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301 Cards in this Set

  • Front
  • Back
3 major cardiovascular changes that take place at birth for normal pediatric heart develpment
(a) The hole between the right and left atria must close (foramen ovale). (b) The ductus arteriosus must close to allow blood flow to the lungs. (c) The ductus venosus must close to allow blood flow to the liver. Congenital heart disease orrures when 1 or more change fails to occur.
Three categories of Heart defects.
(a) defects that increase pulmonary blood flow. (b) defects that decrease pulmonary blood flow including tetralogy of Fallot. (c) defects with mixed pulmonary blood flow include transposition of great arteries.
Patent ductus arteriosus
defect that increases pulmonary blood flow. Its the most common condition found in premature newborns; it can lead to heart failure and inadequate oxygenation of the brain.
Atrial septal deficits
defect that increases pulmonary blood flow. Its characterized by an opening in the septum between the right and left atrial chambers. They result in “wet lungs” (too much blood sent to the lungs) and may lead to respiratory infection; cause the right ventricle to work too hard and may lead to heart failure; and may result in poor exercise tolerance and being small for chronological age.
Ventricular septal deficits.
defect that increases pulmonary blood flow. Its characterized by one or more openings in the muscular or membranous portions of the ventricular septum. More than 50% of cases self-correct by age 5; otherwise, surgery is warranted. They could result in Eisenmenger’s complex or pulmonary vascular obstruction owing to prolonged exposure to increased blood flow and high pressure; symptoms include feeding difficulties, shortness of breath, increased perspiration, increased respiratory infections, fatigue with increased activity, and delayed growth.
Tetralogy of Fallot,
defect that decrease pulmonary blood flow, which is characterized by pulmonary valve or artery stenosis, a ventricular septal deficit, right ventrical hypertrophy, and override of the ventricular septum. Symptoms include central cyanosis, coagulation defects, clubbing of fingers and toes, feeding difficulties, failure to thrive, and dyspnea.
Transposition of Great Arteries
defect with mixed pulmonary blood flow. It is characterized by no communication between the systemic and pulmonary circulations and is the result of coexisting congenital transposition of the ventricles. Symptoms may include cyanosis, congestive heart failure, and respiratory distress
Occupational therapy treatment of children with congenital heart disease
(a) Children whose conditions have not resolved or been treated surgically are likely to have compromised endurance but may develop typically unless a comorbid condition is present. (b) Activities should be appropriately paced. (c) Activities should be selected with care.. (d) The child and family should be educated in general health maintenance (e.g., diet, exercise, avoidance of smoke inhalation.
Types of Dysrhythmia
Bradydysrhythmia and Tachydysrhythmia. Conduction disturbances are most common after surgery and may be temporary.
(a) It is characterized by an abnormally slow heart rate (<60 beats/min). (2) Atrioventricular block is the most common type.. (3) Medical intervention may include a pacemaker.
(1) It is characterized by an abnormally fast heart rate (>200–300 beats/min). (2) It is common in children. (3) Tachydysrhythmia can lead to congestive heart failure. (4) Typical presentation is marked by irritability, poor eating habits, and pallor
Respiratory Distress Syndrome
A acute pediatric respiratory condition. (a) This syndrome is common in preterm infants. (b) It is caused by a deficiency of surfactant, which is not produced until the 34th–36th week of gestation. (c) It results in compromised oxygen absorption and carbon dioxide elimination. (d) Many infants recover after a few days of medical intervention; however, some develop chronic lung conditions.
Bronchopulmonary Dysplasia
A chronic pediatric respiratory condition. (a) Is a result of the prolonged use of mechanical ventilation and other traumatic interventions to treat acute respiratory problems. (b) It results in the airway thickening, the formation of excess mucus, and restricted alveolar growth. (c) Children with bronchopulmonary dysplasia are at a greater risk of respiratory infections and problems.
A chronic pediatric respiratory condition. (a) Asthma is characterized by bronchial smooth muscle hyperreactivity that causes airway constriction in the lower respiratory tract, difficulty breathing, and wheezing. (b) The first symptoms typically appear before age 5. (c) Asthma attacks may be triggered by allergens, smoke, cold air, exercise, and the inhalation of irritants.
Asthma occupational therapy treatment implications
(a) Educate the client regarding the reduction of exposure to irritants. (b) Teach the client self-management strategies, including pacing and stress management. (c) Encourage structured peer-group activities to reduce the likelihood of social isolation. (d) Educate the client regarding breathing exercises, stretching, and controlled breathing to manage attacks.
Cystic fibrosis (CF)
(a) a degenerative condition caused by an inherited autosomal recessive disorder related to a gene on chromosome 7. (b) affects multiple systems and is characterized by the muscle-producing glands malfunctioning and producing secretions that are thick, viscous, and lacking in water; these secretions block the pancreatic duct, the bronchial tree, and the digestive tract.
Symptoms and complications of Cyctic Fibrosis.
(a) An early symptom found in infants is the blockage of the small intestine, resulting in abdominal distension. (b) Salty-tasting skin is another sign and is the result of excessive sodium levels. (c) Greasy, foul-smelling stools are another sign and cue pancreatic insufficiency and problems with vitamin malabsorption. (d) Chronic pulmonary disease is the most serious complication and is characterized by a chronic cough, wheezing, and lower respiratory infections. (e) may result in an enlarged right side of the heart, which could lead to heart failure.
(1) It is characterized by too many red blood cells and elevated white blood cells; it is referred to as transient leukemia.. (2) One in every 150 children with Down syndrome will experience transient leukemia.
Hematologic Disorder (1) It is a blood disorder that commonly affects males; 60% of cases are hereditary. (2) It is characterized by the absence or reduction of one of the clotting blood proteins. (3) Hemophilia results in longer bleeding time or bleeding episodes.
Three Different Types of Hemophilia
Mild hemophilia, Moderate hemophilia, and Severe hemophilia.
Mild hemophilia
Hematologic Disorder A bleeding episode that is usually seen after a traumatic event or injury. Without the traumatic event or injury, this type of hemophilia is usually not detected.
Moderate hemophilia
Hematologic Disorder Bleeding episodes occur after minor injuries.
Severe hemophilia
Hematologic Disorder Bleeding occurs after injuries or without an apparent cause; this type of hemophilia may also affect joints and muscles.
Signs of Hemophilia
Hematologic Disorder (a) Excessive bleeding (b) Excessive bruising (c) Spontaneous bleeding or bleeding without a known cause. (d) Nosebleeds
Hematologic Disorder (a) is caused by iron deficiency in the blood.. (b) It is diagnosed through blood tests and usually treated through diet (i.e., iron-rich foods). (c) Anemia may be symptomatic of other conditions, such as lead poisoning, vitamin deficiencies, leukemia, and sickle cell disease.
Sickle cell anemia
Hematologic Disorder (a) It is a form of anemia caused by abnormally shaped red blood cells. (b) It is most common among African-Americans. (c) Children with it anemia may demonstrate decreased energy for daily tasks. (d) Children with this condition are at a risk for organ damage resulting from blocked blood flow caused by the sickle cells. (e) Children may experience pain and require intervention for pain management.
