Ot Guidelines Child Specific

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Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

1

Clinical Guidelines of

Occupational Therapy to

Children with Specific

Learning Disabilities

Child and Adolescent Working Group,

Occupational Therapy Coordinating Committee,

Hospital Authority

2004


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List of contributors:

Magdalene Poon, Kwai Chung Hospital

Rita Ng, Yaumatei Child Psychiatric Centre

Shiren Wong, Castle Peak Hospital

Sanne Fong, Princess Margaret Hospital

Catherine Fung, Princess Margaret Hospital

Sally Choy, Kowloon Hospital

Pheobe Chan, Kowloon Hospital

Winnie Fok, Tuen Mun Hospital

Rosita Yip, Tuen Mun Hospital

Kitty Lai, Pamela Youde Nethersole Eastern Hospital

Jenet Wan, Northern District Hospital

Rebecca Chan, David Trench Rehabilitation Centre

Phoebe Cheung, Queen Mary Hospital

Linda Yau, United Christian Hospital

Cecilia Leung, Queen Elizabeth Hospital

Barbara Chan, Prince of Wales Hospital

Ingrid Ngan , Prince of Wales Hospital

Carol Chan, Alice Ho Miu Ling Nethersole Hospital

Statement of Intent

This guideline is not intended to be construed or to serve as a standard of medical care. Standards of

care are determined on the basis of all clinical data available for an individual case and are subject to

change as scientific knowledge and technology advance and patterns of care evolve.

These parameters of practice should be considered guidelines only. Adherence to them will not

ensure a successful outcome in every case, nor should they be construed as including all proper

methods of care or excluding other acceptable methods aimed at the same results. The ultimate

judgment regarding a particular clinical procedure or treatment plan must be made in light of the

clinical data presented by the patient and the diagnostic and treatment options available. However it

is advised that significant departures from any local guidelines derived from it should be fully

documented in the patient's case notes at the time the relevant decision is taken.

Co-ordinating Committee in Occupational Therapy, Hospital Authority


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CHAPTER ONE

INTRODUCTION

Specific learning disabilities (SLD) (sometimes referred to as specific learning difficulties

and learning disabilities) is a generic term that refers to a heterogeneous group of disorders that

covers a variety of disorders in area of spoken and written language, mathematics, perceptual motor

skills and the social and emotional components of learning. It is developmental in nature and may

impact to varying degrees on all aspects of the affected childrens lives at school, at home and at play.

Unless given intervention appropriately and systematically, SLD problems may persist to adulthood

(Scientific Committee of the Working Party on SLD 1999). In Hong Kong, Leong (1999) estimated

that there are about 15% of the students having these problems. Occupational therapists often

encounter these children when they had numerous functional problems in visual perception, writing,

reading, managing academic work and other daily living tasks. The most common SLD subgroup

cases referred for occupational therapy intervention includes developmental dyslexia (DD)

(sometimes written as dyslexia) and developmental coordination disorders (DCD) (also known as

developmental dyspraxia or clumsy child syndrome).

Developmental dyslexia (DD) is the largest SLD subgroup. It refers to children who show

measurably below-age reading and written language development despite average or above-average

intelligence, intact emotional adjustment and instructions. According to ICD 10, DD is included

under the specific reading disorder (World Health Organization 1992). There are about 10 to 20% of

children being affected with specific reading difficulties (Lam 1999). On the other hand, DCD and

developmental dyspraxia refers to children who show inefficiencies in visual, tactile, kinestheticand/or vestibular related motor processing. These difficulties can be manifested in either or both fine

and gross motor areas such as balance, postural control and graphomotor skills. In ICD 10, these two

diagnoses are under the branch of specific developmental disorder of motor function (World Health

Organization 1992).

Functional Problem of Children with SLD

Occupationaltherapists are concerned with the role performance of the children and its related

dysfunction. Children with SLD interfere the most basic and familiar tasks in writing, reading,

playing and activities of daily living. These domains of occupational performance are the scope of

practice of occupational therapy. Specifically, children with DCD are not only unable to complete

some tasks, but also have difficulties in quality of motor production and task completion (Coster and

Haley 1992).

Handwriting and Reading Skills

Handwriting skills are fundamental to children while they learn and study at school. McHale and

Cermak (1992) found that 31 60% of the childrens school day consisted of fine motor activities


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and of these tasks, much time was employed in paper and pencil tasks. The prevalence of children

with handwriting problems was 10 34% (Rubin & Henderson, 1982; Smits-Engelsman et al., 1995;

2001). Difficulty in mastery of the mechanical aspects of handwriting may interfere with higher

order processes required for the composition of text (Berninger & Graham, 1998). It is also

significantly related to fluency and quality of composition. Children may forget the ideas and plans

held in memory when they write too slow. They may have low performance at school, stressful

feelingsand loss of self-confidence.

Handwriting problems of the children with SLD may include:

- poor accuracy;- poor readability of letters, words and sentences;- inappropriate spacing between letters or words;- incorrect or inconsistent shaping of letters;- poorly graded pencil pressure;- letter inversions; and- mixing of different letter forms.In addition, there are also specific demands in writing Chinese characters which are square

shaped and occupieda uniform area in text. The structure of the characters is usually in left-right,

top-bottom, circular and semi-circular structures. Thus, in writing Chinese characters, it demands

much pen-lifts, sharp turns, following specific stroke sequences, attention to details of character

formation and writing within confined space (Tseng and Hsueh, 1997).

