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Clinical studies have supported what many allied health professionals, teachers and support workers have observed – deep pressure can help calm children (see references below). Hotdog Roll (You can lay your child at the end of the empty quilt cover and slowly roll your child, wrapping them up in the quilt – some even like a squeeze or massage at the end, before being rolled back out).
Use of beanbag chairs in classrooms or at home laying on the stomach or back for consistent pressure input.
Deep pressure massage with hands or spiky ball (again, not all children like this type of experience, stop immediately if your child becomes distressed).
So, last week we looked at Dysgraphia, what it is, how it can present and what can be done to assess handwriting difficulties. The below are a mix of remedial, functional and compensatory strategies to support children who may have Dyspraxia or handwriting difficulties.
This can include ideas to support handwriting and especially for older primary children, ways of making writing more enjoyable and functional. Some children with handwriting difficulties and low postural control have trouble sitting upright at the table or placing their arm flat on a table, which impacts on writing.
Look at different forms of communication and expressing a point – this could be through oral presentation, mind maps, drawing, dictation apps or even using a scribe more for more intense writing tasks.
Copying can be trickier and increase anxiety and frustration, so reducing copying tasks can further support writing. For initially engaging children who clearly appear to have difficulty with handwriting, encourage them to start by drawing and writing about their interests – this can often be a good way into establishing a better idea of their true strengths in writing. Increasing proficiency on a word processor is important (especially if a child has Dysgraphia) as handwriting is not likely to be their first medium of communication going forward. SnapType for Occupational Therapy is another excellent app that provides reduced handwriting requirements by allowing users use their iPad or tablet to take a picture of a worksheet, whiteboard task etc. then using the device, type out the answers or responses.
These are just some ideas that can be used to support those kids who have handwriting difficulties, or in fact have Dysgraphia. Though this can vary, for many children the below is a brief summary of some of the signs of Dysgraphia. Often a mixture of cursive and print writing (especially at an age wen cursive has been introduced). Despite these mentioned challenges, a child that has signs of one of the above difficulties does not suggest that a child has Dysgraphia. Often a large focus for most OTs addressing handwriting difficulties, including Dysgraphia. Given our heavy focus on Sensory Integration at OTFC, we will also assess a child’s difficulties in touch perception and discrimination. In addition to these, the Handwriting Speed Test will provide insight into a child’s handwriting, compared to age norms of their peers.
From such assessments it is important to establish what therapeutic approach is going to be most effective as well as appropriate.
Moreover, from assessments and information given from a number of people that spend time or work with a child, one can gain a picture of whether or not the child does present with Dysgraphia. Once the above areas are somewhat more consolidated, then we we would place further emphasis on mastering the skills through practice and repetition.
For most children, if they have significant difficulties and clear signs of Dysgraphia, these difficulties will often continue and support will be required. Pencil grips, slant boards, Dictaphones, use of computers, scribes, voice activated software and even oral assessment can be very effective in providing options for those that want to get their ideas across, but struggle to do so. So, now that we know a little bit more about Dysgraphia, we will next week look at some specific ideas to help those with handwriting difficulties, such as Dysgraphia, addressing remedial, functional and compensatory approaches for home and school.
We are back this week to look at part 2 of our most recent OTFC journal club paper on Autism Spectrum Disorders. The below is a summary of the second part of the paper by Mark Fakhoury, from the Department of Neuroscience at the University of Montreal, and covers causes and diagnosis of ASD. There are a few genetic syndromes associated with ASD: Fragile X syndrome (FXS) and tuberous sclerosis (TS), both share abnormal genetic mechanisms similar to those observed in ASD. Epigenetics is an area that is becoming increasingly prominent, and this is certainly the case for studies in ASD.
Despite all this, there is still variation amongst studies about the impact of genetic and environmental factors in the development of ASD, and no single or major environmental factor has been identified as yet.
The ADOS is a standardized diagnostic observation tool that helps evaluate the social and communication deficits associated with ASD-related behaviours.
The strengths of the ADOS and ADI-R are that they are designed to differentiate children with autism from those with other neurodevelopmental disorders. In 2013, the old diagnostic system DSM-IV was replaced with the revised DSM-5, which removed specific diagnostic subcategories for Aspergers and PDD–NOS.
In order to receive a diagnosis for an ASD, the DSM-5 requires that individuals meet all three of the criteria in the category of social-communication impairments, and two of four criteria in the category of restricted and repetitive behaviours. These changes are already having an impact on the individuals currently diagnosed with ASD, especially those with characteristics of Aspergers or PDD–NOS. There is now more research discovering and developing new markers designed to better diagnose ASD. The above table gives an overview of the quantitative approaches used for the measurement of ASD markers.
