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Primitive Reflexes

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• These reflexes are mediated subcortically. • Presence of a reflex beyond a certain age is a signal of possible neurological dysfunction and reflex assessment would be a part of an occupational therapy or physical therapy evaluation. • From a hierarchy viewpoint, primitive reflexes are suppressed or inhibited to allow for more advanced motor behavior to occur which is called...reflex integration.

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Suck/ Swallow: *28 wks gestation to 2-5 months of age

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• S: place finger or nipple into the infant's mouth • R: sucking movements at lips, tongue and jaw. • S: Absence may indicate CNS depression. Nutritional needs.

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Fine Motor Skills

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Development of the hand for grasp and manipulation.

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Snapshots of the Developmental Progression Of Mature Grasp: Birth to 1 Year

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-Whole grasp -Ulnar Palmer grasp -Palmer grasp -radial Palmer grasp -Raking grasp -pincer grasp

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Newborn Hand

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-Reflexive -Gross, Patterned Movement -Flexor Tone

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Mature Hand Function

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-Radial side of hand used for precision -Isolation of individual fingers -Opposition-thumb to each finger tip -Cupping of palm -Palmar arches -Wrist extension

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Newborn

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Reflexive grasp; primitive squeeze; adducted thumb; unable to voluntarily release

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3-4 months grasp

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Ulnar palmar grasp Hands to midline

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Ulnar grasp

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Although the infant progress toward more mature hand use throughout the first year, ulnar grasping patterns may re-emerge for brief periods at later stages if tasks are complex.

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Reflex Timeline:

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At the same time that grasp is beginning to mature, ATNR helps baby learn to reach

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4-5 months Palmar grasp

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4-5 months Palmar grasp -Rolling over helps develop forearm rotation

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Prone on elbow and crawling 4-5

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-provides proprioceptive input to hand, -helps integrate grasp reflex, -encourages wrist extension -promotes expansion of the palmar arches

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6 months

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Radial Palmar Grasp

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7 -9months 10-12 months 19-36 months

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-Voluntary Release...finally -Pincer Grasp (inferior to superior) -Supination --Neat pincer grasp, three jaw chuck ( 2 fingers and a thumb), wrist extension In-hand Manipulation Skills -Translation- coin from fingers to palmar -Rotation- turning a knob ****Scissors skills developing*** ***Pre-writing skills developing

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3 years to 5 years

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Hand dominance emerges -Uses static tripod grasp-fingers not moving but the whole hand -Able to draw vertical line, horizontal line, circle, cross, square, and diagonal lines -Demonstrates increasing skill in mature pinch and grip......

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Mature Pinch Patterns

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-Tip pinch- tip of finger and thumb -lateral pinch-side of the pointer and thumb -three-point pinch- 3 fingers

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Mature Grip Patterns

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-Hook Grip- carrying a suitcase holder -Spherical grip- holding a ball - Tripod grip- holding a pen -Power grip- hammer -Cylindrical grip- bike

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Beyond the Basics

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Tenodesis: passive grasp/prehension There are other types of prehension and there are combinations of grip and pinch, for example the image below illustrates tripod pinch with lumbrical grip

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COTA's Role in Hand Writing

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-Contributes to evaluation through informal or standardized assessments -Collaborates with OT in treatment planning -Provides intervention - individual or group, consultation, HEP -Provides consultation to teachers, family, treatment team

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Handwriting Assessment

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1.Commercially available assessments (see Solomon text Box 21-3 on p. 422) 2. Interview teacher and parents 3. Review handwriting sample 4. "the quick red fox jumps over the lazy brown dog" 5. Formal or informal screening of client factors or components that support handwriting

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Screening Client Factors that Support Handwriting

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-Postural and proximal stability -Positioning and environment -Hand Control -Visual motor skills -Visual perceptual skills -Sensory motor skills

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Proximal Control and Stability Assessment

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-Posture: symmetrical, upright vs. asymmetrical, slumped, slouched -Proximal Stability -Endurance/Fatigue -Abnormal reflexes

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Proximal Control and Stability Intervention

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-Provide appropriate levels of external support if appropriate: footrest, wedges, alternate seating -Improve core strength and trunk control -Prone activity is usually beneficial -Work through SI pyramid Can you see the possibility of primitive reflexes at work here?

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Positioning and Environment: Assessment and Intervention

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-Desk and chair height -feet on floor, 90/90/90 seated position, desk no higher than 2" above elbow height -Environment -Consider lighting, Noise, Distractions -Paper Orientation/Slant

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Hand Control Assessment

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-Hand Dominance -In-hand manipulation skills -Mature use of radial/ulnar sides of hand -Grip pressure -Well-developed arches -Pencil grip: -dynamic tripod vs. static tripod -wrist extended vs. wrist flexed -open web space vs. closed web space -Endurance/Fatigue

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Efficient grips

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Tripod Quadrupod adapted tripod

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In efficient grips

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Thumb wrap Thumb tuck Supinate Index grip Transpalmar Interdigital Brace

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Hand Control Intervention

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-Address problem areas in treatment sessions and HEP -Explore options for writing tools and pencil grips -Use slanted surfaces to encourage wrist extension -Encourage distal finger control with small movements and small pencils/crayons -Provide boundaries, first large then decreasing in size -Provide proprioceptive feedback: weighted pencils, vibration -During handwriting sessions, monitor and provide feedback

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Visual Motor Skills Assessment

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-Definition: using vision to guide motor output -Children learn to imitate, then copy shapes at an early age. -Completion of 1st 9 items on Beery VMI is an indicator of readiness to begin handwriting: -By age 5, the child is able to imitate and copy a triangle.

