There are several specific areas in which OTRs provide therapy. They are discussed in the following section and include development of upper-extremity proximal stability, visual-perceptual, cognitive-adaptive, sensory integration, and self-care skills (Bundy, 1991). OTRs also help evaluate, design, and fabricate assistive equipment, determine appropriate seating and positioning, and evaluate the environment to determine the need for possible modifications (Frostig, 1974).
Upper-Extremity Proximal Stability
Upper-extremity proximal stability refers to the level of stability (firmness), ranging from children's trunk and shoulders (proximal) throughout the arms to the hands (distal). Proximal stability is believed to be the foundation on which hand skills may develop. Proximal stability assists children in sitting upright, which allows them to participate in tabletop activities (Frostig, 1974).
Because of the importance of proximal stability, the OTR often places children on various pieces of therapy equipment, such as bolsters or scooter boards, to enhance proximal stability. Working the trunk and upper body through exercises and activities is thought to promote improved proximal stability and distal hand skills (use of fingers for fine motor manipulation) for use in all areas of education and daily life (Larsen & Hammill, 1975).
Visual-Perceptual Motor Skills
Visual-perceptual motor skills are another area of emphasis in occupational therapy. These skills refer to children's physical responses to visual stimulation. Such skills are later used for activities such as reading from left to right or copying from the blackboard. During occupational therapy treatment, the OTR introduces activities that begin to challenge a child's visual-perceptual performance skills. Activities such as finding hidden pictures (figure/ground), bingo and lotto (visual scanning), concentration or memory card games (visual memory and matching), and block design replication (visual-spatial relations) address different aspects within the area of visual-perceptual motor skills.
Cognitive-adaptive skills are another area of focus in occupational therapy. These skills include a child's ability (cognitively, emotionally, and physically) to interact with others and adapt to different environmental situations such as going to a new classroom, adjusting to rearrangement of the classroom. and adjusting to new teachers.
OTRs work with family members and teaching staff to assess skills acquisition and formulate and present activities designed to enhance growth and development in this area. Some of the elements assessed in cognitive-adaptive skills include how children interact with peers and adults in one-to-one or group situations, whether they play or sit with peers or prefer to play alone, how they respond to reinforcement or discipline, and how well they can solve problems and adapt to new people and situations.
Another area of development an OTR addresses is sensory integration. Sensory integration involves a child's ability to incorporate sensory information into purposeful and successful interaction with the environment. Sensory information is interpreted by all the senses including touch (tactile system), sight (visual system), hearing (auditory system), smell (olfactory system), and balance or equilibrium (vestibular system) (Ayers, 1972).
Sensorimotor skills acquisition is based on a child's ability to integrate and process sensory information to elicit a physical response to the environment. Sensory integration and processing is a complex function of the nervous system. Imbalances or dysfunctions in any of these systems may result in sensory integration difficulties (Cherry, 1971). For instance, the impaired ability to visually scan the environment successfully or process tactile information correctly may result in a child lacking the ability to move about safely at home or school.
Children could have sensory integration difficulties for a variety of reasons. Children who have cerebral palsy, are classified as cognitively delayed, and are autistic frequently have sensory integration difficulties. Indicators of sensory integration difficulties include over or undersensitivity to movement or physical contact, abnormally high or low activity levels, difficulty learning new motor tasks, and delays in language acquisition or cognitive abilities (Ayers, 1972).
To enhance sensory processing, the OTR structures specific activities needed to address the areas of dysfunction. These activities expose children to sensory tasks they may choose to avoid. Sensory activities include playing in gelatin or with shaving cream and locating objects in rice at the sensory table. During these types of activities, children are not forced to participate but may be encouraged and assisted while attempting the task. Sensory integration enhances the nervous system in organizing and interpreting sensory input to enhance the effectiveness of motor output (Ayers, 1972).
In a therapy setting, the OTR might guide "scissor skills" development by helping children develop an appropriate grasp, which enhances eye-hand coordination. Other activities the OTR uses include blowing bubbles and encouraging children to pop them, playing with puzzles, stringing beads, and stacking blocks. These activities are also designed to enhance eye-hand coordination (Ayers, 1972).
Another area of occupational therapy intervention is self-care skills, such as eating, getting dressed, using the toilet, and bathing. Occupational therapy deals with self-feeding, the hand-to-mouth action of eating. It also deals with eating, including chewing and swallowing, which involves functions and dysfunctions of the oral musculature (muscles). OTRs also focus on the relationship of the swallowing mechanisms to the various textures of food (Hotte, 1979).
Although OTRs often provide treatment in the areas of feeding, in many educational programs or clinics oral motor functioning is an area of specialization for speech and language pathologists. In this case, the OTR and speech and language pathologist address feeding dysfunctions as a team because self-feeding is an area of adaptation rather than remediation. The OTR often plays an active role in obtaining any adaptive equipment that is needed. For example, assistive equipment may include "built-up" utensils (thicker than normal) and spill-proof cups. The OTR focuses on proper positions that help children to function well while sitting. Appropriate positioning is crucial for promoting eating skills and helping to prevent choking. The OTR also provides recommendations about the types of foods that are safe for children to eat without choking.
If a child is experiencing feeding difficulties, the OTR working with the child offers suggestions regarding the mealtime experience based on the individual needs of the child. These recommendations are based on tests that have been completed, as well as clinical observations (Trombly, 1983). The child's OTR often provides a program of therapeutic techniques for the parents or caregivers to use at home. Table 10.4 provides a list of some eating difficulties children with motor impairment may exhibit and for which therapy may be effective (Stern & Gorga, 1990).
An OTR works with parents and staff to help a child develop other self-care skills. Children with disabilities frequently take longer to dress and undress. A therapist may suggest routines and help to establish a time to work on developing self-care skills. Dressing requires a great deal of muscle coordination. It also requires balance and control of muscle tension (Eastman & Safron, 1986). The OTR frequently provides guidance on how to help a child relax and best position a child before dressing the child or helping the child get dressed. The OTR might also provide suggestions about the type of clothing best suited for self-care (Pratt & Allen, 1989).
Eating Difficulties that May Be Helped by Therapy
- Diminished head and trunk control;
- Oral hyper- or hypo-sensitivity to stimulation'
- Jaw thrust—a strong protrusion of the lower jaw;
- Tongue thrust—forceful protrusion of the tongue when sucking, spoon- feeding, chewing, or drinking from a cup;
- Tonic bite reflex—a forceful closing of the jaw on stimulation to the teeth and gums (hypersensitivity);
- Lip retraction (called purse string)—extension of the lips into a tight horizontal line;
- Tongue retraction—a strong pulling back of the tongue into the throat (the pharynx), where it is held against the palate;
- Jaw retraction—the jaw is pulled back, preventing the alignment of the upper and lower teeth during feeding;
- Weak or inefficient sucking patterns.
- Poor lip closure—needed to remove food from a spoon;
- Poor tongue lateralization—the inability to move food adequately inside the mouth from side to side;
- Poor chewing technique;
- Excessive mucus or saliva secretions.
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