OT what is it??

OT what is it??
Kids learning through doing!!

Sunday, October 12, 2014

What is Perceptual Processing and Discrimination?

This question is often asked but not so easy a question to answer. The words “discriminating tastes”  bombard us on our TV’s, radios, iPads and billboards. Implying that if you ONLY do this  ONE thing you will be a discriminating connoisseur of ______________________________your whatever.

Such popular definitions can lead to Wishful thinking that can be all at once falsely uplifting, defeating, damaging, misleading, and often incorrect and for the layman, new parent, inexperienced care giver leaving in its wake a pile of misconceptions that leaves a parent truly trying to help her child but who is currently overwhelmed by an avalanche of theories and words that are pouring over the parent turning this barrage of information into a Mother’s Guilt Trip Tsumani.
So let’s pedal back to some very basic definitions of perception itself before with deal with the over-lay of perceptual interactions that eventually emerge as what is commonly referred to as "Processing”.

Without wanting to go too deep into the neurology of the eye the structures within the brain it touch, overlaps and influences lets think of perceptual processing as different instruments in an orchestra. Like an orchestra the perceptual system has its “players’ and functions and only when they all work in harmony do we get the real music of understanding.  (i.e. cognitive understanding)
First Chairs always go to the basic discriminators—theses guys let us all know we are here and more or less in the “seats” we should be in.

Continuing with the "Orchestra Metaphor" think of the brain as described below (an oversimplification, of course)--
Supporting the First Chairs Discriminators and the General Memory players.  These folks remember the most of the music but are really good at playing it immediately after hearing it.
The next section is for gets everyone in their right place and lets them know when they out of their proper place; visual spatial relationships. This section may have the least orderly section with chairs pointed all which ways, but this is the group that has to sound as ONE no matter which way their seats are turned and whether or not their seats turn, straight or backward. All there players have specific relationships with each other.

Our next section has a lot of similar instruments some larger, some smaller but all making similar and/harmonious sounds this included reading their music and those of the other guys so that they can stay on track with the other players.  In visual perceptual terms these are your Visual Form Constancy players.

Then comes Percussion loud when the need to be, soft when required that put the accent marks on well placed melodies while all the other music is going on, these players are your Visual Figure Ground Players.

But last but not least a real orchestra needs a conductor and that is your Visual Closure System.  Just like the conductor can hear the slightest from the back as clearly as he does with those from the front, the Visual Closure System organizes what is only partially seen and brings it forth as a full and integral player for our everyday “orchestra” call LIFE.

And it happens in nano-seconds, automatically as if it is on “auto-pilot.  That is for most of us.

When these systems are not working  (for whatever reason research as not as yet clearly defined) the child experiences life out of sync, discordant and at variance with their environment which may include peers, Teachers, therapists, etc. producing and child that may outwardly appear to be argumentative, have poor impulse control, conflicted, harsh to self and others all the while displaying a self that is inharmonious to both self and others.

Think of yourself with really good table manners invited to eat dinner, elegantly laid out and served on the main deck of a cruiser crossing the over to the Outer Banks of North Carolina.; a 2-hour almost always a smooth as glass  trip …….but…..expected rough currents appear the plates shift the food spills and after initial shock and dither the repair mode sets in.

Imagine time after time knowing how the music should sound, being invited to the best seat at the best table and then never getting there because “something happens’.  For little children the “something that happens” is all too often incorrectly absorbed as their fault and so they try with their limited repertoire of management behaviors to try to “fix it” and it gets worse and their self-esteem plummets producing an array of behaviors from isolation to acting out.
While indeed sensory integration is a huge part of out lives, there are other related systems that must be regarded as well. Independently and in conjunction within our neuro-muscular cognitive neighborhood called our body.  We all are the sum of many parts that create the whole of our unique selves.

Children are no different. Their impulse behaviors may not be as mature, their ability to delay gratification may be more frail, they may have all their emotions right on top and for the most part, their “honesty button” is always on.  Subtle is on their vocabulary list and “wait” is a concept readily used, often selecting more reactionary behaviors.

With computers giving us “popcorn brains” and fast food getting even faster, it is no wonder that we gravitate to fast answers as well. However with developing children with sensory motor perceptual growing constantly going on sometimes a slower more careful look both by observing and testing can give the best result for formulating a protocol that will help your child express their potential, ease into learning, and most of all develop a healthy curiosity that stimulates a life-long habit of wanting to learn.

The following checklist is provided for parents and teachers to begin the conversation IT IS NOT A DIAGNOISTIC TOOL. If more that 2 items in each are noted a full occupational screening is advised. Check items “yes” or “no” ONLY  (“well he does do this sometimes would be counted as a “no”) Remember we are looking for mastery, skills done without assistance and with proper form.

