etch-a-SketchToy
Putty
Geo-Board
SpecializedGames
Handwriting

38. Bilateral Integration: Activities
Lazy-Eights
Mini-
Tramp
Parachute
Jump
Rope
Suspended Ball
CrazyClock
Scooter

39. 4 Key Aspects of Vision
• Acuity (addressed by Dr.)
• Ocular- Motor
• Visual- Perception
• Visual-Motor Integration
 Note on Visual-Motor Integration:
 Diagonal lines develop later than vertical and horizontal
 Developmental sequence for design copying:
l — 0 + / 

40. Visual Intervention: Techniques
 Remove clutter to eliminate competing visual stimuli
 Highlight writing baseline, or important part of a ditto
 Reversals:
 Gray block paper or rectangle
 Letter formation patterns
 Spacing between letters:
 Exaggerate space between words
 The big nothing
 Finger in the space (often difficult)
 Encourage consistent letter formation habits
(Some ideas from Olsen, 1994)

41. Visual Intervention: Techniques
 Vertical and horizontal skills develop earlier than
diagonal skills
 Sometimes children do better when they learn
cursive
 continuous movement
 more developed foundation skills
 fresh start
Visual skills develop through movement

42. Visual Intervention: Activities
•Visual skills develop in concert with movement

43. Visual Motor Intervention:
Chalkboard Activities
Circle Drawings Square Drawings

44. Visual Motor Intervention:
Chalkboard Activities
Tangle RollerCoaster
Bubble Gum Machine (Adapted from Chalkboard Fun, Sena, 1996)
Paint the Fence

45. TrainTracks Fire-fighters
Wallpaper
(Adapted from Chalkboard Fun, Sena, 1996)
Visual Motor Intervention: Chalkboard
Activities

46. (Olsen, 2003)
Visual Motor Intervention: Activities
Sign-InActivity

47. Visual Intervention: Tools
 Vertical Surfaces
 Slant boards
 Adapted Paper
 Highlighted Ruler
BEST!
B- Bump the baseline
E- Easy to read letters
S- Spacing
T- Tall letters tall… small letters small
!- Punctuation!
(Carroll, 2003)
2 lined paper
“Best” Cue Card Shaded Paper
Stop-Go Paper
Highlight Ruler

48. Sensory Regulation / Modulation
 States of Alertness / States of Arousal
 Too High, Too Low, or Just Right
 ―Just Right‖ = settled and focused for learning
 Sensory regulation strategies = ―Sensory Diet‖
 Many times less stimulation is needed
 Allow quiet time-maybe a book or music in a bean bag
 Cubby or cave with comforting items
 Also Important to consider:
 Establish routines
 Warn of changes in routine
(Williams & Shellenberger, 1996)

49. Sensory Regulation Strategies & Tools
Sensory regulation strategies = “Sensory Diet”
 ―As needed‖ or at scheduled times
 Older children learn when and how to use strategies
 Heavy Work (see posture activities)
 Pushing & pulling activities
 Jumping & hopscotch, animal walks, obstacle course
 Squeezing foam ball , putty, clay
 Thumb-Wrestling
 ―Spiders on a mirror‖ / resistive toys
 Deep Pressure
 Compression clothing / lycra clothing
 Hot dog, massage, brushing

50. Sensory Regulation Strategies & Tools
 Heavy Oral Activities
 Sucking or mints or sour hard candy.
 Chewy candy (licorice, gummy bears), dried fruit,
gum
 Sipping from water bottles.
 Movement / Physical Activities
 Swings and scooter board, obstacle course
 Move’n Sit cushions
 Varying positions
 Sitting on a ball or small rocker
 ―Fidget‖ tools (plastic coils, squeeze balls, silly putty)

51. Sensory Regulation: Common Tools
Tennis Balls on Chair
Body Sock
Lap Buddy
Theraband on Chair
Bean Bag Break Area
Move-n-Sit Cushion
Rocker
Chair
Crash Pad

52. Praxis: Key Concepts
 Praxis = The ability to plan and execute new or
novel motor sequences
 Children with poor praxis commonly display:
 Difficulty establishing routines
 Difficulty with self care tasks (open locker
combination, managing belongings)
 Labored handwriting
 Difficulty or reluctance in gym and recess
 Requires more time to complete tasks
 Can be resistant to new activities

53. Praxis: Interventions
 Tactile and Proprioceptive activities (heavy work)
 Obstacle courses
 Play on playground equipment
 Scooter board activities
 Working with clay or putty, resistive mediums
 Multi-step projects
 Crafts
 Constructional toys (Lego's etc.)