Reading is basically involving two steps: auditory process in retrieving meaning from graphic

symbols and conversion to sound and auditory acquisition to relate the written word to its

pronunciation as well as meaning (Woo and Hoosain, 1984). McBride-Chang and Chang (1995)suggested two basic cognitive functioning related to reading, the phonological memory and

orthographic memory, in which reading Chinese characters required the latter skills more. In addition,

Chinese words generally consist of two or more characters. And the same Chinese character can

have multiple meanings and pronunciations, depending upon context, thus, it demands the persons

metacognition (strategies readers use to comprehend and on how they plan, monitor and repair their

comprehension). Huang and Hanley (1995) conducted a study between childrens reading ability in

China, Hong Kong and Taiwan and concluded that reading Chinese depended less on phonological

awareness skills than English but more closely related to visual skills. Thus, Chinese children with

visual perceptual problems should have more difficulties in reading than children studying in

English.

Children with reading problems often have difficulties in recognizing and memorizing Chinese

characters. Therefore, they experience great difficulties in comprehension of the passage with

unrecognized words in between which seriously affect the learning process. In addition, they usually

perform poorly in dictation for they cannot memorize the Chinese characters.


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Activities of Daily Living

Children with DCD, in particular, may also have self care development and associated problems

in use of chopsticks in eating and the motor clumsiness may also affect the childs organization of

work in performing other self care activities such as buttoning, zipping, shoe tying and cutting nails.

In managing school work, children with SLD will have difficulties in packing school bags and

maintaining a well organized place for study. Thus, they need help to maintain notebooks for

assignments, records of their work and drafts of their assignments (Cermak and Larkin 2002).

Play Skills

DCD children were reported to have poor performance of various gross motor skills such as

balancing, throwing and catching a ball, skipping, hopping, or jumping. They also found to have

difficulties in engaging ball games and group sports such as soccer, basketball, and baseball. Some

of these children were unable to maintain their own personal body space and as a result, they bump

into other people and objects easily.

One study by Puderbaugh and Fisher (1992) examined play skills of children with

developmental dyspraxia between the ages of 12 and 54 months. They examined the qualitative

aspects of play and found that the children with motor coordination delays had poorer play skills

than typical peers in the areas of motor skills (including skills such as reaching, moving, and

manipulating objects) and in process skills (including skills such as sequencing, organizing and

investigating objects and actions). Clifford (1985) noticed that they often have history of quitting

community-sponsored physical activity programs. May-Benson (1999) found that 50 % of children

with dyspraxia had problems riding a bicycle, 67 % had poor ball skills and 71 % had difficulty with

sports.

Social Skills

Social skills was defined as a childs ability to develop and maintain appropriate peer

relationships is considered to be an important predictor of positive adult adjustment and behavior

(Cowen, Pederson, Babigan, Izzo and Trost, 1973). Research documented that children with SLD

exhibited deficits in social skills. Factors contributing to the social skills deficits included social

perception, behavioral problems, problem solving ability, and verbal communication (Cermak &

Aberson ,1997). McConaughty and Ritter (1986) examined the social competence and behavioral

problems of boys with SLD ages 6-11 by using CBCL. Parental reports indicated that boys with SLD

displayed significantly more behavioral problems in comparison to the normative sample.

LaGreca and Stone (1990) concluded that children with SLD had significantly lower peer

acceptance, fewer positive nominations, lower feelings of self worth and more negative self

perceptions regarding social acceptance.

Other literature also indicated that children with SLD had been found to have deficits in social

perception and are less attuned to nonverbal communication than typical peers (Axelrod, 1982;

Jackson et al., 1987; Sisterhern & Gerber, 1989). Studies also showed that a childs difficulty in social


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skills may relate to problems reading non-verbal cues, which were due to visual perceptual problems

(Harnadek & Rourke, 1994).

Self-esteem /Emotion control

ODwyer (1987) found that 11-year-old boys with motor coordination problems were less

outgoing, less emotionally stable, less tough-minded and self-reliant, less shrewd and calculating,

less self-assured, and more introverted, and had lower self-esteem and poorer peer acceptance than

their more coordinated peers. Schoemaker and Kalverboer (1994) also found that clumsy children

were more anxious, had low self-concept, were more insecure and isolated, and were less competent

in social and physical skills than their peers.

Koomar (1996) found that anxiety co-occurred with dyspraxia for 5- and 13- year-old children,

with a greater degree of anxiety manifesting with more severe dyspraxia.

Comorbidity

In addition, a variety of disorders may co-exist in a significant percentage of children with SLD

such as attention deficit and hyperactivity disorder (ADHD). SLD was present in 70% of children

with ADHD and children with such co-morbidity had more severe learning problems than children

with SLD but no ADHD (Mayes,Calhoun & Crowell, 2000).

Furthermore, among the children with disabilities, children with SLD had more problems in

perceived competence than those with physical or visual impairment. They tended to perceive

themselves as lacking in competence and consider failure as an indication of their own lack of

competence and thus as threat to their self-esteem (Weisz & Stipek, 1982). They either hid their

emotions, or reacted aggressively in achievement situations and following failure.According to Child behavioral checklist (CBCL) and Teachers report form (TRF), the dyslexic

group had significantly more behavioral problems than the control group. They had higher scores on

total behavioral problems, internalizing and externalizing sub-domains and the subscales attention

problem (Heiergang, Stevenson, Lund & Hugdahl, 2001).

For adolescents who were diagnosed with DCD at younger age, research indicated that reading

problems were associated with some increases in disruptive behavior in their teenagers.