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VMI Recording and Scoring

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indicate the readiness of a child in writing Students who could copy the first nine forms on the VMI performed significantly better than students who could not correctly copy the first nine VMI forms on both versions of the Modified SCRIPT

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Some common problem areas related to visual motor skills Visual motor problem

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Hand writing with tear (sheet) HWT -letter reversal -starting the letters from the bottom of the line -poor spacing between words -going outside of the margin -not being able to recognize the mistakes

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Visual Motor Skills Intervention

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-Address problem areas in sessions and HEP -Use development sequences Use manipulatives which enhance eye-hand -coordination and motor planning: -During handwriting sessions, monitor and provide feedback: letter formation, accuracy in letter placement, writing speed

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Visual Perceptual Skills Assessment

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-Definition: ability to make sense of what is seen -Includes recognizing letters, discriminating between letters that look familiar (b and p), direction of letters (b vs. d), closing letters, ability to remain "on-the-lines," and appropriatelyspacinglettersandwords -Don't forget vision: acuity, accommodation, near-point and far-point -Eye-hand coordination

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Visual Perceptual Skills Intervention

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-Address problem areas in sessions and HEP -During handwriting, monitor and provide feedback: letter formation, spacing, accuracy (line usage, letter height), letter closure -Explore options for writing paper

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Sensory Motor Skills Assessment

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-Crossing the midline (*BIG ISSUE FOR READING AND WRITING) -Motor planning: body awareness in space -Tactile, proprioceptive, and kinesthetic awareness

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Sensory Motor Skills Intervention

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-Address problem areas in sessions and HEP -During handwriting sessions, monitor and provide feedback -Use a multisensory approach (recall the pyramid)

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TRAINING ; REMEDIATION

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-Identify and address problem areas -Follow developmental sequences -Writing practice sessions should be short and frequent -Handwriting without Tears Mat Man, for learning shape, size, direction of letter components Paper/Pencil letter formation -Left handed writers (see Solomon text pg. 434)

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COMPENSATORY STRATEGIES

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-Word processor/tablet/keyboard/handwriting aps -Classroomstrategies/accommodations -additional time for assignments; sloppy copies accepted -preferential seating -just right positioning -modify testing procedures to eliminate writing component -vertical surface -smart pens (liveScribe) -letter strips on desktop

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Prerequisites for Scissor Skills

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-Ability to open and close hand -ability to use hand together in helper/dominant fashion -ability to isolate finger movements, especially at radial hand - ability to coordinate arm, hand,eye movements -ability to interact with environment in the constructive developmental play stage

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Development of Mature Scissor Skill Early Stages: (18-24 months)

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• Grasp ;may use both hand to hold handles ;may place fingers in loops, but not thumb • Cutting Strategy ;open and shut scissors without paper

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Intermediate Stages: (24-36 months)

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• Grasp ;more mature grasp: thumb in "top" loop; middle finger in "bottom" loop ;child may try to gain stability by placing handles at proximal parts of the fingers ;movements may be exaggerated and in mass patterns ;forearm is often in pronated position ;overflow movements/associated reactions • Cutting Strategy ;short snips; lack of synchronized movement between scissor and paper

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Advanced Stages: (36 months +)

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• Grasp ;advancing maturity of finger position: ;Neutral forearm position • Cutting Strategy ;pushing scissor into paper with paper stabilized by non-dominant/helping hand efficient strategy: "thumb-on-top position and scissor at 90 degr angle to paper >efficient skills: cutting curved lines with coordinated movement between paper and scissor (3.5-4 y/o) >efficient skills: blades are opened only partially with appropriate combinations of short snips and continuous gliding movement

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Peabody Developmental Motor Scales cutting sequence

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According to this evaluation, children typically learn cutting skills at the following ages: *2 years: can snip with scissors *2 ½ years: cut across a 6-inch piece of paper *3-3 ½ years: cut on a line that is 6 inches long *3 ½ -4 years: cut out a circle *4 ½ -5 years: cut out a square More complex cutting skills develop between 6 and 7 years

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Interventions: to develop opening and shutting of the hand or scissors:

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animal walk- weight bearing and strenghtening, squeeze theraband (stress ball) open and closing rubber band, salad tong puppet open/close

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•to promote isolated control of fingers:

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Finger ladder tip to tip stringing beads

