FAQ´s: Occupational Therapy

1. What is attention?
   Attention is the ability to obtain and sustain appropriate attention to a task. This can be influenced by motivation, self-esteem, sensory integration and language difficulties. Effective attention is what allows us to screen out irrelevant stimulation in order to focus on the information that is important in the moment.

The main building blocks for attention include:

• Sensory processing
• Self regulation
• Receptive (understanding) Language
• Auditory processing difficulties
• Hearing impairment
• Learnt helplessness
• Limited motivation
• Environment
2. What are the necessary elements to build attention and how does Occupational Therapy help?

OTs combine consider all elements such as environmental factors, sensory related needs, and play skills to target attention from the child, tailoring these factors according to each individual child.

1. The teacher says my child is not holding the pencil the correct way. What can I do to correct it?
   Development in prewriting skills begins around 1 year of age when children are exploring with different writing tools – crayons, markers while scribbling and doodling. As children grow, their grasp on the writing tools become more refined and controlled. An occupational therapist is able to observe how the child holds a pencil and assess his or her control and how it impacts writing. Besides determining the type of grasp the child utilizes, considerations will be given to the child’s endurance, pressure on paper and upper stability. Occupational therapy intervention may include fine motor strengthening, development of age-appropriate grasp and endurance training, so as to facilitate the ease and legibility of writing.
   
2. My child does not like to color. When he colors, he just colors all over the paper. Sometimes he colors very hard and other times it is very light. What can I do?
   Coloring is a simple and fun activity that most children enjoy. However, when it is broken down, there are several components involved. Visual attention is required to locate the lines and boundaries between the different areas. Fine motor control is needed to color in different areas and still stay in the line. The ability to integrate sensory feedback from the paper is required to know how much pressure to apply when coloring. If the picture is large, endurance is required to finish coloring the entire area. Darkening or bolding the outline of the picture or figures with a marker increases the contrast and allows your child to become more visually aware of the spaces within. Coloring by numbers is a good way to way to limit the number of colors used (too many color pencils/crayon options may be distracting) and the numbers provide a visual cue to the boundaries and what colors to use where. An occupational therapist would be able to identify which specific area your child is struggling with and provide strategies to try at home.
   
3. I cannot tell if my child is left-handed or right-handed. Sometimes he uses his left hand, but then he would switch half way. Should I force him to use one hand over the over?
   It depends on how old your child is. During the early years, children use both hands to explore the environment and to manipulate things around them. Hand dominance begins to develop around 2 to 3 years and should be established around 5 to 6 years of age. It is recommended to allow children to use both hands (and to switch between both) in the early years to promote fine motor dexterity, bilateral coordination and integration. Switching hands during activities may be a sign of fatigue. A good indication of hand dominance is the quality of manipulation and dexterousness of each hand. An occupational therapist can assess your child’s fine motor skills and development, then suggest different activities to try at home.

What are gross motor skills?
Gross motor skills are larger movements your child makes with his arms, legs, feet, or his entire body. So crawling, running, and jumping are gross motor skills.

Why are gross motor skills important in a child’s development?
Gross motor skills are important to enable children to perform every day functions, such as walking, running, skipping, as well as playground skills (e.g. climbing) and sporting skills (e.g. catching, throwing and hitting a ball with a bat). Gross motor abilities also have an influence on other everyday functions. For example, a child’s ability to maintain table top posture (upper body support) will affect their ability to participate in fine motor skills (e.g. writing, drawing and cutting) and sitting upright to attend to class instruction, Gross motor skills impact on your endurance to cope with a full day of school.

My 7 years old child handwriting quality is very poor. His teacher always complains for his poor handwriting quality. How can I help him to improve it?
There may be many reasons for your child’s poor handwriting.  Firstly, children with sensory processing issues may have difficulties paying attention while participating in any table top task. They find handwriting tasks to be very challenging as they cannot stay focused on their task. Next issue could be related to your child’s visual motor integration (VMI) which includes both visual perception and motor coordination.   Handwriting will be affected if he has difficulties in any of these areas. Other reasons for difficulties with writing may be your child’s low body muscle tone, poor body posture, inappropriate pencil grip while writing and sometimes lack of motivation to write properly.

