Learning new motor skills creates important neurological connections in brain cells and allows for habitual patterns of movement. For children with deficits in gross motor skills, typical physical, social and emotional development may be affected.

Children love to move!
It is the primary way they explore their environment and discover the world. For the typical child, movement comes naturally. Crawling, walking, running and jumping all happen as the developmental plan unfolds. However, some children experience problems, and critical steps in gross motor development are missed.

Gross versus fine motor skills
Gross and fine motor sequences are the two different motor patterns that allow children to adapt physically to their surroundings and perform activities necessary for daily living. While fine motor sequences involve the smaller muscles of the body (hand muscles to grasp objects, face muscles to chew), gross motor movements of the body involve the large muscle groups, such as for sitting, standing and walking. From infancy, children use gross motor patterns to crawl, roll, jump, hop, skip, climb stairs, balance on narrow surfaces, and countless other activities that seem to come naturally, but are actually a complex developmental pattern of neurological connections between brain and body.

Gross motor movements are produced by the brain’s signals through the nervous system to the muscles involved in a particular action. Motor skills are executed through the motor cortex, a part of the brain’s cerebral cortex, and through those areas associated with memory and learning. The brain works to “teach” the body the motor sequence. Children are born with a certain number of brain cells designated specifically for certain actions such as breathing, circulation of blood, and more complicated executive tasks and activities.

Achieving gross motor milestones
For some children, the neurological connections to the body are slow or interrupted, and this creates a deficit in gross motor skills. These deficits are usually discovered during a routine checkup, where the pediatrician compares the child’s gross motor progress with standardized guidelines. Some parents notice problems when their child is playing with other children, and they see a difference in balance, coordination or strength. Since not all children develop along the exact same time line, differences noted between children are usually normal and no cause for concern. Some early cautionary signs for a gross motor deficit would be not attempting to roll or trying to sit up by 6 months, not cruising on furniture by 10 months or not walking by 15 months (see Gross Motor Milestones).

Why physical therapy (PT) is important
Deficits in gross motor skills can affect general health by discouraging movement around the home or community in a confident and safe manner. If a child is uncomfortable performing a task (e.g., climbing, swimming, running, hopping), then he loses the strength and skills that would otherwise come naturally in the developmental time line. Less physically confident children may become fearful of their surroundings and begin exploring less, which can limit cognition-increasing experiences and social opportunities that build peer relationships.

PT should start as soon as a deficit is noted. Pediatric PT ranges from birth to 21 years of age and focuses on gross motor strength, coordination and motor planning. During a typical PT session, a child engages in activities designed to address specific deficits. For infants and toddlers, the functional activities in PT help to achieve milestones such as rolling, sitting up alone, cruising along furniture and walking. In older children, standing on one foot, maintaining balance on tiptoes to reach overhead, jumping, hopping, skipping, running, ascending and descending stairs, and catching and throwing a ball are all activities that help in achieving PT goals.

Choosing a physical therapist
To help their child achieve his highest potential in motor function, parents need to make sure the therapist is qualified and experienced. Therapists should have at least a bachelor’s degree and be a licensed physical therapist. Some therapists have advanced training and are certified in specialty areas such as neurodevelopmental techniques, interactive metronome and torticollis.

The therapist’s work place is also an important factor to consider. Therapists can work out of daycare centers, in patient’s homes or in a clinic, and parents need to take note of the atmosphere of the work space. Is it energetic, fun and playful? Is it attractive and appealing to children? Is there plenty of room for the child to move?

The child and his physical therapist should have a comfortable and relaxed relationship. The therapist should spend time building trust, as well as taking an interest in what motivates the child so that activities are more likely to lead to achievement of gross motor goals. The right physical therapist makes a huge difference in a successful outcome.

Ryan’s story
Most children experience great improvements with gross motor function when they take PT. Success, however, should be measured by each individual child. When I first met Ryan, he was 14 months behind in stationary skills, 42 months behind in locomotion skills, and 33 months behind in ball skills. He had little awareness of his own body and therefore was not sure how to accomplish certain gross motor skills. As we worked together, Ryan began to trust me. He knew that I would not challenge him past the point of his abilities. We worked on catching a ball only when thrown from five feet away, ambulating on a 4-inch wide balance beam, and ascending and descending stairs with one foot on each step without hand support. We improved balance on uneven and unstable surfaces using a rocker board and standing on one leg at a time. We also performed a lot of deep pressure and strengthening activities for his sensory system which enhanced his joint receptors. We used vibration, wearing a weighted vest, and range of motion of the joint for awareness. There was a focus on his vestibular system as well, to improve equilibrium and balance through his whole body.

By the time he transitioned out of my clinic, he was able to walk up and down stairs, jump forward independently for 23 inches, jump down from an 18-inch surface, transition over obstacles, catch a tennis ball, and hop independently. He gained full gross motor potential in the stationary component, was only 24 months behind in locomotion, and 26 months behind in ball skills. All these accomplishments demonstrated improved motor planning and heightened body awareness. Ryan now plays with his peers at school, and with his younger brother at home. Thanks to early intervention, a caring and qualified therapist, and family support, Ryan experienced a successful outcome.

Angela Johnson, MPT, IMC is a physical therapist at Kid’s Creek Therapy. She has experience working with children with autism, torticollis, Down syndrome, cerebral palsy, CVA, hydrocephalus, and developmental delay. Her certifications include interactive metronome. Angela can be reached at ajohnson@kidscreektherapy.com or 770-888-5221.

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Brain and Body: Gross Motor Skills

Visual-spatial skills are required for play, self-care, social interactions and academic tasks. They are the foundation for more complex skills such as problem solving and abstract reasoning.