So, we have come to the end of our discussion about Autism Spectrum Disorder and its causes, diagnostic factors, theories and characteristics. At OTFC, while we have regular PD meetings amongst the OT staff, we have also started the circulation of current research, to ensure we are keeping keeping up with research trends and best practice! As such, we will start to share some of what we have covered in our OTFC Journal Club blog post. Autism spectrum disorder (ASD) is a set of neurodevelopmental disorders characterised by complex behavioural phenotypes and deficits in both social and cognitive functions. Given the disorder is a spectrum, there are a range of symptoms.
Functional Magnetic Resonance Imaging (fMRI) studies have shown that brain activity in children with autism have morphological dysfunctions, such as long disturbance connections between pathways in the brain.
Neutotypical brain functioning requires a balance in the chemicals and neuronal structures that control excitation and inhibition in brain activity. There is more to the current ASD research story, and this will be examined next week, in part 2 of the blog topic – Causes and Diagnosis. Rice, depending on the form with which it is used, can help children’s explore their sensory world in a great variety of ways. Of course, there are plenty of ways to use rice and I am sure many of you out there have more to share, so please feel free to comment on the post and share your other ideas.
A system that is being employed in a number of schools, and we have had some success in Social Skills groups at our clinic, is Restorative Justice. Similar to this, some people often refer to emotions and emotional control as an ‘emotional balloon’ (i.e. Again, there are a number of other skills and strategies that can be employed, however the above list is a start and provides some useful differences to the ideas for younger children. Social stories around lunch and recess play are very effective strategy for many school aged children, but also for those in a kindy setting and at home. Another useful tool is to understand the differences in children’s abilities and interests. Alternatively, for those that are more anxious or have difficulty regulating their arousal during school, regulating activities supported by older peers or school staff (e.g. In addition to this, teaming up a child with a small group of kids with similar interests would certainly support further social interaction. Engaging in OT, for specialised support, or other general community based activities to further support gross motor skills (home and school) can increase confidence in gross motor skills, ability to engage in simple sport and overall play development.
Visual guides and timers at recess and lunch time can give a ‘gauge’ of how long these unstructured times are. Particularly for children that may be overwhelmed by the noise and commotion of recess and lunch, having a ‘quiet space’ or designated ‘safe area’ for children to retreat to, if overwhelmed, is very important.
It is also Important to have some structure for many transitions during the day, whether it is ‘relaxation’ or ‘specific regulation activities’, to support after recess and after lunch transitions. For many children, having to rely on Social Skills is a challenge at Kindy, School or even at home.
As some children will soon be entering into their final stages of Kindy, the transition to school is a big change. Providing support for group play (start with pairs) then build up to larger groups, especially for those children who are socially less confident. Start with simple physical games, so not as socially confronting, but focusing on taking turns, combining regulation and basic social skills. Parallel play (playing a game along side another child, without specifically interacting directly with that other child) is often a good starter. Sibling Play – how to support play and the inevitability of more heightened emotional situations with siblings at home and in the community. First and foremost, remember that siblings are often together and there is always going to be more disagreement in social play due to this. Trying to avoid too many ‘pet interests’ or ‘obsessions’ to encourage new play ideas and variation with play ideas.


These are just a few ideas and can provide some further guidance for teachers and families. Next time we will look at social skill support for junior primary school children and also for those entering middle and upper primary, where social awareness and social confidence are a factor.
At OTFC we always trying to work with children and families in a holistic manner. While we strive to apply Sensory Integration and Play in our work, we are always keep Neurodevelopmental approaches involved.
Primitive reflexes are so named, as they should have a short lifespan and are evolutionary reflexes important in the early years of life.
ATNR: This reflexes emerges 18 weeks in utero, and is elicited when the baby moves its head to one side, causing reflexive extension (straightening) of the arm and leg on the side in which the head is turned, and flexion (bending) of the opposite limbs. Spinal Galant Reflex: The Spinal Galant Reflex happens when the skin along the side of an infant’s back is stroked. TLR: The Tonic Labyrinthine Reflex (TLR) is essential for head management and movement helping prepare a child for rolling , crawling, standing and eventually walking. STNR: The Symmetrical Tonic Neck Reflex (STNR) is generally present between 6 to 11 months of age. Once you understand exactly HOW Toilet Training is done, it's much FASTER to get your child out of diapers for good. Make A School Memory Book With Your Child ~ Now is the time to organize a school memory book to complete with your child to capture the highlights for each month. How to Potty Train Your Child Before Age 2 - This woman is genius by using the bear to show her girls how to potty. You might have noticed that your child finds extra tight hugs or being squeezed during “rough and tumble” play quite calming. A common symptom of sensory processing difficulties, attention disorders and autism spectrum disorders is high arousal levels or anxiety. This is a nice deep pressure and proprioceptive activity –not all children like this experience; stop immediately if your child becomes distressed.