My child is 9 years old and he complains of frequent hand pain while writing a larger volume of work. How can I help him with this problem?
Children with improper pencil grips, especially applying too much pressure on the pencil to grip it while writing may trigger hand pain. Gripping the pencil with too much pressure results in muscle fatigue in hand muscles, thus causing hand pain. Another reason may be that your child’s proprioceptive senses (joint sense) is poor , and he may have difficulty in gauging how much pencil pressure is needed when gripping the pencil during handwriting.  As a result he or she uses too much pencil pressure and pain happens. Finally, your child’s hand muscle may be very weak, and as result s/he need to apply increased amounts of pressure on his hand muscle to hold the pencil properly.

What are the basic skills a child needs for preschool?
Your child should be able to respond to their name when called and be able to follow basic verbal instructions (such as sit down, give high-5). Your child should be able to indicate simple needs either by words, or taking an adult’s hand. In order to learn, he or she should also have joint attention with adults and other children. Your child should be able to sit for an age appropriate amount of time, such as the time needed to finish a short story book.  Your child should also have foundational social skills such as taking turns, waiting, and sharing.

How can I help prepare my child for transition to primary school?
Help your child prepare to follow instructions in a bigger group by enrolling him or her in group activities such as camps or drama classes. Encourage your child to be more organized by having him or her draw up simple visual schedules and follow through independently. Practice packing and unpacking a school bag, having your child self-check if all items have been packed into the bag. Your child should have simple money skills so that he or she can buy food during recess. Have your child practice buying and carrying a food tray at the food court. Handwriting demands are also increased, so make sure your child is able to write legibly with a good pencil grip.

What is Sensory Processing?
Sensory processing is the normal neurological process of organizing sensations for our use in everyday life. We use sensations to survive, to satisfy our desires, to learn, and to function smoothly. Our brains receive sensory information from our bodies and surroundings, interpret these messages, and organize our purposeful responses.

What are the red flags when a child is having sensory processing problem?

Infants and toddlers

• Problems eating or sleeping
• Refuses to go to anyone but their mom for comfort
• Irritable when being dressed; uncomfortable in clothes
• Rarely plays with toys
• Resists cuddling, arches away when held
• Cannot calm self
• Floppy or stiff body, motor delays

Pre-schoolers

• Over-sensitive to touch, noises, smells, other people
• Difficulty making friends
• Difficulty dressing, eating, sleeping, and/or toilet training
• Clumsy; poor motor skills; weak
• In constant motion; in everyone else’s  “face and space”
• Frequent or long temper tantrums

Grade-schoolers

• Over-sensitive to touch, noise, smells, other people
• Easily distracted, fidgety, craves movement; aggressive
• Easily overwhelmed
• Difficulty with handwriting or motor activities
• Difficulty making friends
• Unaware of pain and/or other people

Adolescents and adults

• Over-sensitive to touch, noise, smells, and other people
• Poor self-esteem; afraid of failing at new tasks
• Lethargic and slow
• Always on the go; impulsive; distractible
• Leaves tasks uncompleted
• Clumsy, slow, poor motor skills or handwriting
• Difficulty staying focused
• Difficulty staying focused at work and in meetings
• Unmotivated; never seems to get joy from life

Q1: What will my child learn in social skills training?
A: Depending on the recommendation from the initial assessment, your child might benefit from individual or group social skills training.  Your child will learn social skills that are required to interact with others through verbal or non-verbal (e.g. gestural, body language) communications with others.

To have effective social interactions with others, some of the skills include but not limited to:

• Joint Attention
• Eye contact
• Following instructions
• Turn taking
• Sharing
• Understanding of emotions (self and others)
• Emotional Regulation
• Conflict resolution
• Negotiation
• Problem solving skills

Q2 : How will social skills be taught?
A: The social skills training will be fun and educational.  Mainly, games are used to facilitate children to learn the various social skills.  Some of the strategies used include: 1) Modelling, 2) Role play and 3) Feedback.  Each session will focus on a different topic and your child will have opportunity to utilise skills learnt from previous sessions.  Parent(s) will be briefed after each session on child’s progress and any follow-up home programmes.

Occupational Therapy

Occupational Therapy is concerned with a persons ability to participate in daily life activities or occupations, including self care, work, and play.

Pediatric Occupational Therapy

A childs job of growing into adulthood involves continual adaptation to the demands of the environment and assimilation of its opportunities. The dynamic nature of this interaction is determined by the childs internal clock of maturation as the child adapts to a changing environment. Occupational therapy practice is based on an understanding of the interactions among children, their activities (or occupations), and their environment.