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Conclusion

SLD affects the children in many aspects. Outcome studies showed that the problem affects the

childrens educational attainment, mental health and adult social functioning. Lam (1999)

commented that these negative outcomes were the result of inadequate effective help and

intervention in early years of the children. She suggested that early identification and intervention

against the negative effects of SLD were therefore essential.

A survey done in paediatric and child psychiatric settings in Hospital Authority in 2003 found

that it was among the five most common diagnoses referred to occupational therapy service (Child

and Adolescent Working Group, OTCOC, 2003). Occupational therapists provide individual and/or

group treatment in children in day and out patient services aiming at improving their functional skills

in learning and coping with daily activities.

This clinical guidelines aim at streamlining occupational therapy service provision for children

in SLD within different settings in Hospital Authority so as to improve the quality of service to these

children and ensure maximal independence in their daily lives.


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CHAPTER TWO

CONCEPTUAL FRAMEWORK AND

COMMON TREATMENT APPROACHES

Treatment Approaches for Children with SLD

In treating children with SLD, the model of practice frequently adopted by occupational

therapists is the Canadian Model of Occupational Performance (CMOP). Under this model, it

defines occupational performance of a person as the result of a dynamic relationship between

persons, environment, and occupation over a persons lifespan. It refers to the ability to choose,

organize and satisfactorily perform meaningful occupations that are culturally defined and age

appropriate for looking after ones self, enjoying life, and contributing to the social and economic

fabric of a community (Canadian Association of Occupational Therapy 1997). Specifically, we may

consider playing and learning being the major occupations of children. Occupational therapists

introduce environmental change aiming at enhancing occupational performance, or enabling persons

to restore, develop, maintain, or discover their occupational potential in their environment.

The process of occupational therapy practice is divided into seven stages:

Stage 1: Name, validate and prioritize occupational performance issues related to self-care,

productivity and leisure

Stage 2: Select theoretical approach(es)

Stage 3: Identify occupational performance components and environmental conditions

Stage 4: Identify strengths and resourcesStage 5: Develop action plan with clients

Stage 6: Implement plans through occupation

Stage 7: Evaluate occupational performance outcomes (Canadian Association of Occupational

Therapy 1997).

There are a number of treatment approaches in which occupational therapists will adopt during

the treatment of children with SLD. These approaches assist in focusing the core problems of

children for remedial therapy and adaptation to daily life activities.

Perceptual Motor (PM) Approach

Perceptual motor approach focus on the persons ability in perceiving sensory information from

environment, then responding with judgment and executing a coordinated motor response (Hong,

1984; Folio & Fewell, 1983). Perception is needed for all activities. Different from sensation, it has

to be learned. It means that the child has to interpret what he sees, hears, feels and smells from the

environment. Perceptual motor theorists all have similar assumptions that motor learning is a

foundation for perceptual development (Kephart, 1971, Frostig, 1973 and Getman, 1965). They

contended that learning problems occurs mainly because children fail to acquire normal

perceptual-motor development.


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The PM approach is a kind of bottom up intervention. It involves a variety of different

intervention procedures based on the assumption that a causal relationship existing between motor

abilities and that underlying perceptual qualities (Mandich et al., 2001; Sigmundsson et al., 1998).

Perceptual motor dysfunction is regarded as a sensory input disorder which results in maladaptive

motor responses (Parush & Hahn-Markowitz, 1997). The goal of the PM training programs is to

remediate the underlying component of perceptual motor dysfunction which results in learning

deficits.

Sensory Integration Therapy

Sensory integrative approach is one of the most frequently used approaches to treat children

with SLD that have sensory integrative dysfunction (Mandich, Polatajko, Macnab & Miller, 2001;

Vargas & Camill, 1999; Chu, 1996; Cemak, 1985). Evidences supported that sensory integration

therapy is effective in remediation of these children (Vargas & Camilli, 1999; Kaplan, Polatajko,

Wilson & Faris, 1993; Wilson, Kaplan, Fellowes, Gruchy & Faris, 1992; Polatajko, Law, Miller,

Schaffer & Macnab, 1991; Humphries, Wright, Snider & McDougall, 1990; Densem, Nutall,

Bushnell & Hoen, 1989).

Sensory Integration (SI) is a theory of brain-behavior relationships. SI refers to the ability to

organize, integrate, and use sensory information from the body and the environment. The concept of

SI arose from a body of work that was developed by Jean Ayres (an occupational therapist and

licensed clinical psychologist) based on studies in the neurosciences, physical development, and

neuromuscular function.

Sensory integration theory has three components. The first pertains to development and

describes typical sensory integrative functioning; the second defines sensory integrative dysfunction;and the third guides intervention programs. SI intervention procedures are based on the premise that

plasticity exists within the CNS. Therefore, therapy was designed to effect changes in the brain by

improving the efficiency with which the nervous system interprets and uses sensory information for

functional use. The control of tactile, vestibular, and proprioceptive sensory inputs is believed to

enhance nervous system function.

Biomechanical Approach

Biomechanics is a system of assumptions about forces affecting the human body. It is based

primarily on the mechanics of musculoskeletal system with the use of direct strengthening

techniques involving the application of resistance. It is commonly applied to impairments of the

musculoskeletal, cardio-pulmonary, integumentary, and nervous systems with its goal to increase

strength, endurance, and joint range of motion. In treating children with SLD, the application of

biomechanical approach mainly concerns the ergonomic of the children and the related

compensatory techniques in writing. The treatment considerations include: stabilities of posture,

shoulder and wrist and the environmental adaptations in the furniture arrangements and the

development of the pencil grip. In addition, the strength and endurance of the childs

musculoskeletal function of the hand will also be emphasized.


