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

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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.

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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

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Guides to my practice

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

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

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

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Response to Intervention: 3 Tiers

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

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Tools & Techniques

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

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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

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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

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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

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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

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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

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The Student’s Educational Team Parents Therapist(s) TeachersStudent Para-Educators Administrator

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

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

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Posture Intervention: Key ConceptsDo seatwork after ―heavy work‖ (gym, playground, etc.) and movement experiencesWork 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)

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

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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

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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

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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

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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)

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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 forearms natural position  Beginner printers can start with the paper on a horizontal plane (Sources: Pape &Ryba, 2004 and Olsen, 1994)

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

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Stability and Control: Hand (Grasp)  Typical children use static or dynamic tripod or quadripod grasp by age 5 Mature Tripod Quadripod  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

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Common Incorrect Grasps Tower Thumb Wrap Index tucked, Trap Grasp Grips Trap Grasp Fisted Grasp Extended Finger Grasp Extended Finger, Ungrounded Forearm

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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)

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Grasp Intervention: Training Activities Pegs Coin Activities Color-forms Kitchen GadgetsTweezers Putty Coins

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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)

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Grasp Intervention: Gripper Tools Stetro Grip The Pencil Grip ThePencil Grip Handiwriter Handiwriter

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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)

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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)

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

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Bilateral Integration: Activities Handwriting Coin Flips Geo-Board Etch-a-Sketch Toy Putty Specialized Games

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Bilateral Integration: Activities Jump Rope Lazy-Eights Parachute Mini-Tramp Crazy Clock Scooter Suspended Ball

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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 + / 

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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)

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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

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

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Visual Motor Intervention:Chalkboard Activities Circle Drawings Square Drawings

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

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Visual Motor Intervention: ChalkboardActivities Train Tracks Fire-fighters Wallpaper (Adapted from Chalkboard Fun, Sena, 1996)

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Visual Motor Intervention: Activities Sign-In Activity (Olsen, 2003)

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

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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)

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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

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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)

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

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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

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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 (Legos etc.)

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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)

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

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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

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QUESTIONS?

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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

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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 Childrens 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: Users 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.

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References: (3 of 4) Dunn, W. (1999). Sensory Profile. U.S.: The Psychological Corporation. Dunn, W. (2006). Sensory Profile School Companion: Users 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 teachers guide. Cabin John, MD.: Handwriting Without Tears, Jan Z. Olsen.

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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 examiners manual. Austin: pro-ed. Richards, R. M. (1988). Classroom visual activities. Novato, CA: Academic Therapy Publications. Sena, L. (1996). Chalk-Board fun. Bisbee, AZ: Imaginart Press. Williams, M. S., & Shellenberger, S. (1996). How does your engine run?: A leaders 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.