Weaknesses in visual-spatial skills often lead to academic diffi culties in areas such as reading, handwriting, spelling, math and organizational skills. Children with visual-spatial weaknesses may struggle with coloring, assembling puzzles, building with Legos®, manipulating fasteners, tying shoes, planning, organizing, problem solving and following directions. Frequently, social skills are affected as well since children misinterpret nonverbal communication signals such as facial expressions and body language.

What is visual perception?
Visual-spatial skills can be separated into two main categories: visual perception and visual-motor integration. Visual perception is the ability to understand what is seen. It allows you to find things, notice differences between items, and remember things you have seen. The following are the major visual perceptual skills:

• Visual discrimination: the ability to notice differ ences and similarities between objects. Initially the child notices global characteristics (these toys are both white) and eventually can notice more subtle characteristics such as slight differences in size or shape.
• Visual memory/visual sequential memory: the ability to recognize and recall details of things the child has seen in the past. Visual sequential memory involves the recall of a sequence of visual information. For example, being able to recall letter sequence in a word for spelling or remembering the sequence of how to form a letter.
• Visual-spatial relationships: the ability to perceive the positions and directions of objects in relation to your own body and to other objects. This is the foundation for the emergence of directional language such as under, behind, or on top, as well as the inte gration of the concepts of left and right.
• Visual form constancy: the ability to recognize the fact that an object or shape remains the same when there are differences in detail, size, position, distance and background. For example, all books are still books even though they come in various shapes, sizes and colors.
• Visual figure ground: the ability to distinguish relevant information from “visual clutter.” For example, finding a math book in a backpack , choosing a specific toy from the toy box, or finding your place in a workbook.
• Visual closure: the ability to accurately identify an object when part of it is hidden or missing. For example, figuring out a dot-to-dot puzzle, or finding a missing shoe when all you can see is its shoelace sticking out from under the bed.

What is visual-motor integration?
Visual-motor integration is the ability to coordinate what you see with body movements. For example, controlling a pencil to start and stop a stroke with precision, or to form a letter or shape with smooth strokes. It also includes cutting or folding accurately and making sure that when writing, all the letters sit on the line. Copying text from the board or from a book is another task that requires efficient visual-motor integration since the child shifts his gaze from far to near or from the book at his side to the paper in front of him.

Though small hand (fine motor) related skills are often the focus of visual-motor integration testing and academic skills, big muscle movements (gross motor) and skills are an essential part of this developmental category. Catching, hitting, kicking and throwing a ball are all part of visual-motor integration. Accurately turning your head to look towards a sound, reaching for something without overshooting, and moving through a crowded room without bumping into anyone are also aspects of visual-motor integration and have a strong impact on day-to-day function at home and school.

Occupational therapy for visual-spatial weaknesses
Effective evaluation and treatment of visual-spatial skills begins with the child’s level of body scheme (understanding how all the body parts fit together) and body awareness (where the body parts begin, end, and relate to other objects). A successful occupational therapy approach focuses on this strong base of body awareness to help a child experience distance, size, directionality, and the relationships between his body and objects by moving, touching, and playing. During therapy, visual-spatial skills are practiced and promoted in the context of integrating big and small movement, touch, vision and sound. As skills are stimulated and expanded within a single session or across several sessions, more sit-down tasks are integrated into the play and practiced with focus on specific goals identified for daily life (letter formation, writing on a line, tying shoes, or completing a puzzle).

The struggles experienced by children with visual spatial deficits are often frustrating and confusing. As parents and teachers, understanding this essential area of development is the first step to helping a child succeed. There are many strategies for improving, remediating and compensating for visual-spatial skill deficits to improve learning, achievement and success in daily life. Occupational therapists provide strong resources and intervention to meet this goal.

Robbyn Laufer, OTR/L is founder and director of Kids Can Pediatric Therapy Services. She has 15 years of experience helping improve the success of children with sensory integration weaknesses, learning disabilities, and general developmental challenges. She can be contacted at rlaufer@kids-can.com or 770-317-6755.

Special thanks to Emily McLaughlin, OTR/L, Susan Kronenberger, OTR/L, Emily Venable, MHS, OTR/L, and Tiffany West, OTR/L for their contribution to this article.

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Do You See What I See? – A Visual-Spatial Primer

The Basic OT Dictionary Motor Skills
Traditional fine motor interventions sometimes fall short of correcting handwriting issues. Keyboarding skills, as taught through an assistive technology program, can help build written communication skills in young students.

The importance of handwriting
Of the skills a child acquires during the first years of school, handwriting is one of the most essential. Written communication is a necessary life skill for completing school assignments, writing a letter to a family member, filling out an application or simply writing down someone’s phone number. Failure to achieve handwriting success during the school-age years may have a negative impact on a child’s academic success, as well as his overall self-esteem.

School children demonstrate their knowledge in all academic areas through handwriting. Therefore, when handwriting is poor, a child may be misunderstood or even given a bad mark on school work. Jane Case-Smith, OT, in “Effectiveness of School-based Occupational Therapy Intervention on Handwriting,” The American Journal of Occupational Therapy 2002, emphasizes that students who have trouble with handwriting are so fo- cused on correctly forming letters that they may lose attention to the subject matter or to the instructor. The need for neat and legible handwriting only becomes more important as children progress through school. Therefore, early identification and intervention are crucial in order to decrease a child’s difficulties with handwriting.

How assistive technology can help
Due to each child’s unique circumstances, not all children have the same handwriting difficulties; therefore, an individualized plan of care should be considered. However, if problems with handwriting persist and the child’s academic performance is hindered, alternatives to handwriting should be explored. This is where assistive technology becomes important in a child’s academic setting. As defined by the Technology-Related Assistance for Individuals With Disabilities Act of 1988 (Public Law 100-407), assistive technology is “any item, piece of equipment or product system…that is used to increase, maintain or improve functional capabilities of individuals with disabilities.”