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Other Approaches

During the treatment intervention, there are numerous treatment approaches which the therapist

may apply. These include developmental approach, cognitive approach, compensatory approach,

adaptive approach, functional approach and behavioural approach. Developmental and cognitive

approaches are always fundamental to the treatment to children. Therapists will consider the

developmental sequences and establish their performance skills the children have or can develop at

their current level of function. Cognitive approach focuses on examining the underlying cognitive

deficits of the children. The investigation of the cognitive deficits in relation to the children with

SLD and plan related training activities is very essential. Therapists need to update themselves with

recent neurological studies and the relationship with these childrens problems. Compensatory and

adaptive approaches need to be considered as the children still show residual symptoms after an

intensive course of training. When adopting these approaches, therapists may consider the

prescription of aids and adaptive devices together with the other human and non-human

environmental considerations. Throughout the process, the therapist will also apply the

biomechanical approach to ensure that the decisions made are practical to the children.

Very often, the treatment intervention involves teaching learning, thus, the incorporation of

behavioral approach is common. The behavioral theory based on the premise that most behaviors are

learned and the interaction between the human beings and the environment attributed to the learning

of behavior. Thus change of behaviors can be resulted by monitoring the environment through the

application of various learning principles.

The techniques based on operant conditioning had been widely adopted for treating children

with SLD. Shaping which included breaking down the target behavior such as hopping in sequence

into steps and reinforce for achieving certain step of the target such as imitate hopping for once onlyor reinforce for approximation to the target behavior such as praising for touching a throwing ball

instead of really able to catch the ball. Children with SLD often faced frustration when performing

tasks which they had difficulties in doing. Shaping lowered the level of the tasks and thus effectively

set a more achievable target for the children. Positive reinforcement is also a frequently used

technique to increase or maintain the desired behaviors. The reinforcers used may include either

immediate positive feedback from the therapist or through a token system. Behavioral contract and

token economy can be designed to increase the compliance and motivation of home program

prescribed during training. Time out and response cost procedures are designed to decrease or

eliminate undesirable behaviors by removing reinforcing events from the childs environment. In

particular, the children with SLD comorbid with ADHD may need these procedures in order to

maintain the disciplines and group orders so as to ensure effective treatment. Therapist could remove

the child from the activities to time out in a corner when the child is overly impulsive,

non-compliance, temper tantrum during training. In response cost, therapist could give tokens to

specific behaviors such as remain seated, asked permission before acting out and child would lose

the token once he or she cannot achieve the specific behaviors. In addition, inappropriate behaviors

such as hyperactivity or tantrum could also be reduced by stimulus control, that is by avoiding

situations that produce conflict, by avoiding the over stimulating activities and by engaging the child


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in individual training instead of group training.

All in all, occupational therapists always consider the functional level of the children in daily

lives. Thus, the functional deficits at school, home and play, the three major areas of the children are

essential to the formulation of treatment plan of these children.


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CHAPTER THREE

TREATMENT INTERVENTION FOR CHILDREN WITH SLD

Occupational therapy intervention to children with SLD mainly related to three sets of training

activities based on perceptual motor approach, sensory integrative approach and the functional skills

training. Occupational therapists will first identify the childs major problems in the daily activities,

mostly related to their academic difficulties. Then, therapists will assess the related performance

components of the problems. For detail of the assessments done to the children, please refer to

Appendix 1. The treatment programs given will either be in individual or group format or both.

Parent involvement is very important throughout the treatment.

Common Treatment Intervention

Perceptual Motor Intervention

Perceptual motor (PM) programs require the child to perform specific tasks so as to increase

perceptual motor skills necessary for optimize functioning (Parush & Hahn-Markowitz, 1997;

Sellers, 1995). It aims to ameliorate the process that results in learning deficits by treating the

underlying component deficits (Schaffer et al., 1989). Occupational therapists would manipulate and

structure the environment by a sequence of activities with specific task instruction in the way that to

elicit positive visual perceptual response from the child. Different from general educational program

used in school, PM program put more emphasis on skills teaching. Therapists would direct the child

to do the tasks, starting from simple tasks and move on to more complex tasks (Kephart, 1971;Platzer, 1976). The approach also believes that repetitive practice would help the child to master

skills (DeGangi et al, 1993; Seller, 1995). Home program is suggested to encourage child to practice

their skills at home. Besides, parents were encouraged to participate in the program, and the therapist

assisted them to identify and understand their childrens difficulties.

Perceptual motor training can beprovided in group session or individual session. The activities

that are commonly employed in PM programs include fine and gross motor tasks, visual-motor tasks,

visual perceptual tasks, eye-hand coordination tasks and visual perceptual tasks. Examples of

therapeutic activities that can be used are putty games, sponge stamp art, drawing maze, etc.

Sensory Integration Intervention

Sensory Integration treatment for children with SLD using a SI frame of reference initially

focuses on facilitating improvement in the functional support capabilities (FSCs) (Cermak & Larkin,

2002). Deficits in functional support capabilities are viewed as key components contributing to poor

praxis (Ayres, 1985). And poor praxis is one of the weakness area found in children with SLD. The

functional support capabilities are mainly physical capabilities that underlie and support praxis and

other abilities. They help integrating the two distinct types of sensory systems input, alert/arousal,

and discrimination, through providing avenues for modulation of alert. Arousal input and avenues


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for interpretation of discriminative input. Treatment is aimed at underlying deficits rather than

specific behavior or skill development.

