Activities of daily living, fine motor skills and sensory strategies for children with Down Syndrome

Sydney Martin, MS OTR Children’s Hospital Colorado

Outline

•  Medical Characteristics •  Fine motor skills •  Activities of daily living for Children & Adults •  Visual Supports for Daily Living •  Sensory Integration •  Modulation, Behavior & Self-regulation •  Sensory Diet •  Questions and Answers

Characteristics •  Hypotonia

§  Joint Laxity

•  Hand Characteristics §  Smaller hands §  Single Simean Crease §  Wrist Bones §  Clinodactyly (Curved 5th finger)

•  Medical §  Cardiac §  Susceptibility to infections §  Hearing loss

•  Cognitive §  Developmental Delays §  Attention difficulties 3

Occupational Therapy Domain Areas of Practice

•  Sensory and self regulation •  Social skills and emotional regulation •  Fine motor, visual motor skills •  Attending, listening and processing •  Self-help, including eating, dressing, grooming, bathing,

toileting and chores •  Cognitive functions

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Fine motor skills •  Postural Control •  Trunk and shoulder stability •  Reach, grasp and release •  Play •  Dexterity skills for school, daily living skills •  Assistive technology •  Pre-Writing & Writing •  Vocational skills

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Developmental Considerations Postural skills

Trunk Control Shoulder stability (fine motor/dexterity)

Play

Language Self-Care

Social interaction

Engagement in purposeful activities

Postural Skills •  Trunk Control •  Stability •  Stability with gross motor tasks •  Rotation •  Facilitation of reach and grasp •  Shoulder Stability

§  Strengthening activities •  Shoulder •  Placing weight on arms and hands in play •  Promoting arch development •  Fine motor skills •  Motivation during play •  Fun Activities

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Reach, Grasp & Release •  Reach

§  Requires shoulder stability §  Motivation to reach & play

•  Grasp §  Pinch §  Thumb control-opposition §  Wrist movement §  Finger control & coordination §  Types of grasp

•  Palmar •  Pronated •  Tripod •  Pincer (Pinch)

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Dexterity Skills •  Finger Coordination

§  Moving fingers individually §  Poking, pointing §  Holding pencil §  Scissors

•  Wrist §  Turning hand over §  Sensory play §  Self help skills §  Dressing & Fasteners §  Opening lids

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Bilateral Coordination •  Scissor Skills •  Pre-Scissor skills

§  Tearing paper §  Squeeze or loop scissors §  snipping

•  Scissor Skills §  Cutting Straight line §  Move to curved lines §  Shapes §  Hand Strength- spray bottle, squeeze activities

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Printing & Pencil Grasp •  Pre-Printing

§  Markers & Crayons §  Sensory play-sand, clay,

shave cream §  Use Stickers to target and

connect the lines §  Printing §  Vertical surface/wall or

Chalkboard §  Vertical & horizontal

Orientation §  Left to Right §  Sensory play with writing §  Shoulder stability §  Start & Stop

§  www.HWTears.com

§  www.TVTeacher.com

Assistive Technology •  Touch screen programs •  Trackballs- offer better control •  Joy Sticks •  Track pads •  Key guards •  Alternative keyboards

Developmental Considerations Praxis

Initiation, Planning, & Sequencing

Imitation (motor and oral-motor)

Play

Language Self-Care

Social interaction

Engagement in purposeful activities

Teaching Strategies for Activities of Daily Living

•  Intensive Toilet Training •  Chaining •  Picture Activity Schedules •  Video Modeling •  Practice and repetition •  Daily Living Social Stories

Independence in Self Care and Adaptive Skills

•  Wiping at the toilet •  Brushing Teeth •  Brushing Hair •  Showering •  Dressing

•  Making a snack •  Doing the laundry •  Washing dishes •  Setting the table •  Getting bag ready

for school

Chaining •  Chaining is a very useful basic teaching procedure that

you can use for these kinds of skills •  Chain

§  Multi-step actions where all steps have to occur in the correct sequence to finish the task correctly