Osteogenesis imperfecta
Musculoskeletal Congenital Disorder (a) it is also known as brittle bones. (b) Minor trauma can cause a fracture. (c) Multiple fractures or repeated fractures of the same bone may cause a limb to become misshapen and eventually muscularly underdeveloped. (d) it is characterized by decreased bone deposition caused by an inability to form Type I collagen. (e) It is transmitted by an autosomal dominant gene. Children with it can be expected to develop progressive deformities. (f) Activity patterns are affected by caution and time spent in casts. (g) Maternal education in handling and positioning is essential to prevent fractures. (h) Monitored activity that promotes weight bearing should be encouraged.
Fetal Osteogenesis imperfecta
most severe Osteogenesis imperfecta; fractures occur in utero and during birth; mortality is high.
Infantile Osteogenesis imperfecta
moderately severe osteogenesis imperfecta; many fractures occur in early childhood; severe limb deformities and growth disturbances also occur.
Juvenile Osteogenesis imperfecta
least severe osteogenesis imperfecta; fractures begin in late childhood; by puberty, bones often begin to harden and fewer fractures occur.
Marfan’s syndrome (arachondactyly)
Musculoskeletal Congenital Disorder (a) it is caused by an autosomal dominant trait. (b) It is characterized by excessive growth at the ephiphyseal plates. (c) Children with it present with long and slender fingers, skull asymmetries, and tall stature. They may also have differences in their joints, eyes, and heart. (d) This condition is associated with lax and hypermobile joints and poorly developed striated muscles. (e) Common comorbidities include dislocation of the lenses, scoliosis, coxa vara, depressed sternum, stooped shoulders, and fragility of the blood vessels. (f) Walking may be delayed, but the child may otherwise meet developmental milestones.
Achondroplasia (chondrodystrophia or dwarfism)
Musculoskeletal Congenital Disorder (a) It is caused by an autosomal dominant trait that results in the stunting of ephiphyseal plate growth and cartilage formation. Spontaneous mutations also occur. (b) People with achondroplasia usually grow to 4 feet tall or less in height. Their limbs have typical width but are shorter in length. In addition, they may have a prominent forehead and a small nose and jaw. The trunks of people with it are typical. (c) Common comorbidities include lumbar lordosis, coxa vara, and cubitus varas. (d) Back and leg pain are common in people with achondroplasia and more pronounced in adulthood.
Coxa Vara
It is a deformity of the hip, whereby the angle between the head and the shaft of the femur is reduced to less than 120 degrees. This results in the leg being shortened, and the development of a limp.
Cubitus Vara
It is a deformity of the shoulder, whereby the angle between the head and the shaft of the humerus is significantly reduced. This results in the arm being shortened
Arthrogryposis multiplex congenital
Musculoskeletal Congenital Disorder (a) It is associated with reduced anterior horn cells in the spinal cord; however, its exact cause is unknown. (b) It is characterized by an incomplete contracture (fibrous ankylosis) of many or all of the client’s joints, which is present at birth. (c) Often both the upper and lower extremities are involved. (d) Clients with arthrogryposis present with stiff and spindly extremities and the appearance of thickened knee and elbow joints. Their muscles may be underdeveloped, and in some cases, they may experience paralysis because of spinal cord involvement.
Arthrogryposis multiplex congenital Implications for occupational therapy treatment
(a) Increase and maintain the client’s ROM and strength with daily stretching programs, splinting, and serial casting. (b) Increase functional participation with ADLs, IADLS, education, and play through the use of adaptive equipment.
Congenital clubfoot (talipes equinovarus)
Musculoskeletal Congenital Disorder (a) Clinical features include unilateral or bilateral forefoot adduction and supination, heel varus, equinus of the ankle, and medial deviation of the foot. (b) It may be caused by a single autosomal dominant gene and affects more boys than girls. (c) Clients with congenital clubfoot may have bony malformations and underdeveloped lower-extremity musculature. (d) The condition cannot be corrected in utero. However, it can be corrected if treated early in childhood. Means of treatment include taping, casting, splinting, and orthopedic surgery.
Congenital club hand
Musculoskeletal Congenital Disorder (a) Clinical features include partial or full absence of the radius and bowing of the ulnar shaft with absence or underdevelopment of the upper-extremity nerves and musculature. (b) Club hand is less common than clubfoot. (c) The person’s hand often remains functional. However, progressive casting, static or dynamic splinting, and surgery may be used for cosmetic reasons
Developmental dysplasia of the hip
Musculoskeletal Congenital Disorder (a) (congenital hip dislocation) (b) This condition often occurs bilaterally and is more common in girls than boys
Causes of Developmental Dysplasia
(a) Hip laxity may be hereditary or the result of hormonal secretions in utero. (b) Increased uterine pressure, as well as poor presenting positions, may also play a role. (c) Dislocation in utero can also be caused by sudden passive extension or by positioning that keeps the legs extended and adducted (e.g., as in footling breech presentations).
Early diagnosis of Developmental Dysplasia
Early diagnosis is critical because delay can lead to serious long-term disabilities. (a) The dysplasia is often detected by the Barlow test, which examines whether clicking is present when the child’s leg is abducted and pressure is placed on the medial thigh. (b) If treatment with bracing, casting, or splinting is done within the first few weeks of life, children typically have good developmental outcomes. (c) Without early treatment, children with developmental hip dysplasia will develop Trendelenburg’s sign, which means that the child’s hip drops to the opposite side of the dislocation and the trunk shifts toward the dislocated hip when the child is asked to stand on one foot. (d) In severe cases, or if not treated early, developmental dysplasia of the hip may result in the need for orthopedic surgery (i.e., total hip replacement).
Barlow test
It is done by guiding the hips into mild adduction and applying a slight forward pressure with the thumb. If the hip is unstable, the femoral head will slip over the posterior rim of the acetabulum, again producing a palpable sensation of subluxation or dislocation.
Trendelenburg’s sign
It is said to be positive if, when standing on one leg, the pelvis drops on the side opposite to the stance leg to reduce the load by decreasing the lever arm. By reducing the lever arm, this decreases the work load on the hip abductors. The muscle weakness is present on the side of the stance leg. The sign can occur when there is presence of a muscular dysfunction (weakness of the gluteus medius or minimus) or when someone is experiencing pain. The body is not able to maintain the center of gravity on the side of the stance leg.
Limb deficiency (a) It is a physical anomaly in which a person has an excess of fingers or toes. (b) It is relatively common. (c) Bony changes may be present or just extra soft tissue. (d) Surgical amputation or reconstruction is often performed in early.
Limb deficiency (a) is a condition in which webbing occurs between the fingers or toes. (b) It occurs frequently. (c) It is most common in the upper extremity and in boys. (d) Treatment may involve splinting and scar reduction.
Limb deficiency (a) is characterized by overly large digits. (b) People with this condition may have difficulty with ADLs that require fine motor manipulation. (c) Plastic surgery may be performed.
