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

Sydney Martin, MS OTR Childrens 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

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

Developmental Considerations Postural skills

Trunk Control Shoulder stability (fine motor/dexterity)

Engagement in purposeful activities

Social interaction

Play Language Self-Care

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
7

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)

Dexterity Skills
Finger Coordination
Moving fingers individually Poking, pointing Holding pencil Scissors Turning hand over Sensory play Self help skills Dressing & Fasteners Opening lids

Wrist

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

10

Printing & Pencil Grasp

Pre-Printing
Markers & Crayons Sensory play-sand, clay, shave cream Use Stickers to target and connect the lines www.HWTears.com

www.TVTeacher.com

Printing
Vertical surface/wall or Chalkboard Vertical & horizontal Orientation Left to Right Sensory play with writing Shoulder stability Start & Stop

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)

Engagement in purposeful activities

Social interaction

Play Language Self-Care

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

TASK ANALYSIS

Forward Chaining

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 Im 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 Dont 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.

22

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

23

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 ones 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)

36

A Model for Understanding Sensory Modulation

Sensory Integration-Based on Ayres

Frick, Wilbarger
39

Ayres Model of Praxis

Execution Planning Ideation

Ayres Model of Praxis

40

Dunns Model of Sensory Processing

Sensation seeking

POOR REGISTRATION

43

Sensory avoiding

Lane, C. 2011

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

45

Disruption with Sensory Modulation

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

46

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

47

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 childs organization of neural and sensory information to adapt effectively to their environment

48

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

52

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

53

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/ Sensory Diet Time Activity

Wake Up

Transition Other Support

AM Lunch Early PM Dinner Bedtime

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 Content/organized behavior

Child feels upset

Adult satisfies need

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

Cozy corner Headphones Therapy ball Movement Activities

62

Ziggurat Model

Aspy, Grossman, 2008

63

 Education

Education and Advocacy

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 Childrens Colorado Hospital Email: Sydney.Martin@Childrenscolorado.org