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
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)
9. U.S. School-Based O.T. Process
Team
Meeting
Individual
Education Plan
(IEP)
Monitor
&
Report
Evaluation
Re-
Evaluation
Referral
Discharge
Intervention
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
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)
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
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)
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)
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)
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
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
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
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Amundson, S. J. (1995). Evaluation Tool of Children's Handwriting: ETCH
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Beery, K. E., & Beery, N. A. (2004). Beery VMI administration, scoring,
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Bruininks, R. H. (2005). Bruininks-Oseretsky Test of Motor Proficiency
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60. References:(3 of 4)
Dunn, W. (1999). Sensory Profile. U.S.: The Psychological Corporation.
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Olsen, J. Z. (1994). Handwriting Without Tears, workshop
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61. References:(4 of 4)
Olsen, J. Z. (2009). The Printing Tool. MD.: Handwriting without tears, Jan
Z. Olsen.
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