Limb deficiency (a) Microdactyly is characterized by overly small digits. (b) Plastic surgery may be performed.
Limb deficiency (a) It is the absence of a limb or distal segments of a limb.
a type of Amelia; a fully or partially formed distal extremity and absence of one or more proximal segments.
Paraxial deficiencies
a type of Amelia; proximal segments of the limb are correctly developed, but either the medial or the lateral side of the rest of the limb is missing.
Transverse hemimelia
a type of Amelia; amputation of a limb segment across the central area; it is common for bilateral or hemilateral presentations.
Soft-tissue injuries
these injuries involve injury to any of the soft tissues in the body, which include the muscles, ligaments, and tendons. 3 main types: Spain, Strain, and Bruise.
It is a muscle injury that is caused by using too strong an effort or excessive use of a particular body part and is characterized by trauma to the muscle or muscle–tendon insertion.
It is a ligament injury caused by trauma to a joint and is characterized by rapid swelling, heat, and impaired function.
It also referred to as a contusion, is caused by an injury with diffuse impact into the subcutaneous tissue and is characterized by skin discoloration.
Juvenile Rheumatoid Arthritis
(a) It is the most common form of arthritis in children, with onset usually occurring between ages 2 and 4 yr. (b) It is more common in girls than boys. (c) Diagnosis is made on the basis of persistent arthritis in one or more joints for 6 or more weeks. Other conditions are ruled out before the diagnosis of JRA is given. (d) It is characterized by joint inflammation, joint stiffness, joint contractures, and change in growth patterns. Weakness around the involved joints is also common. (e) Although the effects of it are most often connected to synovial fluid changes and joint damage, JRA is a systemic disease. (f) has three forms.
Pauciarticular Juvenile Rheumatoid Arthritis
Type of Juvenile rheumatoid arthritis that involves fewer than five joints.
Polyarticular Juvenile Rheumatoid Arthritis
Type of Juvenile rheumatoid arthritis that involves more than five joints.
Systemic Juvenile Rheumatoid Arthritis
Still's disease, Type of Juvenile rheumatoid that is polyarticular, and organ involvement is present. Symptoms include high fever, rash, anorexia, elevated white blood count, and enlargement of the liver and spleen.
Juvenile Rheumatoid Arthritis Implications for Occupational Therapy Intervention
(a) Splinting may be used. (b) Involve the client in AROM and PROM programs. (c) Monitor joint function and prevention of deformity. (d) Educate the client in energy conservation and the use of adaptive equipment to put less stress on the joints.
It is a broken bone, and can be caused by direct trauma or a sudden and violent muscular contraction. There are 6 types
Symptoms of a Fractures
Pain and tenderness around the site of the break in bone, swelling, bruising, and possibly increased or unnatural mobility.
Complete Fracture
The bone is broken straight through, and no bone fragments are connected to one another.
Comminuted Fracture
The bone is broken into many splintered pieces.
Compound Fracture
The broken bone leads to an external wound at the site of the fracture, and bone often protrudes through the skin.
Epiphyseal Fracture
The break occurs between the shaft of the bone and the epiphysis; this type of fracture only occurs in pediatric clients.
Greenstick Fracture
The bone is partially broken and partially bent; this type of fracture only occurs in children and is frequently found in children with rickets.
Intrauterine Fracture
The bone is broken in utero.
Curvature of the spine that is an anteroposterior curvature directed posteriorly; it is also called hollow back. It is often secondary to other spinal abnormalities or an anterior pelvic tilt. It predominantly occurs in the lumbar region. It may be secondary to severe obesity, hip flexion contractures, and muscular dystrophy.
Occupatial Therapy Treatment Focuses for Lodosis
(a) Stretching tight hip flexors. (b) Strengthening abdominals. (c) Postural training. (d) Back bracing.
Curvature of the spine is a posterior convexity; it is also called round back. It is referred to as Scheurmann’s disease in adolescents; it also occurs primarily in the upper back. It is typically the result of faulty posture; that is, skeletal growth outpaces muscular growth. It is common in children with spina bifida cystica and arthritis.
Occupatial Therapy Treatment Approaches
(a) Postural training. (b) Strengthening. (c) Milwaukee brace. (d) Anterior spinal release and posterior spinal fusion in severe cases.
Curvature of the spine, It is the most serious curvature of the spine. It is usually characterized by lateral curvature, spinal rotation, and thoracic hypokyphosis. Treatment is initiated when lateral curvature is more than 10°. Functional scoliosis can be caused by poor postural tone, hip contractures, leg length discrepancy, or pain. The spine is still flexible. Congenital scoliosis is usually structural and is caused by abnormal spinal or spinal cord structure or diseases of the nervous system. Scoliosis is confirmed by radiographic analysis. Curves of less than 20° are considered mild. Curves of more than 40° may result in permanent deformity. Curves of 65°–80° may result in reduced cardiopulmonary function.
Treatment/Occupational Therapy approaches for Scoliosis
(a) Orthotic intervention. (b) Surgical spinal fusion. (c) Bracing: Boston brace, Thoracolumbosacral orthotic. (d) Occupational therapy intervention may include. (e) Postoperative strengthening of abdominal muscles. (f) ADL adaptations
Cerebral palsy (CP)
(a) It is defined as a nonprogressive condition that encompasses neurologic, motor, and postural deficits. It can be conginitial or acquired. (b) It is characterized by difficulty maintaining normal muscle postures because of a lack of muscle coactivation and the development of abnormal compensatory movement patterns. (c) Classification of CP is based on limb involvement and distribution of tone, on quality of tone, and on function.
Common comorbidities of Cerebral palsy
Language, cognitive, sensory, and psychosocial deficits; seizure disorders and feeding impairments are common. (a) Strabismus: eye alignment deviation. (b) Nystagmus: a reflexive back-and-forth movement of the eyes when the head moves. (c) Dysarthria: difficulty pronouncing or articulating words. (d) Aphasia: associated with poor language development; functionally looks as though the person has difficulty comprehending the meaning of certain words.
Congenital Cerebral Palsy
It is a result of an injury or a disease that occurs at or before birth. (a) Prematurity accounts for the majority of cases of congenital CP because of the increased sensitivity of the central nervous system before full-term birth. (b) Infants born between 26 and 32 weeks gestation are at particular risk. (c) Cerebrovascular accident at or around the time of birth, placental abruption, fetomaternal hemorrhage, placental infarction, and material exposure to environmental toxins may also cause congenital CP.
Acquired Cerebral Palsy
It is a result of trauma, intracranial hemorrhage, central nervous system infections, near drowning, hypoxia, and metabolic disorders.
Evaluations for Cerebral Palsy
Evaluations usually take place over several months and include physicians, physical therapists, occupational therapists, and speech–language pathologists. (a) Canadian Occupational Performance Measure. (b) Perceived Efficacy and Goal Setting System. (c) Pediatric Activity Card Sort. (d) Preschool Activity Card Sort. (e) Child Occupational Self-Assessment. (f) Movement Assessment Battery for Children–2. (g) Sensory Profile.