It can be used in part with a formal screening or as a checklist for teachers and related educational professionals.



__Problems taking on/off coat
__Cannot tie shoes
__Cannot manipulate buttons, snaps, zippers

__Needs reminders to keep track of belongings
__Rejects certain fabrics
__Always wears socks, resists bare feet
__Habituates wearing 1-2 specific outfits


__Poor motor learning (new skills)
__Mixed and/or no hand preference
__Poor handwriting
__Frustrated with fine motor tasks
__Difficulty copying from desk/board
__Writing “floats” off the writing line
__Poor gross motor (Running, jumping, skipping)
__Looses place when reading or copying
__Poor grasp (awkward use of pencil/crayon)
__Poor writing pressure
__Works unusually slowly
__Cannot make numbers in a column
__Cannot color inside the lines as needed
__Poor reproduction of shapes/forms/
__Reverse letters or numbers when reading or writing
__mix up his/her right and left sides


__Difficulty staying focused
__Overly dependent on teacher/parent
__Forgets homework/bookbag, etc.
__Poor sequencing skills
__Sloppy desk/notebook
__Easily distracted
__Gets easily into a “white noise space: so he startles with unexpected noises.
__Difficulty initiating tasks
__Difficulty transitioning from one skill/task to another
__Needs instructions repeated
__Gets confused easily
__Habitually late coming in from activities
__Difficulty skimming page for information
__Poor spelling
__Refuses to get hands dirty
__Gets upset if too many papers, toys in personal area
__Cannot stay with task for any long period of time


__Not many or few friends
__Complains that “someone hit” them
__Difficulty with cooperative tasks
__Multiple somatic (physical) complaints
__Poor eye contact when speaking to peers, adults, new acquaintances (circle one)
__Limited or absent awareness of ambient social cues (i.e. facial expressions, etc.)
__Needs teacher to soothe so that child can nap
___Stays to the fringes of the group instead of interacting with peers
__Talks or gestures to peers while eating
__Shares toys is able to give up a toy easily and go on to another one with minimal disruption
__Withdraws when an unfamiliar person enters area/class/playground etc.
__Messy eater
__Hesitant to interact with peers
__Problems lining up with classmates
__Difficulty discerning personal space
__Poor expression of thought, ideas, and feelings
__Overly sensitive to corrective remarks (criticisms)
__Avoid talking out in class, and/or participating in discussions
__Easily frustrated
__Speaks but only to 1-2 people otherwise very quiet or not speaking at all
--We work well briefly however gives up when first “mistake’ is made
__Not understand jokes
__Waits to watch the actions of peers before entering into an activity
__Has a hard time accepting “no” from teacher
__Has to have his name said many times before a reaction is elicited
__Difficulty reading body language or facial expressions
__Refuses utensils

The checklist was designed and created by Susan N. Schriber Orloff, OTR/L, FAOTA  from various sources and may be use with written permission and source recognition only .It is the intellectual property of Children's Special Services, LLC

Toe-Walking: What does it mean and is it important?

Comprehensive studies (conducted in Sweden on over 1,400 children) suggest that early toe-walkers outgrow their desire to do so and that it is not an indicator of mental or cognitive disorders.

However these studies do also indicate that the incidence of toe walking is higher in children with autism, muscular dystrophy and cerebral palsy than with typical children. But clearly NOT all toe walkers have associated neurological issues.

Children who toe walk past the age of 3 are at risk of developing shortened heel cords, balance issues, muscle stiffness, and associated pain in the legs and feet. It has also been associated with muscle co-ordination issues and can inhibit participation in sports, etc.

Toe walking is technically called an “equinas gait”.  Typical gait is with a heel/toe strike with reciprocal alternating movements.  The coming down on the ball of the foot is referred to a “plantar flexion”. The inability to have normal gait can impact gross motor movements (inclusive of range of motion of ankle and foot) as the child grows impacting not just the feet and legs but the back muscles as well.  Left unaddressed the child can develop contractures that would eventually render typical walking impossible.

In severe cases children have had to have surgery to release their heel chords and/or wear a brace (at night during sleep or an orthotic in their shoes) to stretch out the shortened muscles. Treatment is usually dependent upon how this impacts the child’s daily life.  If the child is excessively falling, demonstrates difficulty running and/or tires easily with gross motor activities then a medical consult is suggested.

While it is difficult to construct a specific correlation, toe walking has been observed in some children with sensory integrative dysfunction. This information is inconclusive because it is unclear whether these children had sensory-based mobility issues first or if they developed them because of the toe walking.  In either scenario, occupational therapy interventions can assist the child with ITW develop more secure proprioceptive and kinesthetic abilities to increase spatial body awareness and adaptive safety/play skills.