Assistive technology ranges from low-to high-tech. Low-tech is defined as tools that are inexpensive, involve a minimal amount of training and typically do not require batteries or electricity. Mid-tech options, typically portable word processors, are explored if low-tech options do not improve the child’s handwriting. High-tech options, like word prediction software, are necessary when a child’s needs are not met by other assistive technology options.

Low-, Mid- and High-Tech Tools

Keyboarding 101
It is imperative that a child learn how to competently use a keyboard in order to utilize assistive technology tools efficiently. Keyboarding can be introduced in occupational therapy, as well as at home or at school, in order to ensure a child will be proficient at word processing. There are essential fine motor skills necessary for keyboarding including the ability to use isolated finger movements and complex hand movements with the arms in a stable position, preferably with the elbows at the student’s sides. For keyboarding success, a child must be able to coordinate finger and arm movements to strike the keys and make the right key choices on the keyboard. Often these fine motor skills will improve after keyboarding instruction and keyboard use. Initially, the fo- cus should be on accuracy, and then speed, when teaching children how to keyboard. In order for touch typing to be functional, the child’s typing speed should be at least equivalent to his handwriting speed. Occupational therapists Janet Rogers and Jane Case-Smith, authors of “Rela- tionships Between Handwriting and Keyboarding Perfor- mance of Sixth-grade Students,” in The American Journal of Occupational Therapy believe a child often begins to learn how to type using the “hunt and peck” style of typing until he is familiar with the layout of the keyboard.

Good, solid typing instruction is important. When choosing a typing program, parents should look for a match between the child’s cognitive and developmental age and the software program’s features. Some features to look for are:

• Large, onscreen keyboards that show both the keys and the correct position of one’s fingers
• Programs where preferences, such as font size and color, can be changed to fit the needs of the child
• Programs that track changes and progress
• Programs that provide a multi-sensory approach combining both visual and auditory input

An excellent typing program will keep the child moti- vated to use the computer while teaching keyboarding skills. An assistive technology trained occupational therapist is a valuable resource for parents who are trying to find an effective instructional keyboarding program.

Web sites with free typing instruction:

www.sense-lang.org/typing
www.bbc.co.uk/schools/typing
www.typingsoft.com for an extended list of typing tutors on the web

Software programs providing typing instruction:

Name of Software / Supplier
Type to Learn 4 / Sunburst Company www.sunburst.com
Jump Start Typing / Available at Target or www.amazon.com
UltraKey 5 / www.bytesofl earning.com

Many respected occupational therapists believe that while the introduction of keyboarding has been recom- mended as early as first or second grade, it should not take over as the primary means of written communication until fourth grade. Once keyboarding skills are achieved, word processing can be used as a means of written communication.

The road block that children with handwriting difficulties face is not insurmountable. There is a way for these students to take part in written communication and find success in school. Parents can turn to assistive technology to help their children improve their written communication skills. Keyboarding and word processing ensure that a child’s written communication is legible for others to read. Typing allows for children to easily correct typing and spelling errors. Being able to use the keyboard also has been suggested to improve a child’s interest in schoolwork and the child’s attitude toward learning how to write. It’s exciting to have assistive technology options that will allow the child to feel a sense of achievement and pride in his written work.

Jennifer Nelson, MOT, OTR/L has worked with Atlanta families for five years and currently is a team member in the assis- tive technology department at Children’s Healthcare of Atlanta. She can be reached at jen.nelson08@gmail.com or 404-785-3779.

Sources: The American Journal of Occupational Therapy AbilityNet website: www.abilitynet.org.uk. Physical and Occupational Therapy in Pediatrics GPAT: Georgia Project for Assistive Technology. www.gpat.org.

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Handwriting Headache – Keyboarding Techniques Might be the Answer

The Basic OT Dictionary Motor Skills

Like other therapies, occupational therapy has a language all its own and can sound very foreign to a newcomer’s ear. Understanding the basic terminology helps equip parents to make effective decisions about their child’s therapeutic developmental plan.

What is occupational therapy? Isn’t that for adults who are re-entering the work/occupation force? Al though this is one aspect of occupational therapy (OT), pediatric OT works specifically to assist children in taking part in all activities (occupations) of childhood: playing, studying, eating and becoming independent in self-care. A child can be referred for occupational therapy from birth through school-age. Children age 3 and under receive OT as part of an early intervention program. The reasons for referral vary as widely as children differ from each other. The child may have a genetic condition, neurological issues or developmental delays. He may have difficulties with attention, motor coordination or in completing daily living activities such as feeding himself. Currently, many referrals are concerned with sensory processing disorders, behavior regulation or problems relating to and communicating with others. Once a child is assessed, including parental input, a plan of intervention is developed with particular goals. Following is an OT dictionary which will help parents familiarize themselves with the terminology.

Muscle tone – the quality of the muscle itself. It may be hypo (low) tonic, hyper (high) tonic or adequate. Some define tone as the ëtension’ in a muscle, which should be high enough to help defy gravity, but low enough to allow movement in space.

Muscle strength – the strength developed by the child as he grows, often confused with muscle tone. The child may have low muscle tone and still be very strong. These are two different measures.

Range of motion – the range through which a joint can be moved. This ability may be constrained by the quality of the muscle tone and/or by muscle strength. It may be that the child will have full range of motion (ROM) if assisted by other means.

Primitive reflexes – these are instinctive reflexes such as those that allow babies to move through the progression of crawling, sitting, pulling up, standing and walking. The reflexes ìintegrateî into normal development once the baby enters the toddler stage. The absence of a primitive re flex, or the reappearance of one after a certain point of development, can interfere with the performance of motor skills.