Chaining Interventions

Backward Chaining

Forward Chaining

TASK ANALYSIS

Chaining

Importance of a chain

•  Each completed step serves as a cue for the next relevant action §  If the chain is interrupted you may lose some steps

in the sequence

•  Examples of Chains §  Tying shoes, making a sandwich, starting a car

•  Before a chain is taught you have to identify every step using a TASK ANALYSIS

Teaching a step in the chain

§ Present initial instruction (e.g., “Put on your shirt.”) • Present the steps instruction (e.g.,“Place

shirt over your head.”) • Use prompts if needed • Use reinforcement for correct responses as

needed • Fade prompts • When behavior occurs without prompts,

move to the next step

Linking Steps Together: Backward Chaining

•  All steps are completed for the client, except for the last, then second to last, etc. §  1-2-3-4-5 (therapist) 6 (client) … mastery §  Example: the shirt and one arm is placed into

the shirt– Child has to put other arm in. §  Reduce prompts as you go for mastery

•  Use when there is a natural reinforcer at the end of the chain– I’m Dressed!

•  Use when task termination is a reinforcer

Forward Chaining

•  Teach the steps in a forward manner, 1 at a time §  1 (reinforcer)… mastery §  1-2 (reinforcer)… mastery §  1-2-3 (reinforcer)… mastery, etc.

•  Use when the client can perform each of the steps

•  Use when the initial steps are easiest

Nail Trimming •  Always after or during bath time when the nails are soft •  Don’t use the word “cut” use the word “trim” •  Provide heavy work activity before •  Video the family trimming their nails & have child watch •  Introduce nail trimmers to cut onto paper first in play •  Slowly introduce nail trimming to your child when they

are calm •  Break the activity into steps •  Take breaks and offer a pleasurable activity during nail

trimming.

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Haircuts •  Take Child to watch the hairdresser •  Complete heavy work activities before •  Use a towel and clip instead of cape •  Take along an extra shirt to change into •  Visual distraction- computer or IPAD •  Sit on parents lap •  Reward with positive reinforcement •  Consider having a hair dresser come to your home if

necessary

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Schedules

Visual Schedule

Picture

Written

Tech Based

Why use activity & Visual schedules? •  To increase behavior that has been learned but is not

occurring independently §  Pre-teach a skill §  Improve Independence

•  To reduce problem behavior during transitions

•  To teach new sequences of behavior and learn new skills

Prerequisite Skills

•  Ability to discriminate pictures from backgrounds

•  Identify matching with 3D objects

•  Identity matching with picture to object

•  Tolerance of manual guidance

•  Ability to manipulate materials

Visual organizers •  Visual Schedules

Picture Exchange Communication System-PECS

Routine-based Strategies Work systems

The individual work system answers four questions 1. What work? 2. How much work? 3. How do I know when I am

finished? 4. What happens next?

http://www.teacch.com/

First this – Then that…

Visual Schedule First - then

Ready/Not Ready •  Teach child to indicate if they are “ready” or “not

ready” •  Associate “not ready” with a means to get “ready”

§  then move them into getting ready §  finally, engage in task at hand because they are “ready”!

Sensory Integration

Pyramid of Learning

Sensory Integration •  Sensory integration is a neurological process •  Theory that describes the relationship and association

between behavior and neurological processes •  “The neurological process that organizes sensation from

one’s own body and from the environment and makes it possible to use the body effectively within the environment.” (Ayres, 1979)

•  The ability to receive, interpret and organize sensory information (i.e. Self Regulation)

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A Model for Understanding Sensory Modulation

Sensory Integration-Based on Ayres

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Frick, Wilbarger

Ayres’ Model of Praxis

Ideation

Planning

Execution Ayres Model of Praxis

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Dunn’s Model of Sensory Processing

Sensation seeking

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POOR REGISTRATION

Sensory avoiding

Lane, C. 2011

Sensory Modulation •  Taking in sensory information •  Processing sensory information •  Functioning within an Optimal Range

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Disruption with Sensory Modulation

•  Observe behavioral difficulties •  Sensory avoidance •  Irritability •  Sensation seeking •  Poor coping and self-regulation

