Appendix 28 –  Occupational Therapy (OT) services

To help your child assume a correct pencil grasp, physically position their fingers on the pencil and gently hold them while you draw.  Encourage the child to look at how you are holding your pencil and try to copy.

1. Use large barrel pencils or markers as these are easier to hold.

2. Use rubber grippers on pencils if your child’s fingers often slip.

3. Try tracing over lines or shapes with markers or just using fingers.  Simultaneously, describe the direction you are moving, e.g. ‘up, down and around’.

4. Draw shapes in sand, paint and shaving foam to add strong visual and tactile input using fingers or tools.

5. Make stencils out of cardboard and have the child draw around them to make pictures.  Stock Blu-tac underneath so they don’t slip.

6. Draw between lines to help learn concepts of up, down, left, right and diagonals.  Start with wide spaces and narrow the channel as pencil control improves.

7. Make shapes with Playdoh.  Later, progress on to letters.

8. Dot-to-dot activities – use a star to indicate the start point and directionality.

9. Work on large surfaces so the whole arm and body ‘feels’ the direction of movement required to make a shape.

10. Work on a vertical surface to encourage wrist extension and to develop strength of the arches of the hand.

11. When learning a new concept, combine verbal instructions with an actual demonstration and ‘hands-on’ approach to maximise information intake.

12.   Before a child can form letters, they need to have mastered some prewriting forms.  These are horizontal lines (=), vertical lines (II), circles (O), squares (⬜), crosses ( ), diagonal lines (/ \) and oblique crosses (X).  These forms incorporate all the pencil movements required to form letters correctly.  Many children find it difficult to learn diagonals so try using different media to reinforce the direction of movement.

13. Try simple mazes which incorporate different actions, angled, diagonal and curved pathways.

14. Colour changing pens are often motivational to get children to trace over shapes or letters and provide a visual reward for correct responses.

Eg of an individual Occupational therapy plan for a school age child and Recommendations

1. Hand strength and endurance –Muscle strength of the hands and fingers increases as children grow and participate in everyday activities. Activities such as climbing, playing with toys or scribbling with crayons all help to develop and strengthen the muscles of the hands and fingers. Hand and finger strength is important as it is required for many everyday activities such as doing up buttons and zips, climbing monkey bars or cutting up a piece of steak at mealtimes. It also helps to develop the endurance to complete activities such as writing a full page. Grip strength refers to whole hand strength. Pinch strength involves the thumb and index finger (and the middle finger if required).  See the link below for activities to promote the strength and endurance for a firmer, more consistent grasp of the pencil. These activities should be completed 3-5 times per week, for 5-10 minutes to see functional changes occur in the short term. HAND & FINGER STRENGTH INFO

2. Facilitate a more mature pencil grasp – the above strengthening program will help with this but also using smaller, broken crayons, placing small items in an ice cube tray with your ‘pinching’ fingers (thumb and forefinger), scrunching tissue paper with fingertips, popping bubble wrap, putting coins in a piggy bank and using connector blocks develops the ability to isolate the thumb and forefinger for a mature pencil grasp.

3. Practice pre-writing patterns - this can be done when drawing or playing with crayons. It is important to ensure that all vertical lines start at the top and finish at the bottom, horizontal lines start at the left and finish on the right and circles start at the top and travel anti-clockwise. These basic patterns will help lay the foundation for the directionality of future writing.

4. Easi-loop or Spring-loaded scissors – these help to introduce cutting skills. These particular scissors reduce the demands of opening and closing the scissors repeatedly, which can be challenging if hand strength is lower. 

   These can be found at: https://www.amazon.co.uk/HAKACC-Children-Preschool-Pre-School-Child-Safe/dp/B074MXSKRF/ref=sr_1_2_sspa?keywords=childrens+scissors&qid=1557399030&s=gateway&sr=8-2-spons&psc=1

5. Cutting technique – Start out beginning to learn to open and close the scissors to make snips on paper and using the helper’s hand to hold the paper whilst trying to make the snips. 

6. Seated position – when seated at the table, try to adopt an ideal seated posture to prevent postural fatigue which can impact attention, focus and stability for fine motor activities (e.g. handwriting). Aim to sit upright, with feet flat on the floor and hips, knees and elbows all at 90 degrees. Shoulders should be relaxed and forearms supported on the table (not hovering in the air).

7. Pencil grip – a pencil grip can help support finger placement on the pencil (e.g. reducing thumb wrapping around the pencil) for a more functional pencil grasp, reducing potential pain/fatigue when writing. The following pencil grips could be really beneficial:

8. Caring cutlery: it is recommended to utilise Caring Cutlery to promote independent use of utensils when eating. This is available to purchase at Caring Cutlery Range - Complete Care Shop or at Amazon. 