Markers for Cerebral Palsy
(a) Retention of primitive reflexes and automatic reactions. (b) Abnormal or variable tone. (c)Hyperresponsive tendon reflexes. (d) Asymmetrical use of extremities. (e) Clonus. (f) Poor feeding and tongue control. (g) Involuntary movements.
Hemiplegic Cerebral Palsy
Cerebral Palsy that affects the upper and lower extremities on one side of the body; may affect bilateral skills; the affected hand may be the “helper hand” or stabilizer, and the unaffected hand may be more involved in activities that require power or precision
Quadraplegic or tetraplegic Cerebral Palsy
Cerebral Palsy that affects the upper and lower extremities on both sides of the body.
Diplegia Cerebral Palsy
Cerebral Palsy that is quadriplegia with mild upper-extremity involvement and significant involvement in the lower extremities
Spasticitic Cerebral Palsy
Cerebral Palsy with increased flexor or extensor tone
Athetosis Cerebral Palsy
Cerebral Palsy with fluctuation of tone from low to normal with little spasticity
Choreoathetosis Cerebral Palsy
Cerebral Palsy with constant fluctuations from low to high tone, without cocontractions; typically appears as jerky movements
Cerebral Palsy Flaccidity
Cerebral Palsy marked low tone (will usually progress to spasticity)
Cerebral Palsy Ataxia
Cerebral Palsy tone usually within the normal range but involving lower-extremity flexion patterns
Functional classifications of Cerebral Palsy
Classification is baised on how the child is able to participate in and interact with the environment, and may involve the (a) Manual Ability Classification System (Eliasson et al., 2006) (b) Gross Motor Function Classification System (Palisano, Rosenbaum, Bartlett, & Livingston, 2007)
Occupational therapy treatment implications for Cerebral Palsy
(a) Children with CP have differences with tone, motor planning, motor control, and coordination that must be taken into consideration in treatment. (b) Maintain AROM and PROM through stretching, exercise, and orthotics. (c) Use adaptive equipment and assistive technology to enhance participation and independence in education, play, leisure, and social participation. (d) Instruct the client in seating and positioning. (e) Constraint-induced movement therapy may be indicated.
Seizure disorders and epilepsy
(a) Seizure disorders are chronic neurological conditions that consist of recurrent seizures, whether or not the person has other brain abnormalities. (b) They are characterized by the epileptogenic focus on or an excessive rate and hypersynchrony of discharges from a group of cerebral neurons that spread to adjoining cells. (c) Causes of seizures may be hypoglycemia, fever, trauma, bleeds, tumors, infections, and lack of oxygen. (d) There are a main types of seizures based on brain envololvment.
Generalized seizures
Seizures that involve the entire cerebral cortex.
Tonic clonic seizures
Type of generalized seizure most frequent type; the person experiences a sensation that the seizure is about to begin; usually followed by a loss of consciousness and rhythmic clonic contractions; the seizure may last as long as 5 minutes; incontinence is common; the child may be drowsy or sleep for the next 1–2 hours
Absence seizures
Type of generalized seizure, a brief lapse or loss of awareness along with the absence of motor activity (including eye blinking); lasts 30 seconds or longer; may be mistaken for daydreaming
Myclonic seizures
Type of generalized seizure, contractions of single muscles or muscle groups
Akinetic seizures
Type of generalized seizure, loss of muscle tone for more than 30 minutes
Status epilectus
Extended seizures; prompt medical intervention needed to maintain body functions and hydration
Partial seizures
Seizures that begin in a single location and then either spread or remain limited to one area of the cortex.
Complex partial seizures
Type of Partial seizure that originates in the temporal lobe and appear as lip smacking, chewing, or buttoning and unbuttoning clothing; characteristics similar to absence seizures
Simple partial seizures
Type of partial seizure that originates in the motor cortex and result in clonic activity of the face or extremities; the person may experience visual or auditory hallucinations or olfactory sensations
Mixed seizure disorder
disordr that occurs when a person experiences both generalized and partial seizures
Infantile spasms
(a) Spasms begin between ages 6 months and 24 months. (b) Development stops or slows considerably. (c) Some skills may be lost.
Medical interventions for Seizures and Epilepsy
(a) Antiepileptic medications. (b) Surgical intervention, consisting of hemispherectomy for progressive disorders. (c) Electrical stimulation of the vagus nerve or the thalamus.
Muscular dystrophies
This condition results in progressive degeneration and weakness of a variety of muscle groups and could lead to death. The degeneration is a result of biochemical and structural changes of the surface and internal membranes of the muscle cells. They have a hereditary link.
Limb girdle muscular dystrophy
Muscular dystrophy that affects the proximal muscles of the pelvis and shoulder girdle. (a) Onset occurs within the first 30 yr of life. (b) The progression is typically slow.
Facioscapulohumeral muscular dystrophy
Muscular dystrophy that affects the face, upper arms, and scapular region. (a) Onset usually occurs in adolescence. (b) This type of dystrophy is characterized by sloped shoulders and limited ability to raise arms above head. (c) Decreased mobility in the facial muscles results in a “masklike” appearance.
Duchenne’s muscular dystrophy (DMD)
Muscular dystrophy that is the most common form of muscular dystrophy, affecting only boys. (a) DMD is caused by a deficiency in the production of dystrophin; muscles degenerate without dystrophin. (b) Boys with DMD develop typically after birth and begin to demonstrate symptoms between ages 2 and 6. (c) Enlarged muscles and a positive Gower’s sign are present. (d) Parents commonly report that children with DMD have difficulty going up and down the stairs and getting up from a lying-down position. (e) The condition progresses quickly, and children often need to use a wheelchair by age 9. (f) ADLS become increasingly more difficult. (g) People with DMD typically die near or in their 20s as a result of respiratory problems or cardiovascular complications.
Gower’s sign
When asked to get up from sitting on the floor, the child will move the hands on the legs as though crawling up to the thighs and then assume a standing position.
Implications for occupational therapy intervention for DUchenne's muscular dystrophy
(a) Maximize and prolong independence in mobility and ADLS for as long as possible. (b) Prevent deformity. (c) Work on strength and ROM. (d) Provide psychosocial and vocational support. (e) Adaptive equipment may be used.
Congenital muscular dystrophy (CMD)
Muscular dystrophy, (a) It is a heterogeneous group of disorders with onset in utero or during the 1st yr of life. (b) Brain involvement is apparent, along with neuromuscular functioning. (c) It is characterized by hypotonia, generalized muscle weakness, and contractures. (d) Common comorbidities include clubfoot, torticollis, diaphragmatic involvement, and congenital heart and spinal defects. (e) There are four categories.
Congenital muscular dystrophy I
Congenital muscular dystrophy that does not involve severe intellectual functioning difficulties.
Congenital muscular dystrophy II
Congenital muscular dystrophy that involves muscle and brain abnormalities.
Congenital muscular dystrophy III
Congenital muscular dystrophy that involves muscle, brain, and eye abnormalities.