Protective reflexes – involuntary actions that protect the individual from harm. Examples: pulling hand back from hot stove, blinking when an object gets too close to the eye.

Postural control (head and trunk control) – the ability of an individual to defy gravity and maintain sitting or standing and moving in space without being pulled to the floor. Because it is the ability to control and or stabilize the body, it is basic to the ability to carry out a skilled task, such as cutting with scissors, reading and writing.

Gravitational insecurities – this term is used when the child experiences an unusual degree of anxiety in response to movement and/or the head position in space when his feet do not touch the ground.

Gross motor skills – the ability to complete tasks that make use of large muscles such as running, climbing, riding bikes and playing sports.

Fine motor skills – the development of skills that will ultimately allow for efficient, precise and timely manipulation of tools and/or objects. This skill is usually thought of as handwriting and closely related to schoolwork. Other tasks, such as dressing, oral-mo tor development and visual motor development are also considered fine mo tor skills.

Sensory motor development – the development of the individual’s skill to receive and act based on the information received by the senses. Inclusive in this area are the areas of postural control, sensory modulation and praxis.

Sensory modulation – this happens when the senses work together. Healthy modulation occurs automatically and unconsciously and allows children to stay organized and pay attention. For children with developmental challenges, the modulation process is inefficient and needs to be regulated through sensory integration therapy.

Sensory integration – the organization of sensory input so that the child can interact with the environment effectively.

Sensory processing – this term is used interchangeably with sensory integration. It refers to the ability to receive, organize and interpret incoming information from the senses in order to behave and learn appropriately and effectively. This term is part of the ënew’ terminology and some OTs may not be using it yet.

Praxis – the brain’s ability to plan and carry out a sequence of unfamiliar actions. Examples: climbing a jungle gym, riding a bike or playing catch.

Apraxia – the loss of the ability to execute or carry out skilled movements and gestures, despite having the desire and the physical ability to perform them.

Dyspraxia – having difficulty planning and completing intended fine motor tasks. These children have uncoordinated, out-of-balance movements.

Perception – the meaning that the brain gives to sensory input.

Sensory defensiveness – an increased level of arousal due to incoming sensory input. This causes the child to over-respond to the sensory stimuli.
Sensory under-responsiveness or sensory dormancy – a decreased level of arousal. The child is under-responsive to the sensory input.

Vestibular input – the input received from the vestibular or balance system. It provides the information of time and space, according to the head’s position in relation to gravity and movement.

Proprioceptive input – information received by the proprioceptive system (skin pressure located on joint and sensory receptors) which tells where one is in relation to his own body, i.e. where to scratch, how fingers bend, etc.

Crossing midline – the ability of the individual to use one side of the body in completing tasks that are on the opposite side without turning the body.

The goal of occupational therapy is to improve a child’s ability to complete and enjoy everyday tasks. By identifying the weaknesses in a child’s motor development, an occupational therapist can develop a plan which will build strengths and facilitate development. A good grasp of OT terminology allows parents to understand the therapist’s documentation. If parents encounter terms and notations they don’t understand, they should consult their child’s therapist. This OT dictionary is not inclusive of all terminology used, but is a good start toward getting parents educated and on the way to understanding their child’s particular needs.

Dr. Milagros (Mili) J. Cordero is founder and president of ITT’S For Children. She is a licensed, registered occupational ther apist with over 30 years of experience working with children with developmental disabilities. Dr. Cordero also has multiple academic appointments and trains occupational therapists in children’s therapy. She can be contacted at mili@ittsforchildren. com or 770-393-9901.

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It Was All Greek To Me – Part 2

Children require varied developmental tools to best suit their unique needs. Through the rhythmic movement of horses, therapeutic intervention is provided for many children with a myriad of special needs.

What do many people think of when they hear the term hippotherapy? Hippos, of course. Let’s leave behind that misconception and note that hippotherapy has nothing to do with a hippopotamus. The word hippotherapy is actually derived from the Greek word hippos meaning horse. Hippotherapy is also not about learning how to ride a horse. As defined by the American Hippotherapy Association (AHA), hippotherapy is a term referring to a therapist using the movement of a horse as a therapeutic tool. Hippotherapy can be used as physical, occupational and speech therapy treatment.

How does hippotherapy work?
Hippotherapy is a multi-dimensional therapy using horse movement that allows therapists to address numerous developmental issues at the same time. A child riding the horse receives constant sensory input including vestibular, proprioceptive, tactile, auditory, olfactory and visual. The vestibular system that controls balance and equilibrium is stimulated because the child is on a dynamic surface. The therapist enhances this input by having the child change the position of his/her head. Changing positions causes movement in the semicircular canals, the part of the body that affects balance. By stimulating this area, the child’s ability to process vestibular input can improve.

Proprioception is the body’s ability to process heaviness, location and resistance of objects in relation to the body. It affects posture, movement and the ability to process changes in equilibrium. The body receives proprioceptive input when the nerve endings in the muscles are stimulated, which happens when a part of the body is touched or moved, even by gravity. For example, typically functioning proprioceptive systems allow a person to close his eyes and still know where his arm ends. When a child rides a horse, the lower extremities receive proprioceptive input from touching the horse. When you add movement, the entire body receives this input. The therapist can also enhance this input by having the child change positions on the horse, having more or less of the body touching the horse.

Both of these systems, along with the tactile system, work closely together and are all stimulated when a child is simply trying to maintain balance on the horse. The touch, sights, sounds and smells of the horse and the barn contribute to stimulating other sensory systems. During therapy, most of these systems are stimulated on a subcortical level because the child is focusing on the activity, such as throwing a ball, and not consciously processing the sensory input. Because of this, the positive effects of hippotherapy continue after the session ends.