The purpose of using a sensory integration approach is to build a repertoire of motor responses

based on good or improved functioning of the functional support capabilities, which support the

childs improvement in the process of motor planning (versus a particular motor skill). Sensory

integration relies on the building of motor patterns by using multiple contexts, and changes in the

surface characteristics of the task. For example, an activity that includes challenges to proprioception

and balance would help improve functioning in those areas as well as increase muscle tone and

cocontraction, all in preparation for an activity demanding more difficult motor planning. Hopping

ball is one of the activities that provide proprioceptive stimulation along with a variety of balancing

challenges. This activity can be incorporated with different kinds of tossing activities and obstacles.

Functional support capabilities are also incorporated into therapeutic activities aimed specifically at

improving praxis. The child with tactile discrimination problem may lead to poor fine motor

coordination (for writing, cutting, eating, fastening clothing, etc.). The child cannot locate where his

body is being touched. His/her performance is much like someone trying to pick up and put together

tiny nuts and bolts while wearing gloves. The muscles and nerves are working adequately, but the

sensations do not accurately direct the brain to carry out the necessary fine motor control. Thus,

when attempting a task, the childs movements may be awkward.

A child with inadequate kinesthesia and proprioception awareness may lead to handwriting

problems such as applying excessive pressure in writing, poor pencil control, etc. Activities that

include challenges to tactile, kinesthesia and proprioception senses may improve the childs fine

motor skills and handwriting. For example, Feeley-Meeley is one of the commonly used activities

that can improve childs stereognosis. In addition, activities related to the kinesthetic abilities such asbalancing on swing, scooter board, etc. All this adds multiple sensory systems and the opportunity to

increase integration of those senses (SI), with adaptive responses resulting in increased support for

accomplishing praxis. The types, intensity, frequency, and duration of sensory input are carefully

evaluated and modified to achieve an optimal level of arousal.

Functional Skills Training in Reading and Writing

Reading

Reading is one of the major deficits of children with SLD. It highly affects the childs learning

from books and other written references. Learning to read Chinese characters involved three basic

skills included phonological process, orthographic process and semantic process. Reading training

will therefore be focused on learning radicals, stroke patterns, characters with same phonetic

meaning and Chinese word structure. For more advanced reading skill, learning of word types such

as noun, verbal and adjectives; reading comprehension; identify key words in sentence; the

understanding of what, why, when, who, where, whose and how questions would be stressed. These

skills would help children with SLD to deal with functional problems in doing homework. It

facilitated their understanding and reading of key words in questions. Children also learnt the

techniques to search and give relevant information to questions. It increased the association between


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the phonetics, orthographic and semantic meaning of a character and hence decreased the confusion

for characters of similar characteristics. The child would have increased accuracy in both dictation

and reading of the characters. Throughout the training process, in order to increase the childs basic

sensory and motor performance, occupational therapists will adopt multi-sensory teaching

techniques: the use of tactile, visual, auditory and proprioceptive input while teaching. In addition,

the children with SLD usually have poor motivation to learn owing the past failure experience,

reinforcement program should also incorporated in order to improve childs motivation, attention

and compliance of the training program. Parent training is also essential as part of the program.

Parent will be invited to practice the learnt skill with child at home. The content of parent training

may include general guidelines on

- the choice of time for reading practice;- coaching techniques in reading such as paired reading and- handling childs misreads.

Handwriting

Handwriting is a complex skill encompassing visual motor co-ordination, cognitive, perceptual

skills as well as tactile and kinesthetic sensitivities (Maeland, 1992). Handwriting problems in SLD

children are often the contribution of more than one of these components. As a starting point,

occupational therapists will deal with these core component skills first. Sensorimotor and perceptual

skills are the two major focused areas. These include postural control, shoulder stability, ulnar

stability, power and pinch strength, in-hand manipulation and dexterity, bilateral integration,

oculomotor control, kinesthetic and proprioception awareness, visual discrimination, position in

space, spatial relationship, visual memory, form constancy etc.. Throughout the training,biomechanical, perceptual motor and sensory integration activities are incorporated.

Generalization of these core skills in functional handwriting is the key of efficient writing.

Treatment plan will follow the developmental sequence of children. Skills like pencil grip and pencil

control, pressure of stroke are addressed through multisensory feedback and perceptual motor

activities. Sometimes assistive writing grip will be used to facilitate a functional pencil grip.

Besides the mechanical aspect, writing also involves stroke control, stroke and form identification.

As mentioned in last session, Chinese characters are a combination of different strokes and radicals,

putting together in a specific spatial alignment. So learning of component strokes and radicals is the

pre-requisite of writing. Next is the general rule of spatial alignment in Chinese characters. Visual

scanning training and strategies are also included in training program. These training will facilitate

Chinese characters identification as well as writing legibility, which in turn enhancing accuracy and

speed.

Environmental modification is another strategy that occupational therapist usually employs in

handwriting treatment. Examples are ergonomic factors of chair, table with reference to the body

position and use of slope table. Besides, human environment modifications such as adjustment of

school demand like homework load and examination time should be made. Liaison with school and

parents are crucial for the successful integration in daily living.


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Focus of Occupational Therapy Intervention at Different Stages of Development

Individuals with SLD may need occupational therapy treatment in different age range ever since

they start to learn reading and writing. Thus, specific focuses of these individuals who receive

treatment at preschool age, school age and adolescence stage will be discussed below.