Congenital muscular dystrophy IV
Congenital muscular dystrophy that involves muscle, brain, and eye abnormalities.
Diagnosis of Congenital muscular dystrophy
It is confirmed by the presence of high serum levels of creatine kinase, electromyograph, and muscle biopsy. Clinical presentation includes a “floppy” (i.e., low tone) child with muscle weakness in the face, neck, trunk, and limbs; decreased muscle mass; and absent deep tendon reflexes.
Implications for occupational therapy intervention for Congenital muscular dystrophy
(a) Increase mobility and prevent contractures. (b) Use adaptive equipment and orthotics. (c) Maintain independent mobility.

Neural tube defects

a Neuromuscular disease.
a) Neural tube defects are malformations that occur early in fetal development.
b) The rate of neural tube defects is decreasing, possibly because of increased awareness of the importance of folic acid for women in their child-bearing years.
c) The three major forms of neural tube deficits

Necphalocele neural tube deficit

1 of three major forums of neural tub deficits.
a) An encephalocele is a protrusion in the occipital region of the brain.
b) It is typically associated with severe deficits, such as cognitive impairments, hydrocephalus, motor impairments, and seizures.

Anencephaly neural tube deficit

1 of three major forums of neural tub deficits.
a) Neural development above the level of the brain stem is lacking.
b) Children with anencephaly do not survive infancy.

Spina bifida neural tube deficit

1 of three major forums of neural tub deficits.
a) Spina bifida is the most common type of neural tube defect.
b) It is a congenital defect of the vertebral arches and spinal column.
c) Spina bifida can be identified through amniocentesis.
d) The mild form of spina bifida is called spina bifida occulta, and it consists of only one or two affected vertebrae with no involvement of the spinal cord. No symptoms may be present.
e) Meningocele spina bifida involves an extensive spinal opening with an exposed pouch of cerebrospinal fluid and the meninges.
f) Myclomeningocele is the most severe form of spina bifida. In addition to an excessive spinal opening with an exposed pouch of cerebrospinal fluid and meninges, the nerve roots are also exposed.

Myclomeningocele spina bifida

a) Children with myclomeningocele usually display sensorimotor problems at or below the level of the lesion.
b) Lower-extremity paralysis and loss of sensation is common.
c) Some children also have hip, spinal, or foot deformities.
d) Complications include hydrocephalus and Arnold-Chiari syndrome.

Implications for occupational therapy treatment of Spina Bifida

a) Bowel and bladder programs may be indicated.
b) Clients may have cognitive and learning issues.
c) Educate the family and client on skin care, urology, and diet.
d) Use assistive devices for mobility.

Peripheral nerve injuries
a Neuromuscular disease
a) Some peripheral nerve injuries result from birth injuries related to the brachial plexus, which is a network of nerves that originate between the C5, C6, C7, C8, and T1 spinal segments.
b) Brachial plexus injuries that are caused during birth are usually a result of the infant’s shoulders becoming impacted (e.g., becoming stuck in the birth canal). Removing the infant from the impacted position may result in the nerves in the brachial plexus stretching or tearing.
Erb-Duchenne palsy
a) Erb-Duchenne palsy is caused by an injury to the upper brachial plexus (the C5 and C6 nerve fibers), such as extreme shoulder flexion (with arm overhead).
b) It is common with breech deliveries.
c) The palsy is characterized by weakness or wasting of the small muscles of the hands and sensory discrimination in the hand and arm.
d) Erb-Duchenne palsy is typically unilateral.
e) Presentation includes upper-extremity paralysis, with more of the shoulder musculature affected than the hand.
f) Children with Erb-Duchenne palsy often hold their affected arms in a characteristic posture: shoulder adduction and internal rotation, elbow extension, forearm pronation, and wrist flexion (also known as the “waiter’s tip position”)
g) Recovery depends on the extent of nerve damage that is present; it typically occurs within 3–24 months.
Klumpke’s palsy
a) This injury results from compression or traction of the lower brachial plexus (C8 and T1).
b) It is less common than Erb-Duchenne palsy.
c) Klumpke’s palsy is characterized by paralysis of the hand and wrist muscles (also known as “claw hand” deformity).
d) Severe Klumpke’s palsy, which is rare, results in full paralysis of the entire upper extremity.
Occupational therapy assessment of Peripheral nerve, Brachial plexus injuries
a) Observation of engagement in occupations (e.g., feeding, bathing, dressing)
b) Manual muscle testing if able and AROM
Implications for occupational therapy intervention of peripheral nerve, brachial plexus injuries
a) Fabrication of a sling that fits proximally around the humerus to ensure proper alignment and prevent subluxation due to gravity
b) PROM and AROM exercises
c) Resistive exercises and weight bearing if strength improves
d) Tactile stimulation to increase awareness (different textures, massage, vibration)
e) Engagement in activities that are bilateral in nature to increase body scheme (e.g., patty cake, peek-a-boo)
f) Retrograde massage for edema
g) Surgical intervention if spontaneous improvement is not noted between ages 3 and 6 months
Other peripheral nerve injuries result from a traumatic injury
a) These injuries occur in older children and are usually the result of an accident that severs the nerve or are secondary to a fracture, dislocation, extreme exercise, or medical injections
b) Diagnosis is made through nerve conduction studies, observation, muscle biopsies, and electromyographs.
c) Traumatic injuries to the peripheral nerves are classified by severity.
d) Depending on the severity of the injury, impairments can include reduced strength, absence of deep tendon reflexes, and impaired sensation.
Other Traumatic injuries to the peripheral nerves classified by severity
Class I injuries are termed neurapraxa; some degree of paralysis is present, but no peripheral degeneration.
Class II injuries are termed axonotmesis; the endometrium is intact, but the axon degenerates distal to the legion.
Class III injuries are termed neurotmesis; these injuries are the most serious type, in which both the axon and the endometrium are severed.
Implications for occupational therapy intervention for other traumatic injuries to the peripheral nerves
a) Treatment depends on the extent, location, and progression of the injury.
b) Generally speaking, splinting (along with rest, nerve and local anesthetic, and surgery) is the standard course of treatment.
Common causes of pediatric Traumatic Brain Injury (TBI)
falls, motor vehicle accidents, child abuse, and sports injuries.
The two types of injuries that cause TBI
a) Closed injuries are caused by rapid movement of the head in which the brain strikes the skull.
b) Open injuries are caused when an object enters the brain.
Types of forces that cause head trauma
a) Impact is force that results from the head striking a surface or from a moving object striking the head.
b) Inertial forces result from rapid acceleration and deceleration of the brain inside the skull, resulting in a shearing or tearing of the brain tissue and the nerve fibers.
C) Most TBIs are a result of both types of injury.
Rating the severity of a traumatic brain injury
The severity of TBI is rated as a range, from mild concussion to more serious injuries, using the Rancho Levels of Cognitive Functioning
Level I: The client shows no response.
Level II: The client shows a generalized response.