Hippotherapy takes place inside a covered arena or outside in a riding ring where the therapeutic situation is always affected by the ever-changing environment. The child participates in therapy when it is hot or cold, rainy or sunny, calm or windy. There are constant potential distractions, such as birds, planes or cars going by, the sound of the rain on the roof or another child running by. Most children are excited and motivated to come to therapy. They love to pet and feed the horses and usually cannot wait to tell their family members or friends about how they “rode” a horse. Some barns are equipped with balls, swings, therapy mats and toys so more traditional therapy can be provided if necessary.

Hippotherapy’s history
The term hippotherapy was coined in the 1960s when physiotherapists in Germany, Switzerland and Austria began using horses as a therapeutic tool. During the 1970s, physical therapists from both the United States and Canada traveled abroad to study hippotherapy and brought learned skills back with them. By the late 1980s, American and Canadian therapists had developed a national standardized curriculum for hippotherapy. In 1994, the AHA (formed in 1992) began registering therapists and setting standards of practice for hippotherapy. A registered therapist must be state licensed, complete the introductory hippotherapy courses offered by the AHA, provide a minimum of twenty hours of hippotherapy under the supervision of a registered therapist and be a member of the AHA.

Therapists and hippotherapy
Occupational therapy (OT), physical therapy (PT) and speech therapy (ST) take place in a number of different settings including schools, daycare centers, homes, clinics, riding stables and pools. Each setting dictates particular forms of therapy. Within the various forms of therapy are ranges of tools that may be utilized. As the forms of therapy have developed, more and more therapists have begun to specialize. Therefore you may have a PT or OT with a specialty in hippotherapy. Since any decisions about a child’s therapy can be complex, it is a good idea to consult with these specialists for a further analysis regarding your child’s developmental plan.

Keep in mind that not all hippotherapy is the same. Although all hippotherapy and equine assisted therapy is done on and around a horse, a child’s goals and treatment plan will be very different depending on what discipline provides the service. It is imperative to determine first if a child would benefit from OT, PT or ST and then decide if that discipline, in the form of hippotherapy, is right for the child.

Although some people consider hippotherapy and equine assisted therapy to be synonymous, they are not. Equine assisted therapy refers to skilled therapy that involves a horse. If therapy is occurring without horse movement, it is actually equine assisted therapy. During a session, a therapist would commonly use both forms depending on the needs of the patient at that time. Children with all types of diagnoses participate in hippotherapy programs. If a physician and evaluating therapist deem it medically necessary for a child to receive occupational, physical or speech therapy it is a collaborative decision as to what treatment forms should be used. Hippotherapy is not suitable for all children with special needs. Each child must be individually evaluated to determine if hippotherapy is appropriate. There are aspects to hippotherapy that may cause more harm than good to the child or put the horse, therapist or volunteers at risk of injury. Hippotherapy is not recommended for children under the age of two. It is vital that the treating therapist, referring physician, the child and the parent or guardian all be in consensus with the treatment plan and be comfortable with the decision to participate in a hippotherapy program.

Case study
Although clinical research is lacking, therapists and families continue to participate in hippotherapy programs because they see the positive effect it has on the children. Joe is a 7-year-old boy with a diagnosis of autism and mild cerebral palsy. He has been receiving occupational therapy in the form of hippotherapy for approximately two and a half years. When he first began receiving therapy, Joe could not maintain midline alignment on the horse, he could not mount or dismount independently, he could not complete a three-step task with verbal cues and he would not attend to any fine motor or visual motor activities. Joe is now maintaining midline alignment independently indicating a significant improvement in proprioceptive processing. He mounts and dismounts independently, and he completes up to a seven-step task with only minimal cueing. He can complete puzzles with minimal assistance and will draw a line independently and a circle with minimal tactile support.
Joe’s mother frequently states that during Individual Education Program (IEP) meetings with his teachers and school therapists, she is constantly telling them that many of the things they are saying he cannot do he does consistently during his hippotherapy sessions. During a recent re-evaluation, it was decided to complete Joe’s evaluation on the horse rather than in the clinic because he was having a difficult time attending to the required tasks. After receiving sensory input from riding, Joe was able to attend and complete the evaluation.

Hippotherapy is a tool in a child’s developmental kit
Success stories like Joe’s continue to be reported by parents and therapists who participate in hippotherapy and equine assisted therapy programs. However, hippotherapy is limited in its applicability, as is every type of therapy with its individual benefits and disadvantages. It addresses only certain aspects of a child’s deficits and problem areas in one particular setting. Children are different and their needs differ significantly. It is important to determine the most significant problems that need to be addressed and, together with your therapeutic advisors, choose the form of therapy and setting that best suits your child’s needs.

Nicole Walker MS OTR/L owns Walker Therapy Services, LLC, a hippotherapy program and can be reached at (678)467-7264, www.walkertherapy.net.

Occupational Therapy Dictionary

• Proprioception (PRO-pree-o-SEP-shun): the body’s ability to process heaviness, location and resistance of objects in relation to the body.
• Tactile: the sense of touch
• Auditory: the sense of hearing
• Olfactory: the sense of smell
• Subcortical: The portion of the brain immediately below the cerebral cortex associated with the higher brain functions—voluntary movement, coordination of sensory information, learning and memory and the expression of individuality.

Equine Definitions

• Equine assisted activities are simply any activities involving a horse.
• Equine assisted therapy refers to skilled therapy that involves a horse.
• Therapeutic riding involves riding skills and horsemanship taught to people with disabilities by a horse expert.
• Hippotherapy is when a therapist uses movement of a horse as a therapeutic tool.