Focus of Occupational Therapy Intervention at Preschool Children

Preschool children with Specific Learning Disabilities (SLD)

Children with SLD are those who exhibit difficulties in managing skills and purposive

movement in the absence of abnormal intelligence, limited physical strength and gross sensory

deficits using the standards and conventional neurological assessment (Gubbay, 1975; Aryes, 1979).

It is a heterogeneous group although all of them show some degree of inability in performing skilled

or complicated motor tasks. Very often, parents would detect their problems rather early. For

examples, they might have found their children poor in hand dexterity or handwriting skills, poorly

manage simple self-care tasks like buttoning, fall frequently and so forth. General characteristics of

the group include poor tactile perception abilities, poor body scheme, poor gross and fine motor

skills, poor coordination, difficulties in transferring skills in daily tasks; and articulation deficits

(Ayres, 1979; Williams, 1983). These problems clearly create lots of distress in the children, and are

associated with a high incidence of learning difficulties, school failure and psychological problems.

These problems would become a major barrier as they progress to increasing academic demands.

Assessment for the Pre-school children with SLD

A comprehensive and thorough assessment is required to measure the different abilities level ofthese children (Appendix I). Using various measurements to assess these children, researchers found

that these children present different patterns of strengths and weakness in terms of their abilities

level (Hartlag & Telzrow, 1983; Fletcher, 1985). OBrien, Cermak and Murray (1988) indicated that

degree of clumsiness was significantly correlated with the degree of visual perceptual, visual-motor

deficits, but clinical manifestations of these deficits could vary greatly among individuals. For

pre-schoolers, assessment will focus more on their hand strength, eye-hand coordination and in-hand

manipulation in managing simple task/play, how they get use of the simple hand tools such as

chopsticks management and scissors manipulation; and their visual perceptual skills. Assessment

should be conducted in relation to their age-level.

Intervention for the Preschool children with SLD

To design the treatment program to preschool children with SLD, various approaches have been

adopted by occupational therapists. The common goal is to reduce the degree of dysfunction and to

promote/ maximize the preserved skills. Both group and individual sessions can be held. Parents

participation is also necessary for the effectiveness of the program. The focus of intervention based

on the major treatment approaches are listed as follow:

Perceptual motor training:

- Aims to remediate the underlying components of perceptual motor dysfunction which results in


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learning deficits

- e.g. Eye-hand coordination training, in-hand manipulation training, pre-writing skill training,

visual perceptual training

Sensory integration therapy:

- Focus on all senses, i.e. vestibular, tactile, proprioceptive, auditory, visual and olfactory.

- Aims to build a repertoire of motor responses which support the childs improvement in the

process of motor planning.

Functional skills training of preschool children includes teaching the specific hand function

skills such as buttoning, use of knife and fork, use of scissors, shoe-lacing, etc. and also assess and

train their writing skills or pre-writing skills required at nurseries or kindergartens.

In general, preschool children referred are over 4 years old in which the children have started

pre-writing or writing activities in their nurseries/kindergartens. Their attention is relatively short

and the fine motor skills are not well developed. Thus, activities assigned will be shorter in duration

and fun-based so as to minimize their negative feelings towards writing.

Focus of Occupational Therapy Intervention at School Aged Children

School-aged Children with SLD

During school age, where children experienced loads of academic demands with new Chinese

and English vocabularies, children with SLD experience many academic difficulties in all the major

subjects. With frustration and frequent failures, some might have emotional, social and family

conflicts (Silver, 1989).

Assessment for School-aged Children with SLD

Assessment for school-aged children with SLD emphasis on functional skills in writing, readingand the related core problems in visual perceptual and motor performance of the children (Appendix

I).

Intervention for School-aged Children with SLD

Similar to the intervention for children at pre-school age, the major approaches adopted are

perceptual motor, sensory integration and biomechanical approach. The goals are to

promote/maximize the preserved skills and reduce the degree of dysfunction. Early intervention and

detection is crucial as the common and major vocabularies are introduced in the first two years in the

primary school. Both group and individual sessions can be given to the children. Parents

participation is essential so as to ensure the effectiveness of the home programs and increase their

understanding towards the childrens difficulties. Close liaison with the school teachers is also

important as the children may need environmental adaptations to cope with the school work. These

include cutting of demand in homework and extension of examination time for these children.


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The major elements in implementation of the treatment programs under different approaches

are as follows:

Perceptual Motor Approach

- Use individualized treatment program in a structured and graded way to remedy

perceptual-motor deficits

- e.g. fine motor skills training, visual perceptual training and functional skills training such as

reading, writing

Sensory Integration Therapy

- Use multi-sensory approach such as visual, auditory, tactile, kinesthetic or vestibular modes to

reinforce learning and facilitate the process of motor planning

Biomechanical Approach

- Apply this approach on muscle strengthening for motor learning and processing, and

compensate deficits on functional tasks such as writing.

Functional skills training for the school age children, in addition to those in pre-school age,

will involve more coping skills training in dealing with the academic work at school and at home.

These may include strategies in packing school bags, planning homework schedule and general

organization in work at home and at school. Sometimes, compensatory approach is needed where

occupational therapists will advice the teachers in the amount of homework assigned and the need in

lengthening the examination time for the children.

As the children often comorbid with ADHD and other emotional problems, treatment provided

will also emphasize the application of behavioral principles to increase motivation and facilitate

learning especially on academic skills and deficits area.