Occupational Therapy Input:

Please note: In order to maximise the effectiveness of Occupational Therapy advice and recommendations within the educational environment, all school visits for children by OT must be attended by a designated Teacher or Education Support Assistant who is familiar with the child.  In this way, the Occupational Therapist will be able to share information and work as a part of the team to support the child at school. Occupational Therapy would not work in isolation with children unless specifically indicated.

Nicola Schechtel, Children and Young People’s Occupational Therapist (CYPOT)

IMPROVING CONCENTRATION AND ATTENTION 

Environment  

• Try to reduce distractions going on around the child by working in a quiet area. 

• Choose a quiet room/corner away from windows and doors, with minimal distractions. 

• Create a space specifically for working and give it a positive title to this work area  e.g. ‘ Brain Power‘ table. 

• Limit the amount of materials to essential items, such as one book and one pen. 

• For younger ones; Initially choose toys / activities which naturally interest your child, use bright colours and attractive things. 

• Reduce distractions such as pictures on the walls. 

• Ensure he/she is sat at a table and chair of suitable height with their feet flat on the floor and elbows resting comfortably on the table top. 

• Initially ask for short periods of attention and gradually increase. 

• Create a reward system e.g. praise ticks on a blackboard, gold stars, public praise. 

• Try keeping a log book to monitor progress. 

Giving instructions 

• Always make eye contact. 

• Use short and simple phrases for instructions. 

• Minimise sequence e.g. tasks at a time. 

• If language is good ask them to verbally repeat instructions back to you 

• Be flexible and try different approaches if appropriate 

• Having a consistent system of giving instructions helps develop a routine for attention, such as getting whole class attention a particular way before giving instructions.   

• Encourage the child to actively participate in demonstrations, or repeating back instructions, to show their understanding. 

Daily schedule 

• Write on board clearly and simply – refer to as move from activity to activity 

• Older children – encourage them to keep own diary 

Classroom organisation 

• Keep class materials always in the same place – clearly labeled 

• Try to keep classroom clutter free e.g. store materials in cupboard etc. 

• Keep blackboard clutter free 

Desk organisation 

• Provide written instructions 

• Prepare worksheets 

• Emphasise direct attention to important visual aspects of the task e.g. underlining, highlights, star beginning and end. 

• Use “fill the gaps” answers rather than requiring the child to complete setting out/lengthy writing process. 

 Difficulty starting activity 

• Give signal to begin working 

• Present work in small amounts 

• Explain purpose of the work 

• Provide immediate feedback and encouragement 

• Use a timer and ask child to say how long work will take. 

Difficulty staying on task 

• Allow the child to continue with an easier part of the task until you can help 

• Tell the child in advance where you expect difficulties 

• Develop a system of mini-breaks when tension gets too much. 

• You may consider 2 places of work for an individual child so they can get up and move around 

• It may be helpful to allow the child to work in different positions – seated, standing, on the floor 

• Use frequent reinforcement 

• Encourage eye contact 

Difficulty staying seated 

• Have clear expectations of “good sitting”. Use a photo to reinforce the practice. 

• Reward good sitting 

• Use a carpet square or spot to keep place at ‘carpet time’ 

• Remove distractions. Position in class where least likely to be passed by others 

• Have equipment needed to hand and reduce the need to wander. 

• Organise and label the room so that things are easy to find 

Needing a lot of attention 

• Assign a buddy/peer for support 

• Ensure child has all requirements for the task 

Working independently 

• Provide activities that are appropriate to the individual child’s development level. 

• Be certain the child can foresee and end to the task 

• Give brief precise directions 

• Give frequent reinforcement, praise the child in front of peers for concentrating 

• Alternate short independent tasks with tasks on which you give assistance 

• Gradually require more independent work before giving help. 

Difficulty following directions 

• · Give short, clear, specific directions 

• · Repeat directions and have child repeat them back to you 

• · Use written directions and plans 

• · Use a buddy who can help with instructions 

• · Position child in class close to your teaching area 

If student fidgets 

• Allow child to hold a small koosh ball or rubber ball 

• Redirect the child to a more constructive task, hand the child an object or book 

• Ignore it 

If the student daydreams 

• When given a worksheet, suggest the child use a coloured pencil or marker to underline or emphasise directions. 

• Place the child nearer to you 

• Reduce activities that require sustained attention.  Allow child structured opportunities to get up and move by collecting materials, putting away items, handing out etc 

• Use of egg timer to focus attention to task 

If student calls out 

• Reward listening 

• Reward child immediately when you observe them waiting to respond 

• Use class room rule cue card to remind child not to call Out 

• Reward peers that do not call out 

• Give each child 3 squares of paper.  During the whole class activity, if anyone calls out remove a square.  Students with all squares at the end are rewarded. 

