Peds Assessment: Handwriting, Ayres

a. Age 10-12 mo: Scribbles on paper. b. Age 2 yr: Imitates horizontal, vertical, and circular marks. c. Age 3 yr: Copies a vertical line, horizontal line, and circle. d. Ages 4-5 yr: Copies a cross, right oblique line, square, left diagonal line, left oblique cross, some letters and numbers; possibly can write their own name. e. Ages 5-6 yr: Copies a triangle, prints own name, copies most letter

a. Small muscle development b. Eye-hand coordination c. Ability to hold writing utensil d. Ability to form basic strokes e. Letter identification f. Print orientation

i. Fine motor control ii. Isolated finger movements iii. Prewriting lines and shapes as mentioned earlier iv. Left-right discrimination v. Print orientation vi. Letter discrimination b. Early exposure to technology for children with more significant cognitive or physical disabilities

a. Primitive grip: The whole hand or extended fingers and a pronated forearm are used to hold writing utensil; the writing movement comes from the shoulder. b. Transitional grip: Writing utensil is held with flexed fingers with pronated forearm and radial side down and then progresses to a supinated forearm position. c. Mature grip: The writing utensil is stabilized by distal phalanges of the thumb, middle, and index finger; the ring finger may also be used; wrist is slightly extended, and the supinated forearm rests on the table.

a. Dynamic tripod: The pencil rests against distal phalanx of the radial side of the middle finger, and the pads of the fingers control the movement; the thumb is opposed to the index finger. b. Lateral tripod: The pencil rests against the radial side of the middle finger, and the pads of the fingers control the movement; the thumb is not opposed to the index finger and rests on the distal interphalangeal joint. c. Dynamic quadrupod: The pencil rests against the distal phalanx of the radial side of the ring finger, and the pads of the fingers control the movement; the thumb is opposed to the index finger. d. Lateral quadrupod: The pencil rests against the radial side of the ring finger, and the pads of the fingers control the movement; the thumb is not opposed to the index finger and rests on the distal interphalangeal joint.

-occupational profile -interviews of parents, teacher, child -analysis of performance-work sample, file review, direct observation (most difficult tasks, behaviors, levels of assistance), classroom setup etc

i. Letter formation: improper letter formation, poor leading in and leading out of letters, inadequate rounding of letters, incomplete closures of letters, and incorrect ascenders or descenders ii. Alignment: letter orientation to the baseline and how the writing is placed between the paper's guidelines iii. Spacing: dispersion of words between words and letters within words iv. Sizing: size of the letters relative to the paper's guidelines v. Slant: angle of the words and letters vi. Word legibility formula: total number of readable words divided by total number of words written

a. This approach is ideal for children who have poor postural control, poor automatic reactions, and limited limb control; children with tone issues and poor proximal stability may also benefit. b. The approach includes preparation activities for posture and the upper extremities. i. Activities that modulate muscle tone ii. Activities that promote proximal joint stability iii. Activities that improve hand function

a. Handwriting should be taught directly. b. Handwriting should be implemented in brief, daily lessons. c. Handwriting instruction should be individualized to the child. d. Handwriting instruction should be adjusted on the basis of evaluation and performance data. e. Handwriting should be overlearned and used in a functional way. f. The different phases of handwriting acquisition are as follows: i. Cognitive phase: The child is beginning to understand the demands of handwriting and develop a cognitive strategy for the necessary motor movement. ii. Associative phase: The child continues to practice and begins to self-monitor; proprioceptive feedback and visual cues are essential at this phase. iii. Autonomous phase: The child can perform handwriting with minimal conscious attention.

a. Multisensory input is provided to enhance the integration of the sensory systems at the subcortical level. b. Various sensory experiences, media, and novel instructional materials are incorporated. c. Multiple writing tools, writing surfaces, and positions for writing should be offered

a. Intervention is focused on the ergonomic factors that influence writing production. i. Sitting posture • Children should be seated with feet on the floor, thus providing support for weight shifting and postural adjustments. • The table surface should be 2 inches above the flexed elbows when the child is seated in the chair; this position allows for motor synergy and symmetry. ii. Paper position • The paper should be slanted on the desktop so that it is parallel to the forearm of the writing hand when the child's forearm is resting on the desk. • Left-handed students with a supinated grip should have their papers slanted to the left. iii. Pencil grip and adjustment of the writing tool • Adaptive equipment to support a functional grip includes pencil grips, triangular grips, moldable grips, wider-barreled pencils, and rubber band slings. • A mature grip should be encouraged in young children; as early as second grade, changing a child's pencil grip may be stressful. iv. Paper modifications

a. Intervention is focused on improving self-control, coping skills, and social behaviors. b. Emphasis is placed on communicating the importance of good handwriting to the child. c. Opportunities to enhance self-confidence are provided.

a sensory integrative approach to view the neural organization of sensory information for an adaptive response

i. A sensory diet is an individualized plan that provides a specific child with the optimal sensory experiences that the child needs to be functional in his or her environment. ii. This intervention strategy is specific to children with sensory integrative dysfunction because children with typical CNS functions are thought to be able to seek out the sensory input that they need on their own.

a. Sensory modulation is regulation by the CNS of its own activity. b. Problems with modulation are characterized by children being unable to grade responses in relation to external stimuli. i. Underreactivity, also known as hyporesponsivity: Children demonstrate a pattern that looks as though they fail to orient to the stimuli. ii. Overreactivity, also known as hyperresponsivity: Children demonstrate a pattern that looks as though they overorient to the stimuli.

Thought to be due to hyporesponsivity to a stimulus; children may seek intense input or large quantities of input. i. Children seeking vestibular input may appear to be reckless or risk takers; they may need a lot to get going. ii. Children seeking proprioceptive input may try to get their needs met by engaging in rough housing and other activities that provide them with deep-pressure input or muscle resistance. Children who seek this type of input may be trying to regulate their experiences of touch or movement.

ay be the result of tactile defensiveness or gravitation insecurity. i. Tactile defensiveness is an extreme reaction or overreaction to tactile input; light touch may be particularly noxious; children may be extrasensitive on their face, abdomen, and palmar surfaces of their hands. ii. Gravitational insecurity is an overresponsivity to vestibular input; children with this type of dysfunction may be extremely scared of movement and may move carefully; in addition, they may prefer to have their feet stay on the ground. iii. Overresponsivity may be present in any of the other senses as well.

-interviews and caregiver questionnaires -SPM, sensory profile, Touch inventory -observations-informal in natural setting and formal: i. Clinical observations are a specific set of observations that allow the occupational therapy practitioner to make some inferences about how the child's CNS is functioning. -Standardized tests: sensory integration and praxis tests, M-Fun, Bruininks, SFA

The guiding principles of Ayres Sensory Integration treatment are as follows: a. Sensory input can be used systematically to elicit an adaptive response. b. Registration of meaningful sensory input is necessary before an adaptive response can be made. c. An adaptive response contributes to the development of sensory integration. d. Better organization of adaptive responses enhances the child's general behavioral organization. e. More mature and complex patterns of behaviors involve consolidations of more primitive behaviors. f. The more inner directed a child's activities are, the greater the potential for the activities to improve neural organization. Other: Purpose is to alter childs CNS, occurs on individual basis, child directed by childs inner drive, just right challenge, play and imagination are important, suspended equipment help with vestibular input

a. Increase in the frequency or duration of adaptive responses b. Development of increasingly more complex adaptive responses c. Improvement in gross and fine motor skills d. Improvement in cognitive, language, and academic performance e. Increase in self-confidence and self-esteem f. Enhancement of occupational engagement and social participation g. Enhancement of family life.