54. Praxis: Tools & Techniques
 Break down instruction into steps
 Repeat directions and provide additional visual cues
 Demonstrate
 Desk Map
 Teach student to ―self talk‖ through a task
 Checklists for routines
 Social stories for routines
 Multisensory handwriting instruction for stroke sequences
 Consider early keyboarding
 Practice self care fasteners
 Lunch packages: parents can cut small hole to help child
open
 Pre-teach gross motor activities
(input from Pape & Ryba, 2004)

55. Organization: Intervention
 Establish routines for where items are stored
 Provide sensory cues for transitions - visual, tactile, sound
 Teach transition cycle:
Set-up
DoClean-
up
Plan
(Carroll, 2003)

56. Organization: Common Tools
 Color coded folders or labels
 Accordion Files
 Copy lid in desk drawer
 Trapper keepers
 Allow an extra space to store items
 Locker : organize books into a.m. and p.m.
 Desk Map: diagram of where things go
 Map of where classrooms are-color coded
 Consistent format with class work

57. QUESTIONS?

58. References (1 of 4)
 American Occupational Therapy Association. (2008). FAQ-Response-To-
Intervention. Retrieved 12 13, 2011, from AOTA:
http://www.aota.org/Practitioners/PracticeAreas/Pediatrics/Browse/S
chool/Copy%20of%20FAQ-Response-to-Intervention.aspx?FT=.pdf
 American Occupational Therapy Association. (2011). Occupational
Therapy in early Childhood and School-Based Settings. Retrieved
December 20, 2011, from AOTA: American Occupational Therapy
Association:
http://www.aota.org/Practitioners/PracticeAreas/Pediatrics/Highlight
s/40881.aspx?FT=.pdf
 American Occupational Therapy Association. (2010). Occupational
Therapy in School Settings. Retrieved January 2, 2012, from AOTA: The
American Occupational Therapy Association:
http://www.aota.org/Practitioners/PracticeAreas/Pediatrics/Fact-
Sheets-on-the-Role-of-OT/School.aspx?FT=.pdf

59. References (2 of 4)
 American Occupational Therapy Association. (2008). Occupational
therapy practice framework: Domain and process (2nd ed.). American
Journal of Occupational Therapy , 62, 625-683.
 Amundson, S. J. (1995). Evaluation Tool of Children's Handwriting: ETCH
examiners manual. Homer, Alaska: O.T. Kids.
 Ayres, A. J. (1988). Sensory integration and praxis tests. Los Angelos:
Western Psychological Services.
 Beery, K. E., & Beery, N. A. (2004). Beery VMI administration, scoring,
and teaching manual (5th ed.). Minneapolis: NCS Pearson, Inc.
 Brown, C. E., & Dunn, W. (2002). Adolescent/Adult Sensory Profile:
User's manual. San Antonio: Pearson.
 Bruininks, R. H. (2005). Bruininks-Oseretsky Test of Motor Proficiency
(2nd ed.). Circle Pines, MN: AGS Publishing.
 Case-Smith, J., & Pehoski, C. (1992). Development of hand skills in
children. Rockville: AOTA.
 Colarusso, R. P., & D., H. D. (2003). Motor-Free Visual Perception Test
(3rd ed.). Novato, CA: Academic Therapy Publications.
 Coster, W., Deeney, T. H., & Haley, S. (1998). School Function
Assessment. San Antonio : The Psychological Corporation.

60. References:(3 of 4)
 Dunn, W. (1999). Sensory Profile. U.S.: The Psychological Corporation.
 Dunn, W. (2006). Sensory Profile School Companion: User's manual.
USA: PsychCorp.
 Fewell, M. R. Peabody Developmental Motor Scales (2nd Edition).
 Gardner, M. F. (1996). Test of Visual-Perceptual Skills (n-m) Revised
manual. Hydesville, CA: Psychological and Educational Publications.
 Hammill, D. D., Pearson, N. A., & Voress, J. K. (1993). Developmental
Test of Visual Perception, second edition. Austin: pro-ed.
 Kuhaneck, H. M., Henry, D. A., & Gleenon, T. J. (2007). Sensory
processing measure. Los Angeles: Western Psychological Services.
 Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajkp, H., &
Pollock, N. (1994). Canadian Occupational Performance Measure
(second ed.). Toronto: CAOT.
 Olsen, J. Z. (1994). Handwriting Without Tears, workshop
 Olsen, J. Z. (2003). Pre-K teacher's guide. Cabin John, MD.: Handwriting
Without Tears, Jan Z. Olsen.

61. References:(4 of 4)
 Olsen, J. Z. (2009). The Printing Tool. MD.: Handwriting without tears, Jan
Z. Olsen.
 Pape, L., & Ryba, K. (2004). Roles of occupational therapy in the school
setting. In L. Pape, & K. Ryba, Practical considerations for school-based
occupational therapists (pp. 1-30). Bethesda: American Occupational
Therapy Association, Inc.
 Reynolds, C. R., Pearson, N. A., & Voress, J. K. (2002). DTVP-A
Developmental Test of Visual Perception: Adolescent and Adult examiner's
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 Richards, R. M. (1988). Classroom visual activities. Novato, CA: Academic
Therapy Publications.
 Sena, L. (1996). Chalk-Board fun. Bisbee, AZ: Imaginart Press.
 Williams, M. S., & Shellenberger, S. (1996). How does your engine run?: A
leader's guide to the alert program for self regulation. Albuquerque:
TherapyWorks, Inc.
 Wold, R. (1970). Screening tests to be used by the classroom teacher.
Novato, CA: Academic Therapy Publications.