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• to promote stabilization of proximal body parts:

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sitting on the ball and catching the ball-core strengthening

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• to progress cutting materials from lighter-weight to heavier-weight, and easier challenges to more difficult challenges:

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start grading from large paper to smaller warping paper then cutting the ribbon

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Adaptations

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• Hold onto the blades as you hand the scissor to the child, as they tend to automatically put their fingers in correct holes. • Adjust wrist for correct direction • Hold the paper for the child or tape it to the edge of the table as he/she learns how to manipulate the scissors. • As the child's skills increase, grade the activity up by introducing material that is more difficult to cut. • Use adapted scissors: spring loaded/self-opening, easy grip, dual control handles

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Sensory integration

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refers to the way the nervous system receives messages from the senses and turns them into appropriate motor and behavioral responses. Sensory - recognition of sounds, textures, and visual images

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OT in School objectives

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1. Identify federal laws that govern the educational services to children with disabilities 2. Explain process involved in an individual educational program (IEP) 3. Types of services provided for children with disabilities 4. OT roles in the school systems 5. Differentiate between direct, consult, monitor roles in OT in schools. 6. Explore IEP writing of goals and objectives with treatment plan.

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Multidisciplinary Evaluation Team ( MET)

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The first step in identifying students with suspected disabilities to special education programs and/or related services is an evaluation by a Multidisciplinary Evaluation Team (MET). This team is composed of educational specialists, with knowledge in the area of your child's suspected disability.

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Individual Educational Plan ( IEP)

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Written education plan for a student with special needs developed by the team of professionals with the student and parent; is review and updated yearly, describes of the student is presently doing, what are the students learning needs, what services the child will need, goals and objectives.

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Individual Family Special Plan (IFSP)

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a process and written document required to plan appropriate activities and interventions that will help a child (0-2 years) and progress toward desired outcomes, review and update yearly, and describes child is doing currently, learning need, and services needed.

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Individual with Disability Education Act 1990 (IDEA)

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federal law provides funding and guidelines to states to support planning of service and delivery of service, including evaluation, assessments, for children who have or at risk of developmental delays/disabilities. - Funds provided through infant and toddler programs (part c of IDEA- early on, for 0-2 years) and (part b: of IDEA section 619 preschool program).

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Early Childhood special education (ECSE)

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federal and state mandated service for children with verified disabilities. Service may be provided in self-contained classes operated through the local school district or intermediate agency, or inclusive settings at the local district

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Early on

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comprehensive statewide program of early intervention service for infants to toddlers with special needs (0-2 years) and families (part C of IDEA)

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Understanding the law and how IDEA is administered

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- Early intervention -parent rule (no, yes for services) -Environment- least restrictive environment -Evaluation of the child and family goals - Benefits minimize the need of the services, low cost to the school give local resource to tap into

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Part 1: Criteria for specific disabilities: the process

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- Child study -Collect data- observation -parent permission to evaluate the child -parent always get the hand book (rules and regulation) - MET paper work to see if eligible (IEP) - goals, objectives, accommodation (every three years (MET) eligible or change to disability IEP- every year review

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OT roles in schools

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Sensory integration dressing- ADLs Fine motor Gross motor- swinging, running Behavior, social Adaptive skills Technology (assist) networking Handwriting Detective Consultant Educator Solver Accommodation (kids can do 1/2 homework at school then finish at home the rest)

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Screening and Evaluation

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-Developmental assessment - Observation - History (gather information from teacher, family) - Handwriting assessment -Hand writing without tears

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Qualifying Criteria for Special education services and who determines this:

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CI: Cognitve impaired IQ below 55 PI: Physical impaired ASD: Autism Spectrum Disorder EI: Emotional Impaired LD: Learning Disability HI: Hearing Impaired VI: Vision Impaired TBI: Traumatic Brain Injury ECDD: Early Childhood Developmental Disability SXI: Severe Multiple Impairment OHI: Otherwise Health Impairment

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Determination of Impairment:

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The child has to have one in the specialty area for example TBI ( MET and Physician input) Emotional impaired- Psychiatry input Vision impaired- Ophthalmology input Physical Impaired- PT and Doctor input Otherwise Health Impairment- Doctor's note

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OT Types of services

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- Work under education model instead of medical model services - Pre-school/ early delayed education 3-7 yrs - school based program 3-26 years - transition 14-17 years - Vocational - all services until 26 years

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Personal qualities of an OT and COTA Role

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- creative - flexible - ready to advocate - creative within the environment - Competent -Empathy - able to build relationship (rapport) - current knowledge of the development of age - working with family - be realistic -professional

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School base model: impacts on treatment

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- Class teacher model - Ethical issues

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Treatment planning (Class group work)

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- The student will be attentive for an hour each day -write the letters within the lines without switching hands with minimum assist - Student will be attentive for 30 minutes before taking personal breaks - Student will be able to print at l;east 75% eligible hand writing - 30 minutes for yoga for balance _ spending 15 minutes in sensory room

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