Focus of Occupational Therapy Intervention at Adolescence

Adolescents with Specific Learning Disabilities (SLD)

As experiencing a normal development, adolescents can master and integrate their

neuron-developmental function (namely, physical or somatic growth, neurological, motor (gross and

fine), visual, cognitive, auditory, language, kinaesthetic, psychosocial, perceptual-motor, integrative

and adaptive) maturely. If deficits in one or all of these neuro-developmental domains are found,

clients may have attention, cognitive and learning problems. Such problems will become more

severe when they reach the adolescence stage and enter an educational setting where the

environmental demands of social interactions and academic performance become more complex.

They will experience serious impairment in function in one or more of the following areas:

mathematical reasoning or calculation, expressive (written or oral) or receptive language (listening

and comprehension), basic reading skills or comprehension, sustained attention, and goal directed

behavior. Problems in attention can affect eye-tracking ability and thus impact their reading ability

(Pratt, 2002). Therefore, it is important to have intervention for the clients with SLD.


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Assessment for the Adolescents with SLD

Comprehensive assessment should be done and recorded (App.1) in order to provide important

clues to designing effective treatment intervention. Additional screening and assessment may be

necessary to assess the clients self esteem and problem solving abilities since they have been

exposed to the SLD dysfunctions for a prolonged period.

Intervention for the Adolescents with SLD

The treatment goal for the adolescents with SLD is minimizing disability and maximizing

potential. Both individual and group treatment sessions can be held. Home program will be provided

as well. As it is mentioned before, SLD is a life long problem to the clients from childhood to

adulthood. Their learning skills may reach a plateau in the adolescent stage. As a result, their ability

may not able to meet the demand of a complex society. Their self-esteem and self confidence may be

affected. In order to maximize their residual ability and prepare for the social and vocational life in

future, the intervention for the adolescents with SLD should not only be focused on special teaching

technique, skill training, but also emphasized more on the compensatory technique. Furthermore, the

intervention on psychosocial aspect of the clients e.g. social skill, life goal / expectation adjustment,

self-confidence development etc. will be addressed to as well. The following recommendations are

listed as reference:

1. Skills training:

- Fine-motor training, transfer of skill training, problem solving skill training can be provided to

adolescents with writing, mathematics problems.

2. Adaptive / compensatory intervention:

- Extend exam time limit, use type writers / computers to lessen the stress caused by fine motor

deficits- Use aids like ruler or bookmark as a place holder to focus attention

3. Advice parents/teachers in the teaching techniques to the adolescents:

- Teach concepts or comprehension skills through direct instruction

- Provide specific intensive courses / tutors in reading, arithmetic and writing etc.

- Improve memory skills by teaching through repetition, cue cards etc.

- Tape recording of lectures to allow slow learners to have repeated revises on the lectures

- Goal / expectation adjustment to both the client and parents if necessary

4. Evaluation on the need for pre-vocational skill development by vocational assessments and

vocational exploration assessments. Advices on the vocational choice or areas for further studies can

also be given

5. Self-confidence, motivation and self-esteem establishment through the successful experience gain

from the treatment session


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CHAPTER FOUR

GLOSSARY OF TERMINOLOGIES

Area Terminology Definition

Visual Perception

Alertness It is reflective of the childs natural state of

arousal

Selective attention It is the ability to choose relevant information

while ignoring the less relevant information

Visual vigilance It is the conscious mental effort to concentrate

and persist at a visual task

Visual attention

Shared attention It is the ability to respond to two or more

simultaneous tasksShort term memory It is the location necessary for newly acquired

data perceived from the environment. The

information gathered by visual short-term

memory disappears if it is not processed further

Visual memory

Long term memory Visual memories that endures for days and years


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Object/form

recognition

It is the ability to identify the object by its

features

Object/form

matching

It is the ability to note the similarities among

specific objects

Form

constancy

It is the recognition of forms and objects as the

same in various environment, position and sizes

Figure ground It is the differentiation between foreground and

background forms and objects. It is the ability to

separate essential important data from distracting

surrounding information

Object/form

perception

Visual closure It is the identification of forms or objects from

incomplete presentations.Spatial

concept

It is the ability to understand how to place one

object in relation to another. For example: in, on,

under, out of, together, away from, up top, apart,

toward, around, in front of, high, in back of, next

to, beside, bottom, backward, forward, down,

low, behind, ahead of, first, last, etc.

Visual

Discrimination

Spatial

perception

Spatial

relation

It is the ability to determines the position of

objects relative to each other, the ability to

determine the direction of forms

Directionality It refers to the way print is tracked during reading

and lay down during writing


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Sensory Motor

Tactile Tactile input is received through tactile receptors

that are found throughout the skin and, are

activated by externally applied stimuli such as

touch, pressure, pain, and temperature

Vestibular Along with the visual and proprioceptive system, it

is responsible for detecting changes in the direction

and rate of rotary head movements, linear head

movement and head tilt

Proprioceptive/Kinesthesia Those receptor mechanisms, most noticeably in the

joints, muscles, and tendons, that signal

information about the posture and movements of

the body as a whole. It referred to the awareness of

where the body parts are in space and the position,

force and extent of their movement that arise from

information from the muscles, joints, and skin. It

promotes awareness of extent, weight, timing, force

and direction of movements

Sensory

Motor Planning/Praxis It is the process of organizing a plan for action. It

involved the choosing of starting point, the

direction, the speed, and the exact time to change

direction, and the place to terminate the movement


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Joint stability It refers to the contraction of muscles around a joint

to hold it steady. It includes balance reactions;

trunk control against gravity; shoulder

cocontraction and joint stability; arm and hand

strength; and the ability to isolate movement of the

arm from the shoulder and the trunk

Muscle

strength

It is essential for the development of the

development of well-formed hand arches, which in

turn are important for efficient pencil grips

Postural motor

control

Muscle tone It is the resistance of a muscle in passive elongation

or stretching

In-hand

manipulation

It is defined as an adjustment of an object in hand

after grasp

Eye-hand

coordination

It is the development of highly refined fine motor

skills. Its development is based on the integration

of sensorimotor control mechanism that can locate

the hand and object in visual space and bring them

together

Fine motor

skills

Bilateral hand

coordination

It involves a sequence of bimanual movements in

which the child simultaneously controls arm and

hand stabilization and movement. These

movements can be asymmetric and dissociated

when performing the task with both hands

Motor

Sequence and

timing

Reaction and

movement

time

Reaction time analyzes important information

about the speed and accuracy of sensory

information processing, the translation of that

processing into a plan of action and the initiation of

an overt response.