If the aim is to help our child to calm down, then our voices and movements should reflect this. Using salivary cortisol to measure the effects of a Wilbarger protocol-based procedure on sympathetic arousal: a pilot study. This week we will discuss some of the therapeutic approaches mentioned last week and some ideas and activities that can be tried at home and school to support handwriting difficulties, such as Dysgraphia. We have decided them up into Home Support and School Support, however some of the ideas can be done in either space. Using a slant desk or slope board can support a more upright stance, functional wrist position, reduce fatigue and enhance writing. If you feel like your child may be having a great number of difficulties in these areas, try some of the above ideas, and if there are still challenges, seek professional advice from Occupational Therapists or Psychologists in your area.
We have already touched on Dyspraxia, which has links to Dysgraphia, however Dysgraphia is a seperate entity and  a common difficulty experienced by children and observed by OTs. It requires motor, sensory, perceptual, praxis (motor planning) and cognitive functions and the integration of these functions. It is also important to understand that handwriting and drawing can often take time to develop and just because your child may have difficulty with this skill in kindergarten or Reception, it doesn’t necessarily mean they have Dysgraphia or significant writing difficulties.
Rather, a combination of these challenges can signify difficulty in fine motor tasks, such as handwriting, or potential Dyspraxia. Avoidance of these tasks during preschool can further impact on the foundation skills of the hands required for handwriting. These can be observed in standardised OT Assessments such as the Miller Preschool Assessment, Beery VMI and SIPT.
For many older primary children, changing pencil grips, spending hours on letter formation and correction may not produce the desired outcomes. Often after the assessment process, there is discussion around the best course of action to address writing difficulties.
Similar to other skills (particularly fine motor skills of cutting, threading, twisting) handwriting can be improved through support addressing specific motor plans and sequences. Furthermore, potential factors that can influence the predisposition to ASD include exposure to air pollutants, nutritional disorders infection occurring to the mother during pregnancy, poor socioeconomic status, and low maternal educational level. FXS is characterised by distinguishing facial features, and cognitive impairments of variable severity and TS (an autosomal dominant disease) has clinical manifestations including epilepsy, learning difficulties, and behavioural problems, with more than 40% of individuals with TS also having an ASD diagnosis. These focus on the behavioural characteristics of children with ASD and include: The autism diagnostic observation schedule (ADOS) and the autism diagnostic interview-revised (ADI-R). It involves the observation of a subject performing a variety of imaginative activities and socials tasks that normally illicit spontaneous behaviour. There are a number of neurotransmitters that have been identified as possible ASD markers (e.g.
This has led to some research into identifying facial phenotypes of those with ASD. The above markers have proven to show some clinical success for the diagnosis of ASD, but also for the identification of appropriate support to those with ASD, to improve social and cognitive skills. As we a re drawing close to the end of April and in turn Autism Awareness month, we hope this article provides further insight into where the research stands on Autism Spectrum Disorders. This week we will look at Autism Spectrum Disorders – examining current clinical features, theories and diagnosis. ToM studies have reveled those with ASD have significant difficulties in integrating mental state information. Part 3 looks at a simple idea that can be used temporarily, or if you get a few, longer term.
It effect is more or less determined by the activity chosen, as such we will look at activities and then explain further what they are doing to help support a child better understand their sensory world. Importantly this can provide deep pressure directly to the hands, which is calming on the nervous system.
Some children have difficulty sitting on their chair during dinner, so rather than getting a weighted lap pad, a try a bag of rice.
Some children seek sensations, especially touch, and rice can be a very effective way to support this. Just find a length of PVC, some rice, drilling a few holes into the pipe and running sticks through, then covering both ends, will be enough to make your own rain maker. So next time you decide to get rice, think about getting a bigger bag and using it for a bit…then cooking the rest! Here, if a social skill or situation requires refinement, it is often a great idea to pick that up in the moment. Replaying a scene or reflecting on what has happened and then allowing a child to ‘redo’ that scene can help reinforce the appropriate social skill, with scaffolding from other peers and adults.
We often find that older children are more able to appreciate the range of emotions, and can often correctly identify their emotions for each context. Once children reach the later primary, years 5+, then they there are often more cognitive strategies that can be employed. As some more anxious children do struggle with the unstructured nature of recess and lunch, visual guides and timers can provide a predictability and structure. These are often difficult times for many children, so the more structure and predictability, the better. Managing conflict, dealing with the unpredictability of another child (or children) and requiring language to support play are often skills that require scaffolding and teaching.