Level III: The client shows periods of being awake; can follow some simple commands.
Level IV: The client is confused and agitated.
Level V: The client is confused, has a short attention span, may need step-by-step instructions, and may respond inappropriately.
Level VI: The client may demonstrate memory and cognitive processing problems and may still be somewhat confused.
Level VII: Attention may still be a concern. The client’s actions are more appropriate to the situation, although breakdown in skills may occur during times of stress. The client should be able to complete self-care routines.
Level VIII: The client’s actions are purposeful and appropriate; more flexibility in thinking and better problem solving are noted.
Why injury occurs
Injury occurs as a result of the initial injury and because of swelling, intracranial pressure, hematomas, emboli, and hypoxia.
Red flags associated with a TBI
include loss of consciousness, lethargy, confusion, severe headache, nausea, vomiting, or speech or motor impairment.
Children who suffed a TBI
a) Children who have experienced a moderate to severe injury will typically be unresponsive after the injury; they will then progress to opening the eyes and having generalized responses to noxious stimuli; then to a period of agitation, which can often be difficult for family members; and then to being able to attend and concentrate and be more goal oriented.
b) Children with TBI typically have better prognosis than adults; however, children may experience some persistent long-term effects.
Persistent long-term effects of TBI
a) Impaired motor skills
b) Impaired process skills
c) Impaired communication and interaction skills
d) Impaired mental functions, sensory functions, neuromusculoskeletal, and movement-related functions
e) Difficulty with academic skills and participation at school
Effects TBI can have an impact on cognition
a) Short- and long-term memory
b) High-level executive functions, such as impulse control, sequencing, insight, judgment, and long-term planning
c) Decreased insight
d) Perceptual difficulties, possible impairment of receptive and expressive communication
e) Depression (common during recovery, along with periods of anxiety or agitation).
f) Mood swings (common).
Effects TBI may have on motor function
a) Commonly, paresis or paralysis of one side of the body; dependent on the location of the brain injury
b) Spasticity
c) Ataxia or decreased coordination
e) Dysphagia or difficulty swallowing
f) Vision and hearing changes (including loss in some cases)
Acute care Occupational Therapy setting for TBI
a) Sensory stimulation can promote awareness.
b) ROM can help maintain joint mobility.
c) Positioning can help prevent skin breakdown and promote distal function.
d) Splinting can help maximize hand function.
Assessment in the Rehabilitation Occupational Therapy setting for TBI
a) Canadian Occupational Performance Measure
b) Perceived Efficacy Goal Setting System (Missiuna et al., 2004)
c) Assessment of motor and process skills (e.g., Assessment of Motor and Process Skills, School AMPS, Miller Function and Participation Scales, Dynamic Occupational Therapy Cognitive Assessment for Children, A–ONE, Behavioral Assessment of Dysexecutive Syndrome)
d) Assessment of visual–perceptual skills (e.g., through functional activities that require the use of visual discrimination, visual closure, visual figure ground, and visual memory)
e) Assessment of visual–motor integration (e.g., through the use of functional activities that use eye–hand and/or eye–foot coordination)
f) Assessment of sensory processing (e.g., monitoring a client’s performance in environments that present various types of stimulation, including auditory, visual, vestibular, tactile, and proprioceptive
g) Assessment of psychosocial factors (e.g., observe interactions with staff and other patients, monitor for signs and symptoms of depression, anxiety, aggression, and impulsivity)
h) Safety assessment
i) ADL and IADL assessment (e.g., School Function Assessment, Pediatric Evaluation of Disability Inventory)
Rehabilitation Occupational Therapy setting for TBI
a) Assessment
b) Regaining function with ADLs (e.g., increased levels of independence and decreased need for assistance with basic self-care tasks and bed mobility)
c) Regaining function with IADLs (e.g., increased levels of independence and decreased need for the assistance with community-based activities, home management, and other role-related responsibilities)
d) Regaining executive functioning skills (e.g., increased ability to problem solve, sequence, and self-initiate actions)
e) Training on assistive devices for school reentry and organization
Community reentry Occupational Therapy setting for TBI
a) Home and community visits to assess activity demands and to problem solve strategies on the basis of the client’s occupational performance in these settings
b) Home or school modifications and introduction of adaptive equipment
c) Collaboration with school personnel, family, and rehabilitation team
Goal of school personnel collaboration in pediatric community reentry setting for children with TBI
a) Reducing the amount of written work
b) Providing notes before a lesson
c) Color-coding folders
d) Picture schedules
e) Daily checklists
f) Peer models
g) Reducing classroom stimuli
h) Changing the student’s desk to another location
i) Task analysis to examine when breakdown of skills happens
Intellectual disabilities
a) The most common developmental disability
b) Three key factors leading to diagnosis
The Three key factors leading to diagnosis of Intellectual disabilities
1) Significantly impaired intellectual ability, as measured by a psychoeducational assessment: A child is considered to have an intellectual disability if his or her scores are more than 2 standard deviations below the normative range for the child’s age
2) Onset before the age of 18
3) Impairment of adaptive abilities that are necessary for ADLs and IADLs
Levels of intellectual disabilities
a) Mild: IQ between 55 and 70; ability to learn academic skills at the third- to seventh-grade level; able to work with minimal support
b) Moderate: IQ between 40 and 55; able to learn academic skills to at least the second-grade level and able to perform unskilled as well as some skilled work tasks
c) Severe: IQ between 25 and 40; able to communicate and perform some basic ADLS and health habits; often requires support to complete routines
d) Profound: IQ below 25; requires caregiver assistance for basic tasks; also generally has neuromuscular, orthopedic, or behavioral deficits
Common causes of intellectual disabilities
a) Problem acquired in childhood through trauma, toxins, or infections
b) Problems of fetal development and birth
c) Chromosomal problems
d) Central nervous system malformations
e) Congenital anomalies
f) Metabolic, neurocutaneous, and endocrine disorders
Common comorbidities with Intellectual Disabilities
a) Speech problems
b) Ambulation problems
c) Seizures
d) Visual problems
e) Chronic conditions (e.g., heart disease, diabetes, anemia, obesity, and dental problems)
Early indicators of intellectual disabilities
a) Delays in meeting motor and speech milestones
b) Unresponsiveness to handling and physical contact
c) Reduced alertness
d) Limited reactions to play
e) Feeding difficulties
f) Neurologic “soft” signs
Neurologic "soft" sign early indicators of intellectual disabilities
a) Poor balance
b) Motor asymmetry
c) Decreased perceptual–motor skills
d) Decreased fine motor skills
Requirement for Formal diagnosis of intellectual disabilities
usually made when the child enters school because of the emphasis on performance on psychoeducational assessments.
Implications for occupational therapy treatment of intellectual disabilities
a) Early years: support to meet development milestones; enriching the environment; supporting parents
b) School age: support development of functional skills; collaboration with special educators and other related service personnel; acquisition of student role
c) Adolescence: supporting the development of vocational interests and skills, social skills, sex education, and community mobility skills
d) General adaptation of the environment
-Use of assistive technology with a specific strategy for implementation
-Switches or communication devices (e.g., Dynavox).