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S.T.E.P.S.I. •  Model of Sensory Integration designed by Stackhouse &

Wilbarger

•  S ensation •  T ask •  E nvironment •  P redictability •  S elf Monitoring •  I nteraction

Copyrighted to Stackhouse and Wilbarger

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Goal of OT with SI Treatment •  Purposeful activity and Goal oriented responses •  Facilitation of the adaptive response •  Based on integration of sensory and motor input •  Self-regulation •  Motor planning •  Improving the child’s organization of neural and sensory

information to adapt effectively to their environment

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Classical SI – Bottom UP •  The use of sensation through the adaptive response produces sensory integration, the basis of praxis & motor planning

•  Qualities of sensation include focused work on foundation of disorder §  Vestibular §  Tactile §  Proprioception

Adaptive Response

How We Treat Sensory Issues •  Careful analysis of the problem •  Sensory Diet & Sensory Based Activities •  Classroom, Home and Community based Program instructions & suggestions

Sensory Systems

•  Vestibular (movement) •  Tactile •  Proprioception (heavy work) •  Auditory •  Olfactory •  Visual

Sensory Diet Components •  Proprioceptive & Tactile discrimination activities •  Movement (Vestibular) input •  Mouth activities: Organizing & Self-Regulation •  Auditory input: Music, listening programs •  Effective strategies for transitioning •  Reducing behavioral outbursts •  Help with shifting •  Task and environment modification

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Self-Regulation is the Key •  “Self-regulation is the ability to attain, change, or

maintain an appropriate level of alertness for a task or situation.” (Williams & Shellenberger 1996).

•  Self Regulation helps us to adapt to our environment •  Coping skills and Calming skills

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Movement

Information to muscles and joints

Alertness Strategies

The Sensory Diet Concept •  Originated by Patricia Wilbarger, M.A., OTR

Sensory Diet Components

•  Routines for transitions •  Family lifestyle and preferences assessed and

modified •  Can be used during new learning •  Task/activity modification •  Environmental modifications

The Key is Building a Daily Schedule Event/Time

Sensory Diet Activity

Transition Other Support

Wake -Up

AM Lunch Early PM

Dinner Bed-time

Sensory Based Strategies Movement: Modalities

§  What sensory receptors are stimulated?

§  What areas of the brain are activated?

§  How does it effect arousal & alertness?

§  How does it support function?

•  Intensity •  Frequency •  Duration •  Rhythmicity

The Relationship of Arousal to Attention, Learning and

Performance GOOD

ADAPTIVE RESPONSE --------------------------------------------------------------------------- (Attention, Learning, Performance) POOR __________________________________________________________

LOW ⇑ OPTIMAL RANGE ⇑ HIGH OF AROUSAL

After Hebb, 1949

Arousal-Relaxation Cycle Builds Self-Regulation

Child

experiences a “need”

Child feels upset

Adult satisfies need

Child Feels Content/organized

behavior

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Sensory Strategies

•  Sensory Play •  Tactile •  Heavy Work •  Movement (Vestibular) •  Auditory (music) •  Oral Proprioceptive •  Visual

•  Cozy corner •  Headphones •  Therapy ball •  Movement Activities

Ziggurat Model

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Aspy, Grossman, 2008

Education and Advocacy •  Education

§  School & community personnel §  Explaining learning strategies §  Explaining behavioral differences

•  Advocacy §  Educating about Down Syndrome conditions §  Teaching strategies for success §  Promoting success across all environments

Resources •  “Fine Motor Skills for Children with Down Syndrome” by

Maryanne Bruni, BScOT •  The Sensory-Sensitive Child: by Smith & Gouze •  “How Does Your Engine Run” www.thealertprogram.com •  www.texasautism.com Ziggurat Model •  www.southpawenterprises.com •  www.therapro.com •  www.Therapyfunzone.com •  www.sensorycomfort.com •  www.softclothing.net

Thank you for your Attention! Contact Information: Syd Martin MS, OTR Children’s Colorado Hospital Email: Sydney.Martin@Childrenscolorado.org