As such, we are going to look at a few stages of a child’s social skill development that we often see in clinic and also discuss with parents.
This can lead to increasing comfort levels and can provide a ‘guide’ for those more uncertain with social cues and social skills.
It can give some children confidence in being and playing around others, before delving into more complex reciprocal play.
Having specific and set time for individualised play 1:1 can lead to more positive experiences between a child and parent and also allows parents specialised time with each child.
A child with a retained Moro reflex past 4 months, may become over sensitive and over reactive to sensory stimulus. During the birthing process, it is one of the reflexes responsible for helping babies to ‘unscrew’ themselves down the birth canal. This reflex is designed to help the infant defy gravity in order to help them get up from lying on their tummy and into a crawling position. You'll find these 7 Tips for Easier Nighttime Potty Training very helpful if you are in the middle of potty training your son or daughter! Deep pressure is commonly used by occupational therapists to help reduce arousal levels and anxiety or support “sensory modulation”. For example, if we trial deep pressure massage with lots of energy and a big loud voice as if we are tickling our child, this will NOT have a calming effect. Ensure the child has a seat that gives them a 90 degree angle at their hips, with feet flat on the ground (or propped up on something if the chair is too high).
Apps such as Notability allow for voice recording, free drawing, adding text and collaborating projects  rather than type them.
When you identify all the individual components required in writing, it is not surprising that many children have great difficulty undertaking and being confident in the skill of writing. This is largely due to the difficulties in the foundation skills in writing, by a later age. However, while the role of environmental factors in causing ASD has been examined in more detail in recent yeas and, there is still no conclusion that a single environmental factor is sufficient to significantly influence a predisposition to ASD. The ADOS is commonly used in conjunction with ADI-R, which uses a stye of interview process with the parents in order to detect abnormalities that are consistent with deficits seen in children with Autism.


To accompany these, is the childhood autism rating scale (CARS), which uses a numbered score to determine the severity of the disorder based on specific criteria for clinical observations. In addition, revision have been made to the criteria for a diagnosis of ASD, to make it more precise and reliable. GABA, glutamate and Serotonin). For example, the neurotransmitter Serotonin plays an important role in behavioural regulation, autonomic and cognitive functions. As the article covers quite a bit of detail and is essentially a literature review of the current evidence in this area. Core symptoms include difficulty with social interaction and communication skills, as well as unusually repetitive behaviour – all that have a range of how they impact an individual.
Moreover, abnormal patterns of brain connectivity (hypo or hyper) have recently been observed in autistic children. Mutations and environmental factors that create an imbalance with an increase in excitatory synaptic inputs in the brain, or reduced inhibitory synaptic functioning, can lead to an increased risk of ASD. They are involved in functions such as the recognising motor acts by others and regulation of social, emotional, and cognitive tasks, and dysfunction of them may create difficulties in these areas. A bag of rice, a few small, coloured items (with an inventory), some material and plastic sheeting – and you can make a bag or items for searching and working on visual attention, figure ground and form constancy. Encouraging this form of problem solving can increase independence in social skills and decision making. Again, this is an example of how problem solving can support independence in problem solving. Given we are constantly striving for positive social interactions, when undertaking social skills groups, we are also keen to ensure conflict is managed in an equally positive manner.
Through the use of the scale, children can identify where they are feeling, or where others are, so they can modify behaviour to support interaction.
While some of these strategies about are also useful for that age group, some cognitive based strategies can be employed more successfully.
From here we will address some ways to teach and support social skill development and success at school and home. Primitive Reflexes are automatic, involuntary movements controlled from the brain stem and executed without cortical involvement.
Inhibition, though involvement of higher cortical centres, will ensure more mature neural structures to develop.
Functionally this can appear as poor impulse control, emotional lability, sensory overload, anxiety and immaturity, motion sickness and difficulties with balance and coordination.
This in an important reflex in the birthing process and should inhibited between by nine months. Prone – as shown in the photo on the left, when the head is tilted forward and the hands turn more fisted with elbow flexion. Children who retain the STNR may have not crawled or instead walked on hands and feet, bum shuffled or pulled themselves to stand then walk. This is because this type of touch to the body can cause the release of certain brain chemicals (such as dopamine – the “pleasure” neurotransmitter), creates a parasympathetic response in the body (more relaxed, neutral state) and can reduce cortisol levels (the “stress” hormone).
However, if we have a quiet calm voice, move slowly and rhythmically during the activity this will support a more relaxed environment.