Who are the children who can benefit from an occupational therapy intervention?

Children having difficulties in:

• Fine motor skills
• Gross motor skills
• Coordination
• Sensory integration issues (Modulation and Discrimination of sensory input)
• Motor planning (praxis)
• Visual motor integration
• Visual perception skills
• Oral Motor (Oral Defensiveness, and Motor Planning)

These difficulties might result in the following issues:

• Handwriting
• Balancing responses
• Clumsiness
• Manipulation of objects and tools
• Independence in self care tasks
• Performance in physical education
• Sitting still in class
• Hyperactivity due to sensory seeking behaviors
• Short attention span
• Feeding Issues

Occupational Therapy Services include:

• Assessment (screening and in depth):
• Standardized assessments
• Informal assessments that includes clinical observations
• Assessment is important in order to:
• Find out where is the core cause of the difficulty
• Set intervention goals
• Set a base line of where is the starting point of abilities before intervention had started
• Intervention (individual sessions)
• The use of childs strength to compensate his weaknesses
• Direct targeting of root causes of the observed behaviors
• Modification of environment to match childs abilities
• Teaching strategies
• Direct training in targeted tasks
• Remedial approaches for sensory integration that may include a Sensory Diet
• Oral Motor intervention to improve feeding and oral defensiveness
• Advising parents and teachers how to manage the child at home and in school
• Occupational therapy intervention is child-directed and it incorporates play for motivation and experience. It is important to design a suitable challenge fo the child to provide an opportunity to learn and improve while not discouraging the child by failure.
• The occupational therapy session should be fun and motivating for the child in order for him to benefit and get the opportunity to learn and improve his skills.

The Role of Occupational Therapy

A childs occupational performance might be affected by developmental, physical, sensory, attentional and learning challenges. The goal of occupational therapy is to improve the students performance of tasks and activities important for successful school and life functioning.

The occupational therapist is concerned with ensuring an understanding of, and match between the students skills and abilities and the expectations placed on him.

Sensory Integration Theory was formed by A. J. Ayers who was an Occupational Therapist with advanced training in Neuroscience and Educational Psychology. She defined Sensory Integration as the neurological process that organizes sensation from one's own body and from the environment and makes it possible to use the body effectively within the environment.

All the information children receive from their environment arrives through the sensory systems. Most of us are familiar with the sense of Smell, Taste, Sight and Sound. There are 3 more senses that we are less aware of and these are: the sense of Touch (the Tactile Sense), the sense of Movement (the Proprioceptive Sense) and the sense of Balance (the Vestibular Sense).

The SI theory puts an emphasis on these 3 important senses:

Tactile system detects qualities and locations of external stimuli applied to the skin. Information from the skin, about location of touch, pain and temperature is transferred through this system to the brain.

Proprioceptive system refers to sensation of movement (i.e. speed, rate, sequencing, timing and force). It's important for the development of body scheme, praxis (motor planning), and adaptive action. The information on proprioception arrives from the muscle receptors and partially from skin receptors which provide to the brain information about muscle change during movement. This allows generation of proper amount of force needed to act on objects

Vestibular system - the vestibular input contributes to posture and the maintenance of a stable visual field. The receptors for vestibular input are located in the inner ear. There is a combined impact of vestibular and proprioception input on muscle tone, posture, equilibrium, and motor behavior

Dysfunction in Sensory Integration (DSI)

If one or more of the sensory systems are not fine tuned to work with harmony with the rest, or information from the senses is not well processed the level of functioning of the child might be compromised.

Symptoms that are commonly displayed in DSI include:

• Being overly sensitive to touch, movement sights or sounds
• Being under reactive to sensory stimuli
• High or Low Activity Level
• Coordination problems
• Delays in speech or language skills
• Poor organization of behavior
• A poor self concept

Sensory Integration (SI) Therapy

It is important to do an assessment with the child and interview the parents in order to identify the areas of strengths and weaknesses in order to tailor an individual intervention plan and to create a base line for future intervention.

The SI therapy is being done mainly in a special gym that includes plethora of suspended equipment (swings, ladders, tunnels, therapy balls and many more). The equipment allows us to give a variety of stimulation to all the sensory systems.