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Walking Through the Steps of Hippotherapy

In the summer edition of Kids Enabled, occupational therapist Linda Stephens discussed sensory integration deficits. Once sensory difficulties are identified, as well as how they affect a child’s life, many activities can be prescribed to help get him organized to better participate in school and play tasks.

A “sensory diet,” constructed by occupational therapist Patricia Wilbarger, is a set of sensory activities. Usually prescribed by an occupational therapist, the activities are incorporated into a child’s daily routines. Its purpose is to help the child become more focused, adaptable and skillful.

A sensory diet includes a combination of alerting, organizing and calming activities. The sensory plan typically targets a child’s ability to engage and participate in everyday activities, such as maintaining attention to a task, playing appropriately with others, participating in selfcare tasks, transitioning from task to task or tolerating new textures of food. The Out-of-Sync Child, by Carol Stock Kranowitz, contains various strategies that parents can do with their children to help them attend to and complete tasks.

Alerting activities benefit the underresponsive child who needs a boost to stay organized and focused. These include:
crunching foods such as dry cereal, chips, crackers, nuts, carrots or apples,

• playing with cold water,
• listening to fast, loud music, and
• bouncing on a therapy ball or beach ball or jumping on a trampoline.

Organizing activities help regulate a child’s responses. They include:

• chewing chewy foods (i.e. granola bars, dried fruit or gum),
• pushing or pulling heavy loads, and
• getting into the upside-down position.

Calming activities help the oversensitive child respond more appropriately to sensory stimulation. They include:

• sucking a pacifier, hard candy or frozen fruit bar,
• pushing against walls with the hands and back, and
• rocking, swaying or swinging slowly.

Various types of activities can be used in sensory diets to increase the child’s ability to complete tasks. The following are a list of activities that can be used in each sensory area:

Tactile

Children who are hypersensitive to touch and are touched unexpectedly might react by hitting or punching. Conversely, children under aroused by touch might not react at all. Activities can be used to encourage processing of tactile system such as:

• Rub a dub dub: Encourage children to rub a variety of textures on their skin. Offer different kinds of soap (shaving cream, lotion soap, etc.) and differently textured scrubbers (loofa sponges, plastic brushes, etc.).
• Finger painting: (shaving cream jell-o and sand) If a child craves it, let him wallow in it! If he shuns it, encourage him to stick a finger or two into the goop, but don’t force him if he’s uncomfortable.

Auditory

When children are hypersensitive to sound, they might hold their ears with their hands if noises, such as vacuum cleaners or the toilet flushing, are too loud. If children are underaroused, their name being called might not even register. Activities to encourage more appropriate auditory processing are:
Teaching children to play a musical instrument.
Talking a child through loud
noises that might be scary.

Vestibular

When children are hypersensitive to vestibular (movement) input, they might be overly fearful of heights or vomit after a short car ride. If children are underaroused, they tend to seek a lot of movement to get their arousal level “up.” Activities to encourage more appropriate vestibular processing are:

• Sliding: Try a variety of positions including sitting up, lying down, frontwards, backwards, holding on to the sides, not holding on, with legs straddling the sides, etc.
• Swinging: Encourage (never force!) the child to swing. Gentle, linear movement is calming.
• Jumping on a trampoline: A kid-sized trampoline with a handle is a good option.

Proprioception

When children have difficulties with their proprioceptive system, they can be clumsy and have poor body awareness. They might often roughhouse inappropriately with their peers. Activities to encourage more appropriate proprioceptive processing are:

• Pillow crashing: Jumping into a pile of cushions or bean bags.
• Pushing and pulling: Pushing a vacuum cleaner or comforter. Heavy work has powerful calming and organizing effects on the nervous system.

Visual

When children have problems with their visual system, copying homework from the chalkboard,
for example, can be a challenging task. A child who has an over-aroused nervous system might be overly sensitive to lights, for example, while a child who has an underaroused nervous system might not respond easily to visual stimulation. Activities to help with visual processing include:

• Flashlight games: Focus your light on the wall or ceiling and ask the child to meet your spot with his light. Have him follow the path of your light as you move it across the wall. Trace shapes and ask the child to name them.
• Preferential Seating: Sit the child at the front of a classroom where there are fewer visual distractions.

Smell

When a child is oversensitive to smells, they often begin to gag or begin to cry at the scent of certain foods. When children are underaroused, they might not even register smells. Activities to try are:

• Explore scents: Lavender, vanilla and rose are generally calming. Peppermint and lemon are usually alerting.
• Play smelling games: Have him close his eyes and try to identify different smells.

Motor Coordination

When children have motor coordination challenges, they may have difficulties with complex tasks like skipping, pedaling a bike and playing team sports such as soccer or baseball. Activities that can help include:

• Obstacle courses: Use tunnels, balance beams, boards, stepping stones, steps, ladders, monkey bars, stepping in shoe boxes, etc. for a fun activity.
• Animal walks: Encourage the child to walk like a bear, crab, turtle, snake, duck, frog, kangaroo, rabbit, elephant, gorilla, horse or other animal.

If you notice that your child continues to have difficulty in the area of sensory processing, discuss your concerns with your pediatrician and request a referral for an occupational therapy evaluation. A sensory diet may be suggested to enhance your child’s ability to reach his optimal potential in his daily life.

Shahnoor Dharmsi MS, OTR/L and Nicole Golante OTR/L work together at an Atlanta outpatient pediatric practice. Shahnoor can be reached at shahnoor02@yahoo.com and Nicole can be reached at ngolante@yahoo.com.

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Sensory Diet Nutrition for your sensory system

Some children might be labeled “lazy, stubborn, shy or headstrong” when sensory integrative problems are the real culprit. Identifying the underlying causes of these behaviors can be a vital step toward helping children reach their fullest potential.