In an article by Brian Hoppestad, PT, MS, EdD in Physical Therapy and Rehabilitative Medicine (Vol. 24.Issue 22 Page 16) he states that, “…children with ITW* present with other developmental problems, principally language delays; and to a lesser extent, fine- and gross-motor deficits and visuo-motor impairments.3 Engstrom et al. estimated the prevalence of toe-walking in the general population. Of the children in the study cohort, 2.79% were previous toe-walkers, and 2.09% continued to toe-walk at 5.5 years of age. Children with a diagnosis of developmental delay or neuropsychiatric disorder had a prevalence of toe-walking of 41.2% (both inactive and active toe-walkers)…”
(*ITW; idiopathic toe walkers)

Current antidotal reports suggest that toe walking may impact skeletal maturation inclusive of potential joint deterioration. ITW should now be regarded as not as benign as previously thought. However most articles are case studies and not statistical so definitive answers are not available at this time.

Clearly ITW impacts a child’s posture as well as related mobility/stability patterns both necessary for attention and learning. Recent studies report however, that even with interventions some residual gait issues may persist into adulthood.

Toe-walking can also change the child’s visual field and visual scanning abilities. As they tilt forward this may force their eyes to move “up” so that they are looking from the “top” of their eye sockets and this could impact reading, writing and motor navigation. It could also factor into potential headaches and sensory organization concerns.

At this time there are no definitive “cures”, causes and/or treatments.  Additional ITW research studies are needed to answer these questions.

Thursday, October 2, 2014

Narcolepsy in Children

Narcolepsy is usually found in adults and although it is rare in children there are significant occurrences that studies have been published on it  from both the prestigious Cleveland Clinic and the Hospital of University of Pennsylvania.

The basic definition is that it is excessive sleepiness and that it can occur at any time throughout the day. It can interrupt regular sleep patterns as well as impact a child’s ability to learn and play.  It is thought to involve the areas of the brain that control sleep.  The Hypothalamus, the area of the brain that is our “stop and think” center also controls both wakefulness and sleep.  Over simplified, in conjunction with the brainstem (think about this being the base of your head and top of your neck)  and the back of the Hypothalamus keeps us awake (activating the “up center in the brainstem) and the front of the Hypothalamus puts us to sleep.

Sleep is not a passive process the brain is very actively  “thinking—cortex” inclusive of executive functions, memory and creative thought (think dreams that seem real).

Narcolepsy carries a DSM-5 code of 347.00 (Diagnostic Statistical Manual of Mental Disorders and an ICD-10 code of G47.419 (International Classification of Disease).

All of the above information is to affirm that the behaviors associated with narcolepsy, while they may seem intentional are not.  If fact these behaviors are so disruptive to the saccadic life rhythms that left untreated they can be associated with anxiety and depression.

There is no cure for narcolepsy but there is treatment that includes medication, behavior modification, education and activity regulation.

In school aged children the provision of scheduled nap times even in teens can be essential for the child to maintain critical learning abilities. Conversely forcing such a child to “stay awake” can cause frustration and negative behavioral reactions.

Narcolepsy should be classified under “other health impaired” for IEP purposes and specific accommodations and modifications should be made for these children. Suggestions for addressing narcolepsy during the school day are:
1.      Provide time for the child to take one or two short (15-20 minutes) naps during the day
2.     Make sure teachers are aware of the condition so that this behavior is not mistaken for laziness or lack of interest
3.     Avoid activities that could be a danger to health such as swimming, except when child is in an affirmed state of wakefulness
4.     Establish and maintain a set schedule so that the child’s wake/sleep rhythms can be addressed
5.     Avoid boring and repetitive tasks –diversity is key to sustaining wakeful interest
6.     Provide extra time for tasks and tests’ inclusive of short breaks during class and/or tests.
7.     Have teacher share with student “missed material” via email, slides, powerpoint, etc.
8.     Providing audio versions of textbooks may also be helpful
9.     Use of “SmartPens” that can record and write so that taking notes is facilitated during “down times”
10. Make sure the child stays active in class, let them sit in the back so they can get up as needed, sit on a sitball that gives sensory feedback, chew gum, etc.
11. Take and exercise break after a test for about 15-20 minutes
12. Studying and discussing assignments with a “work buddy” also increases alert behaviors.

At home:
1.     Keep the rooms cool
2.     Do homework while standing (maybe near the kitchen countertop)
3.     Limit after school activities
4.     Take a short nap when the child gets home from school
5.     Have a regular sleep schedule


Broughton RJ, Guberman A, Roberts J. Comparison of the psychosocial effects of epilepsy and narcolepsy/cataplexy: a controlled study. Epilepsia 1984; 25:423–33.