This increases speed and efficiency and allows the student to focus more completely on complex thoughts and ideas. It can manifest itself as difficulties with spelling, poor handwriting and trouble putting thoughts on paper as well as speed and quality of handwriting. Importantly, we have a number of advances in technology that can provide alternate options that can be cost effective and more likely adopted by the child. As such, we will struggle to make progress in handwriting if there are difficulties in tactile perception, visual perceptual challenges or motor planning – hence the links with Dyspraxia. As such, more needs to be done to understand the role of environmental factors as a cause of Autism.
Similarly, the CARS differentiates ASD from other developmental disorders such as Intellectual Disability and PDD-NOS. In more than 25% of patients with ASD, Serotonin blood levels are found to be elevated, supporting links to altered levels in patients with ASD. Rather than include all the details, we have adapted the article and included a summary of the paper by Mark Fakhoury, from the Department of Neuroscience at the University of Montreal. Current findings have also highlighted that children with autism can have early over growth of certain brain structures, including the frontal cortex, amygdala and cerebellum. Many studies have found that individuals wirh ASD have higher levels of glutamate blood levels, suggesting higher glutamate (an excitatory neurotransmitter) levels in the brain. However, for children with ASD, ToM is delayed and initial aspects of ToM require them to appreciate that people can have beliefs about things, that may not be factually correct.
These neurons are important for social and cognitive functions and support coordination between the motor cortex and higher visual processing areas. fMRI, electroencephalography (EEG) and electromyography (EMG) have been used to show deficits in mirror neurons in children with ASD, suggesting difficulty understanding the actions of others.
Given that many older children have a greater understanding of emotions, Restorative practices are often a good way to further develop feelings of empathy, and enhance problem solving and emotional understanding for children – hence its fit for social skills. In this, it can also be an effective strategy to team up ‘good players’ and those who find it ‘more challenging’. Also providing scaffolding to guide’ what game will be played’, to initially provide ideas of what games to start and how to play. These types of reflexes have survived evolutionary changes in humans, as they work on enhancing the chances of survival, growth or development and protect a child’s body from its external environment. As mentioned above, if primitive reflexes are retained beyond 12 months of life, they suggest evidence of a structural weakness or immaturity of the central Nervous System (CNS).
A retained ATNR can include difficulty crossing the midline from one side of the body to the other (including eye movements, such as tracking words across a page), poor bilateral coordination, affected balance when the head is turned, and lack of dominant sides (e.g. Retention can impact postural control (particularly seated posture), coordination and sustained attention. This reflex should gradually integrate, with other systems maturing and disappearing by about the age of 3-3.5 years. Crawling is an essential skill which helps train the child’s eyes to cross midline and learn eye-hand coordination. Deep pressure touch is also known to help increase our body awareness and over extended periods of time reduce hypersensitivity of the tactile system.
Hyper-Responsivity to touch and vestibular stimuli as a predictor of positive response to sensory integration procedures by autistic children.
Because writing requires a complex set of motor and information processing skills, just saying someone has ‘Dysgraphia’ is not always sufficient or even correct! The best course of action is often dependant on the level of difficulty experienced with handwriting. The current diagnostic manual is the DSM-5, which has specific criteria, that if met, denotes diagnosis of Autism Spectrum Disorder. Alternatively, alterations in the inhibitory neurotransmitters, can account for clinical features including epileptic seizures and intellectual disabilities.
Here, we are often encouraging children to take more responsibility for their emotions and actions – though this does require explicit teaching and support from adults. Essentially, some children are more confident in play and those children can often be patient and supportive of others who find the unpredictability and social requirements of play with others difficult.
Retention can lead to reduced muscle tone, balance difficulties, motion sickness and has been linked to a tendency to toe-walk.
A retained STNR reflex can present as poor muscle tone, particularly a tendency to slump while sitting, impact concentration, reading and basic ball skills. Behavioral and physiological effects of deep pressure on children with autism: A pilot study evaluating the efficacy of grandin’s hug machine.
Criteria include difficulty with a number of social, cognitive and communication skills, as mentioned above. Despite research in this area, it is still not very well known how these neuronal abnormalities influence brain circuitry and in turn social behaviuors. Early symptoms can be identified by the age of 2-3, although later diagnoses are also common. There is also the suggestions that social difficulties are a result of difficulty recognizing and appropriately responding to emotions. As such, exploring social skills in children with ASD is crucial in identifying deficits and supporting emphatic and emotional capacities.
In addition, the presence of immunological markers, such as inflammatory cytokines and autoantibodies, also correlate with the underlying features of ASD.



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Comments

  1. 585, 29.11.2014
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  2. skazka, 29.11.2014
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