Difficulty following classroom rules 

• Display rules clearly and reinforce rules verbally and with pictures 

• Keep rules clear, specific and simple 

• Be consistent with rule implementation and consequences to breaking rules, give the child their own list of the rules. 

• Use classroom contracts with pupils and parents 

Hyperactivity 

• Deep firm pressure is often useful to calm down, push on shoulders, roll up in mat/blanket – make hot dogs! 

• Time out space in classroom e.g. with soft furniture/bean bag 

• Place heavy bean bag on child’s thighs whilst sat at desk 

• Keep tasks short and allow short rest breaks if tired. 

Memory

Memory and attention are interlinked, if you can not attend to a task long enough to absorb and store the information, it will not be remembered and therefore not learned. 

• Kim’s game – place several objects on a table, look at the items then cover them up and ask your child to recall the items remembered. Progress by adding more items 

• Card games – using an ordinary pack of cards,  

• Try using prompts such as a diary, calendar, notebook and things to do list. 

Difficulty remembering 

• Use mnemonics 

• Have child repeat directions 

• Use songs, poems, rhymes to enhance recall 

• Colour code significant details. 

• Give short, clear, specific instructions 1 at a time 

• Use charts /pictures/ whiteboard to reinforce time table 

• Avoid changing the learning environment frequently and routines. 

Visual and Auditory Distractibility 

Visual and auditory distractibility refers to the child being overwhelmed with visual and auditory stimuli, to the point where it interferes with functional ability. They may respond negatively to unexpected / loud noises or make excessive but repetitive noises to compensate. They may become confused by a visually cluttered environment and unable to see an object, or they may stare excessively at one item. 

Useful classroom strategies 

• Giving additional verbal / visual clues may help the child prepare for the experience. 

• Identify which children will be most affected by noises and give them extra reassurance to make them feel safe. 

• Consider which children are more likely to find large groups like assemblies, difficult. Ensure they are not placed in front of speakers etc and are near the end of the line. 

• Consider the use of very low volume background music. This helps children to habituate to noise and not orientate to every sound. 

• Ensure that only one item at a time is presented to the child e.g. one crayon rather than a bunch of crayons, and encourage the child to put one item away before receiving another. 

• Consider the use of workstations with table surrounds, to ‘blinker’ the child from other visual stimuli. 

• Keep group times short. 

• The use of visual timetables helps the child to predict changes. 

Tactile Hyposensitivity 

Children who do not register tactile (touch) sensations often do not perceive touch accurately and want to get more touch. They, therefore, crave or seek out touch to get more information to their nervous systems from the environment. They can also be slow to react to pain, temperature etc. 

Things to try at home 

1. Brush arms, legs, back and face with a flat palm, soft cloth or a soft bristled brush. 

2. Play with clay, sand, finger paint, shaving cream and any other new and interesting textures. 

3. Hide an object in a bin of beans or rice and try and ask the child to try and find it.  

4. Eat lemons, peppermints and salty, tart and spicy foods to give opportunities to try new textures and flavours. 

5. Eat fizzy sweets such as sherbet lemons. 

6. Wear clothes with a variety of textures. 

7. Eat foods with a variety of textures and temperatures. 

8. Wear a variety of clothing textures. 

9. Use an electric toothbrush. 

If these activities increase the child’s activity level you may want to switch to some more calming activities such as 

• Eating foods that require heavy chewing such as fruit gums. 

• Rolling child up tightly in a blanket or a towel to make a ‘hot dog’. 

• Get child to squeeze their hands together, play with firm toys or with playdoh. 

• Get child to press their palms together, press down on a  firm surface or against their body 

• Play in an enclosed environment 

• Lay between mats / cushions to make a “sandwich” 

• Chew chewy sweets such as fruit gums 

Sensory Processing: Proprioception (body awareness) 

Sensory processing refers to how we process sensory information from our environment and our bodies. We receive information from the following senses; touch (tactile), hearing (auditory), taste (gustatory), smell (olfactory), sight (visual), proprioception, and vestibular. Proprioception is the information we receive from our joints and muscles telling us in what direction we are moving and how much force we are using. Our vestibular sense is our sense of movement. It tells us what direction we are moving, where we are in space and what speed we are moving at. Adequate sensory processing is the foundation for higher skills such as learning, attention, writing, listening, reading and movement activities.  

Some people need a high input of a sensation for the brain to register it. We say that these people have a high threshold for sensory input. Some people just need a little bit of the sense for the brain to register it. We say that these people have a low threshold for sensory input. Different people will experience different thresholds and these thresholds will vary across environments and depending on your ability to process at that time e.g. you may not process sensory input as well if you are tired or upset. Sensory processing difficulties became a concern when they impact on functional performance, learning or behaviour.  