Movement time is a measure of the speed ofmovement execution and can be viewed as an

indirect indicator of the efficiency of motor system

function


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APPENDIX I

Gum Label

OCCUPATIONAL THERAPY DEPARMENT

Occupational Therapy Assessment Report

Date of Assessment :

Date of Report :

I. HistoryBirth/Medical History (only applicable for cases with history with very low birth weight)

Gestation Period : Weeks

Mode of Delivery: NSD CS Vacuum Others________

Birth Weight : kg

Complications :

Social History

Family Background:

Major care taker Time spent with child on homework________

Siblings:

EB/ES/YB/YS EB/ES/YB/YS EB/ES/YB/YS EB/ES/YB/YS

Age: Age: Age: Age:

Education level: Education level: Education level: Education level:

Academic performance: Academic performance: Academic performance: Academic performance:

Parents concern and attitude:

Major complaints and concern

Expectation

Current strategies in handling


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Schooling:

School name Grade Hx of repeat

Academic performance (performance in Chinese, English & other major subjects)

Peer relationship

Special Service

At school At Special Education

Dept

Educational Manpower

Bureau

Other rehabilitation

services

II. General Behaviour

III. Clinical Observation

Postural Stability

Muscle tone:

Sitting tolerance:

Fine Motor Skills

Hand dominance: _______

Power grip: (unit ___)

Pinch grip: (unit ___)

R

R

L

L


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Tripod grip: (unit ___) R L

Dexterity/in-hand manipulation:

Bilateral coordination:

Copying and writing skills

Pencil grip:

Pencil control:

Legibility:

Accuracy:

Stroke

Sequence:

Speed:

(Tension on pencil, pressure on paper, pencil manipulation)

Self Care


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IV. Assessment Results**

Movement Assessment Battery for Children (Movement ABC)

Manual Dexterity

Ball Skills

Static and Dynamic Balance

Total Impairment Score

Motor Score Percentile(HK/US norm)*

* Remarks : < 5 percentile = severe; 5-15 percentile = borderline; > 15 percentile = no problem

**Select specific assessments where appropriate


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Brunininks-Oseretsky Test of Motor Proficiency (BO Test)

Gross Motor Composite

Subtest

1.Running Speed and Agility

2.Balance

3.Bilateral Coordination

4.Strength

Gross motor composite

(subtest 1-4)

Standard score

(mean = 15, S.D. =5)

Standard score

(mean = 50, S.D. = 10)

Percentile

(US norm)

Fine Motor Composite

Subtest

5.Upper limb coordination

6.Response speed

7.Visual motor control

8.Upper-limb and dexterity

Fine motor composite

(subtest 6-8)

Standard score

(mean = 15, S.D. =5)

Standard score

(mean = 50, S.D. = 10)

Percentile

(US norm)

Complete Battery

Subtest

Upper limb coordination

Gross motor composite

Fine motor composite

Battery composite

Standard score

(mean =15; S.D. = 10)

(mean= 50; S.D. = 10)

(mean= 50; S.D. = 10)

(mean= 50; S.D. = 10)

Percentile

(US norm)


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Peabody Developmental Motor Scales

Development Motor

Quotient

(mean =100; S.D. =15)

Gross motor subtest

Skill A : Reflex

Skill B : Balance

Skill C : Non-locomotor

Skill D : Locomotor

Skill E : Receipt & propulsion

Total score

Age equivalent

Mean S.D.

Fine motor subtest

Skill A : Grasping

Skill B : Hand use

Skill C : Eye-hand

coordination

Skill D : Manual dexterity

Total score

Age equivalent

Mean S.D.

Remarks: -1 S.D. = no deficit


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Developmental Test of Visual-Motor Integration (VMI)

Visual motor integration

Visual perception

Motor coordination

Percentile Age equivalent (US/HK norm)

Developmental Test of Visual Perception II (DTVPII)

Subtest

1.Eye-hand coordination

2.Position in space

3.Copying

4.Figure-ground

5.Spatial relations

6.Visual closure

7.Visual-motor speed

8.Form constancy

Percentile

(mean = 10; S.D. =3)

Composite

General visual perception

Motor-reduced visual

perception

Visual motor integration

Quotients

(mean = 100, S.D. =15)


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Test of Visual Perceptual Skills (TVPS)

Subtest

Visual discrimination

Visual memory

Visual-spatial relations

Visual form constancy

Visual sequential memory

Visual figure-ground

Visual closure

Median Perceptual Age

Percentile Rank

Percentile Rank

Tsengs Chinese Handwriting Speed Test

Word per minute

Mean

Legibility

Error

S.D.

Sensory Integrative Function

Sensory Modulation:

Sensory Processing

Tactile

Vestibulo-proprioceptive

Motor planning


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