All of us depend on the integration of our senses to carry out daily tasks in work, play and self-maintenance. Sensory integration disorders can greatly influence our ability to function but also can be so subtle that they easily go unrecognized. Particularly in young children, it is easy to attribute behaviors and reactions to other causes (“He doesn’t want to do it,” or “She’s spoiled.”) or to consider it within the norms of the wide range of personality and developmental characteristics. Identifying and addressing sensory integrative dysfunction is important, however, to enable children to function at their best and to minimize disruption in family life.

What is Sensory Integration?
Sensory integration is the ability to take in information through senses (touch, movement, smell, taste, vision and hearing), to put it together with prior information, memories and knowledge stored in the brain and to make a meaningful response. Sensory integration occurs in the central nervous system and is generally thought to take place in the mid-brain and brainstem, portions of the brain responsible for such things as coordination, attention, arousal levels, autonomic functioning, emotions, memory and higher-level cognitive functions.

A. Jean Ayres, Ph.D., was an occupational therapist who first researched and described the theories and frame of reference we now call sensory integration. In her book, Sensory Integration and the Child, Ayres makes several analogies that describe sensory integration and its dysfunction. One analogy compares the brain to a large city with traffic consisting of the neural impulses. She writes: “Good sensory processing enables all the impulses to flow easily and reach their destination quickly. Sensory integrative dysfunction is a sort of `traffic jam’ in the brain. Some bits of sensory information get `tied up in traffic,’ and certain parts of the brain do not get the sensory information they need to do their jobs.”
Various characteristics of sensory integrative dysfunction include attention and regulatory problems, sensory defensiveness, specific activity patterns and troubling behaviors.

Attention and Regulatory Problems
The level of attention to a task depends on the ability to screen out, or inhibit, nonessential sensory information, background noises or visual information. Children with sensory integrative dysfunction frequently respond to or register sensory information without this screening ability. Often, they’re considered distractible, hyperactive or uninhibited. These children are always “on the alert” and constantly asking about or focusing on sensory input that others ignore (refrigerator motor, heater fan, distant airplane, etc.). Other children fail to register unique sensory input and are unresponsive. For example, children might not turn around or respond when their names are called. One parent said that her child was oblivious and unresponsive to a loud noise in the same room but immediately responded when he heard a piece of candy being unwrapped two rooms away.

Children with regulatory disorders often have difficulty establishing appropriate sleeping and eating patterns, are unable to calm or console themselves and might overreact to environmental stimuli.

Sensory Defensiveness
Sensory defensiveness is a sensory integrative disorder characterized by a “fight, flight, or fright” reaction to sensory information most individuals would consider harmless. In the 1960s, Ayres identified this as tactile defensiveness or hyper-responsiveness to touch. Since that time researchers have recognized defensiveness in other sensory areas as well. The individual who has sensory defensiveness typically has a highly aroused nervous system that prepares the body for survival but does not recognize that the input is nonthreatening.

Behaviors associated with tactile defensiveness are aggressiveness, avoidance, withdrawal and intolerance of daily routines. Combing or shampooing hair, cutting fingernails or brushing teeth can be exhausting and difficult for families of children who react defensively with acting out behaviors or tantrums. Other children cope by being rigid and demanding, insisting on certain textures of clothing, cutting all tags and labels out of clothing or displaying extremely limited choices of food because of intolerance to textures. Social skills can be limited if the child withdraws or picks fights as a result of unexpected touch.
Auditory defensiveness can occur with negative responses or fears related to sounds and noises. Some children are so fearful of sounds such as vacuum cleaners, lawn mowers, hair dryers, leaf blowers or sirens that parents must arrange to use appliances when the child is out of earshot. Other children might show an intolerance of sounds and noises by cupping their hands over their ears. One child I knew could not tolerate the sound of a flushing toilet, while another covered his ears when his preschool class had music.

Visual defensiveness can occur with hypersensitivity to light or avoidance of eye contact. Oral-motor defensiveness (tactile defensiveness within the mouth) can cause distress with brushing teeth and dentist visits as well as intolerance to textures or temperatures of food. Children with olfactory defensiveness (intolerance to odors) might gag or be distressed with certain smells that other people don’t notice or don’t mind. One child I know could not tolerate going into a deli with his mother because the odors made him feel sick.
Vestibular defensiveness can result in intolerance to movement or unstable surfaces with fearfulness, avoidance or motion sickness. The child might be afraid to go down steps or to ride an escalator.

Activity Levels
Children are, by nature, active. We expect the toddler to be “into things” and the preschooler to be curious, to explore and to play vigorously. We don’t expect the young child to have a long attention span. Characteristics that indicate problems in one child might be perfectly normal in a younger child. Here are some warning signals related to activity levels:
 

1. The child is disorganized and lacks purpose in his or her activity. Even though the child might appear to be interested in a toy or object initially, once he gets it he might throw it aside, dump it out of the container or immediately be distracted by something else. On the playground the child might run around a lot but does not organize his activity to climb, swing or explore equipment.
    
2. The child does not move around or explore the environment. This is the “good” baby or toddler who is content to stay in one place and does not make many demands on his caretakers. The older child might use good verbal skills to engage the adult in conversation as a way of avoiding manipulating with his hands or actively engaging in activity.
    
3. The child lacks variety in play activities. Some children become repetitive or stereotypic in playing with toys. For example, children might line up toy cars but do not pretend they are going places or experiment with rolling them down an incline.
    
4. The child appears clumsy, trips easily or has poor balance.
    
5. The child has difficulty calming himself after exciting physical activity or after becoming upset.
    
6. The child seeks excessive amounts of vigorous sensory input. Many children like to jump, swing and spin. When the activity is excessive, however, it could indicate a problem.