Proprioceptive System:   

The proprioceptive system is our sense of body awareness. The proprioceptive system is activated when we move our body (muscles and ligaments) against resistance. This then tells us information about where our body is.  

The role of the proprioceptive system is to tell us:  

• To tell us where our body is – our sense of body awareness  

• Works with the vestibular (movement) system for good balance and posture eg being able to sit up straight in your chair.   

• To be able to move our body parts without having to look at them e.g. so we do not have to look at our feet when we are walking or look at our lips when we are talking.   

• Enables us to move and coordinate our body movements.   

• Enables us to judge force: how hard and how soft to touch something.. For example it will allow you to know how hard to push the page with your pen, how hard you have to hold an object not to drop it and how hard to tap your friend on the shoulder to get their attention without hitting.

• Has a key role in calming the nervous system so is an important sensation for helping calm and regulate arousal levels.  

Below is a table with some behaviours you may observe if your child has difficulties with processing their sense of proprioception:   

Will have clumsy and uncoordinated body movements. 

Will walk with heavy footing, stamping around.  

Will like to jump down the stairs rather than walk. 

Will like to crash and bang into things e.g. will jump on the bed but will like to “crash” rather than jump. 

Will like rough and tumble play.  

Will have poor posture e.g. will slump in chair at table, will lean head on hands 

Will lean against everything! If sitting on the carpet will lean against other children, will lean against walls when standing up. 

Will have difficulty judging force, how hard/soft to push/hold things. Some behaviours linked to not being able to judge force include:   

• Push down too hard on page when writing so will push through the page 

• Not push hard enough on the page so you cannot read writing 

• Will hold pencil too slight so they have no control over the pencil 

• Will hold pencil so tight that their hands hurt when they are writing 

• Will slam doors 

• Will hug too tight – will squeeze really hard when hugging 

• Will “push” other children over but not mean it 

Will have difficulty sitting still in their chair. May wrap their feet around the base of their chair. May constantly be rocking or moving their legs when sitting down.  - Prefer to sit on the floor than in a chair. 

Proprioception is the key sense for calming the nervous system. When children are over aroused (angry or happy) they will seek proprioceptive input to try and calm themselves down. Some children may bite (others or themselves), pinch or hit their heads/faces.  

Excessive chewing – will chew everything! Clothes, pens……everything! 

Messy eater – as not aware where their mouth is when eating so may miss their mouth with their spoon.  

Chewing: They may not notice when food is falling out of their mouths or will chew with a wide mouth. 

May not close their mouths and have difficulty with saliva management.  

May have difficulties settling at night to sleep.  

May have some strange dressing routines and habits.  

Children with poor balance (also linked to the vestibular system) will run everywhere rather than walk. This is because it is easier to balance when you are moving fast. Imagine you are on a bike. When the bike is going fast it is easier to remain upright. As the bike slows down it is harder to stay balanced.  

Proprioception and Modulation: Whole body heavy work activities 

Modulation is our ability to stay in the “calm/alert” state we need to be able to learn and perform our occupations. This is when we are alert enough to pay attention but calm enough to remain focused.    Children with difficulties with proprioceptive processing difficulties cannot “calm/alert” state as they are not getting adequate calming sensory stimuli into their brains.   

Proprioceptive (heavy work) activities are always calming. 

Whole body: actions involving pushing, pulling, lifting, playing, and moving  

Oral motor: actions such as chewing, sucking, and blowing  

Use of hands: for squeezing, pinching, or "fidgeting" 

Whole Body Proprioceptive Activities: Calming and Regulating 

Get the child to play on their tummy pushing up with their arms. Use a motivating toy or activity to keep the child in this position. This is also a good position to practice drawing in

Carrying objects 

• Shopping bags: Let your child help you carry when shopping when you are out.  

• Weighted backpack: Let your child wear a backpack with some weight in it when you are out in public. Make sure the bag is not too heavy so that your child adopts a poor posture.  

• Stacking or moving chairs/books: At school let the child help with setting up/clearing away of the room. Give them a task to do when they need proprioceptive input e.g. let them move a box of heavy books for you.  

• Filling up a watering can and letting them water the garden.  

Pushing or pulling objects and activities, such as... 

• Toy shopping cart or shopping trolley when out shopping (rather than them sitting in the trolley).

• Laundry basket, toy vacuum, mopping or sweeping the floor and see what other household activities your child can help you with.  

• Tug of war rope

• Mop/sweep floor with a mop, broom and dustpan for kids

• Raking leaves, dirt etc. using a kids wheelbarrow

• Brio Garden Tools: rake, spade, shovel and broom

Jumping and bouncing on/with items, such as:

On a trampoline, on an old mattress or soft area, into bean bag chairs, on a therapy ball (with adult assistance of course), on a pogo stick