-Mobility devices such as scooters and walkers
Autism spectrum disorder (ASD) note
Note. The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; Ameri-can Psychiatric Association [APA], 2013) eliminates the separate diagnoses of autistic disorder, Asperg-er’s disorder, childhood disintegrative disorder, and pervasive developmental disorder–not otherwise specified and replaces them with a single diagnosis of autism spectrum disorder (ASD). Because it will take time for this change to make its way into textbooks, curricula, and testing, AOTA’s NBCOT® Exam Prep materials may occasionally refer to Asperger’s disorder as described in the 4th edition (revised) of the DSM.
Autism spectrum disorder
a) ASD is a spectrum of conditions that reflect a range of deficits.
b) ASD is characterized by severe and complex impairments in social interaction and communication skills and by the presence of stereotypical behaviors, interests, and activities.
c) Onset is typically before age 3.
d) Increased diagnosis may be related to increased awareness.
e) Boys are more likely than girls to be diagnosed with ASD.
f) ASD is considered a neurobehavioral disorder.
g) ASD often coexists with other neuropsychiatric disorders (e.g., seizures, attention deficit hyperactivity disorder [ADHD], obsessive–compulsive disorder, Tourette’s syndrome).
Asperger's Disorder
The Autism Spectrum Disorder (ASD) diagnosis now includes children who would previously have been considered as having Asperger’s disorder.
a) Disturbances are common in social interactions, communication, behaviors (i.e., ritualistic behaviors and repetitive behaviors), and sensory and perceptual processing.
b) Communication abilities may range from being nonverbal and reliant on picture exchange systems and/or augmentative communication devices to children appearing to speak tangentially, being long winded, or not picking up on others’ nonverbal cues.
c) Implications for occupational therapy intervention include sensory integrative therapy, highly structured and specialized education programs, and visual supports (e.g., picture checklists, communication boards).
Autism spectrum disorder Difficulties with sensory processing and sensory modulation
a) Children with ASD have been known to respond to stimuli differently than neurotypical children; this response pattern has been found to be consistent in children who will later have a diagnosis of an ASD before age 12 mo.
b) Children with ASD can overrespond to sensory stimulation; they may have difficulty ignoring stimuli in the environment and appear to be hypersensitive to certain types of stimuli. This overresponsivity can have a negative impact on occupational performance. For example, children may not be able to tolerate getting their hair or fingernails cut; they may not be able to tolerate foods that are of a certain texture or to complete school work if a light is flickering.
c) Children with ASD can also be underresponsive to sensory stimulation; their sensory systems may be habituated to certain types of input; therefore, they need more of this type of input to register it. This underresponsivity can have a negative impact on occupational performance. For example, children may seek out vestibular input by spinning around while they are waiting in the lunch line or they may rough house with peers who do not want to engage in full body contact.
d) Sometimes the repetitive and ritualistic behaviors in which children with ASD engage are driven by an underlying sensory need, and sometimes the behaviors serve another function.
e) Assessment tools to address sensory processing and sensory modulation disorders include the Sensory Integration and Praxis Test, the Sensory Profile (which has different tools for infants, children, and adolescents), and the Sensory Processing Measure (which looks at processing in home and school environments).
Autism spectrum disorder Difficulties with cognition
a) Children with ASD may have difficulty with empathy or taking others’ perspectives and hypothesize about what they might do next (theory of mind).
b) Children with ASD often have an acute sense for detail, almost to the point of missing the bigger pictures (weak central coherence).
c) Children with ASD may have cognitive inflexibility and may be easily upset by changes in their routine and to unexpected circumstances.
Autism spectrum disorder Difficulties with motor skills
a) Many children with ASD have dyspraxia or poor motor planning abilities.
b) Dyspraxia can be seen with fine and gross motor activities.
c) The underlying sensory integrative functions are often addressed as a way to remediate this dysfunction.
Autism spectrum disorder Difficulties with communication
a) Children with ASD often have difficulty with prosody, or using variation in their pitch, emphasis, or rhythm of speech.
b) Children with ASD often have difficulty with pragmatics, or the use of language in social situations.
d) Children with ASD may benefit from social skills training.
Rett syndrome and Autism
a progressive neurologic disorder caused by a genetic mutation that is found only in girls. The previous edition of the DSM categorized it as a type of autism; the DSM–5 removes it as a separate condition because ASD-like behaviors are a factor for a only brief period in children who have the syndrome. Clinicians are instructed to use the specifier “with known genetic or medical condition” to indicate ASD-like symptoms in girls who have Rett syndrome.
Rett syndrome progression
a) Development appears normal for the first 6 mo of age.
b) In childhood, the child’s head growth begins to slow; she loses hand skills and demonstrates poorly coordinated trunk and gait coordination.
c) Initially, a loss of social skills occurs, but social skills reemerge later.
d) Common comorbidities include microcephaly, spasticity, and seizures.
e) A characteristic behavior of girls with Rett syndrome is handwringing and other repetitive behaviors; in addition, waking hyperventilation is common.
f) Girls with Rett syndrome are usually nonambulatory and nonverbal by late childhood.
a) ADHD is a behavioral disorder with unknown causes.
b) Boys are more likely to be diagnosed with ADHD than girls.
c) Common signs of ADHD include difficulty maintaining attention and increased hyperactivity and impulsivity.
d) Symptoms vary in degree.
e) Brain activity significantly diminished in the parietal lobes, which are responsible for inhibition and attention control.
f) Pharmacological intervention is common but controversial to some parents and is not without negative side effects.
g) Medication alone is ineffective in addressing all the needs of children with ADHD; psychotherapy may also be used.
Common signs of ADHD
includes difficulty maintaining attention and increased hyperactivity and impulsively.
a) Difficulty paying attention to details
b) Difficulty keeping attention during play
c) Difficulty listening to instructions or conversation
d) Difficulty with organization
e) Avoiding tasks that require a great deal of sustained attention
f) Frequent fidgeting
g) Excessive talking
h) Blurting out answers and not being able to “filter” responses
Occupational therapy assessment for ADHD
a) Clinical observations in various settings
b) Interview with the child and family
c) Assessment tools
-Assessment of Motor and Process Skills
-Canadian Occupational Performance Measure
-Child Occupational Self-Assessment
-School Function Assessment
-Short Child Occupational Profile
-Sensory Profile
-Sensory Processing Measure
Implications for occupational therapy intervention for ADHD
a) Cognitive–behavioral therapy: challenging automatic thoughts, reducing cognitive distortions, challenging underlying beliefs and assumptions, mental imagery, controlling recurrent thoughts, controlling behavior
b) Behavior modification
c) Educational interventions, including safety awareness
d) Social skills training
e) Modifying classroom environments, especially organization of space and objects
f) Self-management techniques
g) Interventions to enhance sensory modulation and support organizational routines
Learning disabilities
a) Learning disabilities are a group of problem that affect a child’s ability to perform and master academic skills, process information, and communicate effectively.
b) They are not associated with any underlying neurologic insult.