Troubling Behaviors
Sensory integrative dysfunction can adversely affect many areas of a child’s development, including emotional and social. Many children become discouraged or develop a poor self-concept, especially if they become aware of differences between their function and those of their peers. If a young child has difficulty with motor skills and play activities, it could be hard for him to make friends or to be part of a group. Sensory defensiveness can cause aggressive behaviors or cause the child to be a loner.

Sometimes behavior problems are the first indications that the child might have sensory integrative dysfunction. The child might lack flexibility, be explosive or have difficulty with transitions such as leaving one place to go to another. The child might show extreme irritability or crying that seems unexplainable until it is discovered that he is fearful of certain sounds, overwhelmed by visual stimuli or is intolerant to wrinkles in his socks. Sometimes children are so rigid in their behaviors that families go to extremes to accommodate them in order to maintain peace. The mother who follows the child around with a spoonful of food, begging him to eat, or the parents who allow children to sleep with them in their bed because they won’t go to sleep otherwise might be taking care of the short-term problems without addressing underlying issues.

Sensory integrative problems manifest themselves in a number of ways. Any particular child might show only a few of the characteristics described, and some characteristics could be caused by something other than sensory integrative dysfunction. Parents and professionals should look at the pattern of behaviors and the “big picture” of how the problems interfere with the child’s play, physical and emotional development and ability to develop independence. Any child who is suspected of having a sensory integrative disorder should be evaluated by a professional, usually an occupational or a physical therapist, who has had additional training in sensory integration evaluation and treatment.

Linda C. Stephens, OTR/L, is an occupational therapist and the owner of Atlanta Children’s Therapy in Dunwoody. She can be reached at 770-451-7220 or through her Web site at www.brimer.net/act.

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Understanding Sensory Integrative Dysfunction

Handwriting is an everyday activity. As children, we learn to write in school, and everyone just “does it,” albeit in their own style and manner.

Or, maybe they don’t.

For most of us handwriting is “automatic” —writing flows from our hands, keeping pace with our thoughts. For others, however, handwriting skills must be taught. The positive news is that, with support and appropriate intervention, children who are struggling can acquire the handwriting skills they need.

The Importance of Handwriting
With today’s dependence on computers, some people might think that handwriting is less important than it used to be. Computers, however, cannot replace handwriting. The Scholastic Aptitude Test now requires an essay in the test taker’s handwriting. Job and medical forms often require writing and cannot be transferred to computer. According to the U.S. Department of Education, 44 million Americans in 2003 were unable to fill out any kind of application or form by hand. In addition, more than 70 percent of school dropouts, according to WrightsLaw.com, site poor handwriting and reading skills as their reason for discontinuing their education.

Perhaps an even more important reason to emphasize good handwriting skills is deeply rooted in a child’s self-esteem. Because writing is a more visible, permanent form of communication than spoken language, it can be risky for children to put something on paper when they know their representation does not match what they see their peers produce.

Addressing Underlying Deficits
Initially, the use of any writing implement to remediate handwriting is the wrong way to go. Instead, for children with handwriting challenges, discovering the root causes and treating them with graded activities can turn the feared activity into fun and create facility from failure.

Common underlying problems for a child with poor handwriting include an incorrect pencil grip, which can be wrapped and intense or floppy with poor control, and decreased strength, tone or motor coordination. A child might also have visual perceptual deficits. In addition, mastering in-hand manipulation abilities—moving a single object in your hand while moving your arm across a page—is a complex task and is often difficult for children who struggle with handwriting skills.

Getting children to use the sensory skills necessary to address these underlying deficits often can be done in games and alternative activities, including:

• Playing pick-up sticks for creating and strengthening pincer grasp as well as five-finger coordination;
• Practicing ball and jacks for facilitating eye-hand coordination and increasing hand strength and dexterity. If jacks are too difficult, consider catching balls in scoops made from empty laundry detergent plastic bottles with the bottoms cut out or in wiffle ball scoops or fishing nets;
• Adapting games such as Connect-Four and checkers by using wooden clothespins for picking up the pieces and placing them in the slots. In addition to fostering strategy skills, this is a grasp release activity needed for holding and controlling pencils while writing;
• Using maze books with wide to medium “avenues” for stimulating the writing/tracking connection;
• Tracing from a coloring book with old-fashioned tracing paper and then coloring the traced picture with short colored pencils for fostering better control; and,
• Shuffling cards for increasing hand strength and dexterity.

All of these activities should be done in a fun, game-like atmosphere and should not be treated like homework. If parents become anxious during these activities, children will pick up on that emotion and reject the activity, making it almost impossible to re-engage them in similar situations.

So take a deep breath, do a few deep knee bends and plop down on the floor with your child for an old-fashioned round of jacks. Most importantly, make sure both of you have fun!

Handwriting Programs: PART OF YOUR ARSENAL

Most experts agree that identifying and addressing underlying deficits should be the cornerstone of helping children develop good handwriting skills. Once that plan is in place, a structured handwriting program might prove to be a valuable tool. Parents might want to consult their child’s occupational therapist for advice before purchasing such a program.

Two of the popular programs occupational therapists use that are available for home use are Handwriting Without Tears and Loops and Other Groups.

Handwriting Without Tears (www.hwtears.com; materials range from $1 to $49.95) teaches letters in a developmental sequence, beginning with strokes that are easy for children and then building on what they have mastered. The program, which teaches both printing and cursive, uses multi-sensory teaching aids and methods.

Loops and Other Groups (available at www.pfot.com; $54 for a complete set) is designed to teach cursive handwriting to students in second grade through high school. The program, which teaches letters in groups that share common movement patterns, uses auditory and motor cues to help simplify the cursive writing process.

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Helping Children Develop Handwriting Skills