Different types of learning disabilities
a) Dyslexia: difficulty with reading
b) Dysgraphia: difficulty with writing
c) Dyscalculia: difficulty with math
Behaviors Associated with learning disabilities that Children may have any combination of
a) Disorders of motor function (i.e., dyspraxia)
b) Educational disorders
c) Disorders of attention and concentration
d) Disorders of thinking and memory
e) Problems with speech and communication
f) Auditory difficulties
g) Sensory integrative and perceptual disorders
h) Psychosocial problems
i) Specific learning difficulties (reading is the most common)
Implications for occupational therapy intervention for Learning disabilities
a) Early childhood: sensory integration, play, socialization, and self-help
b) School age: sensory integration, perceptual–motor integration, writing skills
c) Early adolescence: independent living skills, social skills, and the development of compensatory and adaptive techniques
Tourette’s syndrome
a) Tourette’s syndrome is a neurological disorder.
b) It affects boys more often than girls.
c) Symptoms include lack of muscle coordination, involuntary purposeless movements, tics, and incoherent grunts.
d) Sometimes adolescents with Tourette’s syndrome will experience coprolalia and involuntary swearing.
e) Tourette’s is often treated with medication.
Genetic and chromosomal disorders
a) Genetic anomalies involve one gene.
b) Chromosomal anomalies involve more than one gene and may involve thousands of genes.
c) Such syndromes are characterized by symptom patterns, and diagnosis can be confirmed through analysis of a child’s body tissues.
d) Amniocentesis may be able to detect some genetic and chromosomal abnormalities before birth.
Trisomy 21 or Down syndrome
A chromosomal disorder
a) Children present with a short, stout stature and often have small heads that are flattened in the back; low-set ears; a flat nose; a slack jaw with slight tongue protrusion; shorter extremities; broad, short fingers and toes; and a single crease in their hands (i.e., simian crease). They have fewer hand bones, a lower set thumb, and a small or missing middle phalanx on the fifth digits.
b) Cardiovascular anomalies, obesity, and respiratory infections are common. Visual acuity often requires correction.
c) Children may have atlantoaxial instability (AAI), which can lead to the more serious dislocation of the atlantoaxial joint. AAI is a result of abnormal ligaments associated with the atlantoaxial joint. AAI can lead to permanent spinal cord damage and neurological implications. Precautions for children with AAI include receiving clearance for sports. Children with AAI should not hyperflex their neck and should not perform front rolls.
d) Occupational therapy evaluation may include interviews with the child’s family to understand the child’s unique developmental trajectory, clinical observation, and standardized assessment tools.
e) Children with Down syndrome typically have an intellectual disability.
f) Occupational therapy intervention includes feeding support, addressing developmental delays, supporting motor planning and cognitive development, environmental and task modification, family coaching and training, support for the development of self-determination skills, prevocational training, supporting the development of ADL and IADL skills, and educational interventions.
Trisomy 13 or Patau’s syndrome
A chromosomal disorder
a) Children with this syndrome have multiple anomalies affecting their eyes, ears, nose, lip, palate, and digits.
b) In addition, they have microcephaly and neural tube differences. Only about 20% of children with this disorder survive.
Turner’s syndrome
A chromosomal disorder
a) Children with Turner’s syndrome present with webbing of the neck, congenital edema of the extremities, and cardiac problems.
b) In addition, children may be short, may develop obesity, and lack secondary sexual characteristics.
c) Children with Turner’s syndrome typically do not have intellectual disabilities, although they may have difficulty with visual perception.
Cri du chat syndrome
A chromosomal disorder
a) Children with this syndrome have a weak and “catlike” cry in infancy.
b) They often present with microcephaly, down-slanting eyes, cardiac abnormalities, and failure to thrive.
d) In addition, they also have an intellectual disability, hypotonia, feeding, and respiratory problems
Klinefelter’s syndrome
A chromosomal disorder
a) Boys born with Klinefelter’s syndrome have an extra X chromosome.
b) Boys with this syndrome have learning disabilities and emotional and behavioral problems; they are tall, slim, have small genitalia, and are unable to father children.
Fragile X syndrome
A genetic disorder. Children present with an intellectual disability, craniofacial deformities, elongated face, prominent jaw and forehead, large ears, high-arched palate, pes planus (flat feet), and hypermobile joints.
A genetic disorder
a) Children with this disorder present with multiple tumors (fibromas) on the central and peripheral nerves, café-au-lait birthmarks, and vascular and visceral lesions.
b) Children with neurofibromatosis may have mild intellectual impairments or learning disabilities, speech disorders, short stature, and skeletal anomalies.
Prader-Willi syndrome
A genetic disorder. Children with this disorder present with moderate intellectual disabilities, food-seeking behaviors, hypotonia, poor thermal regulation, underdeveloped sex organs, and a long face with slanted eyes.
Williams syndrome
A genetic disorder
a) Children with this disorder present with cerebral and cardiovascular abnormalities.
b) Children with Williams syndrome have an intellectual disability, but a characteristic affinity for music, social skills, and writing.
c) In addition, they have common facial characteristics and difficulty with visual, spatial, and motor skills.
Phenylketonuria (PKU)
An Inborn errors of metabolism.
a) PKU is an inborn error in processing an amino acid in proteins.
b) Children with PKU usually have blond hair and blue eyes.
c) If untreated, children with this condition have severe intellectual and behavioral difficulties and may present as though they have autism.
d) The Guthrie test can be done at birth to diagnose PKU.
e) Diet is the primary means to treat PKU, and the condition may resolve around age 10 if the diet is followed consistently.
An Inborn errors of metabolism
a) This disorder involves the inability to convert milk sugar to glucose, which could result in spleen and liver dysfunction.
b) Symptoms include jaundice, vomiting, diarrhea, lethargy, cataracts, and systemic infections. If not treated, it can lead to death.
c) Treatment involves avoidance of milk products and breast milk.
d) Without treatment, learning difficulties, perceptual problems, tremors, choreoathetosis, and ataxia may be present.
Lesch-Nyhan syndrome
An Inborn errors of metabolism
a) This syndrome is a progressive neuromuscular disease that is a result of difficulty metabolizing purines.
b) Only boys have this syndrome.
c) Boys appear normal for the 1st yr and then begin regressing. They then present with intellectual disabilities, neuromotor degeneration, and spasticity, as well as nail-biting and face-rubbing compulsions, which can be damaging.
d) Treatment involves preventing self-injurious behavior.
Developmental coordination disorder
a) Other names for this condition include developmental disorder of motor function, developmental dyspraxia, and congenital maladroitness.
b) This disorder is primarily a condition of motor incoordination, and other developmental delays must be ruled out.
c) Early symptoms include delayed achievement of motor milestones and basic self-care skills.
d) Symptoms in school-age children include difficulty with fine motor and gross motor skills, including handwriting and ball skills.
e) Children may experience difficulty with social skills and academics owing to decreased motor coordination.
f) Developmental coordination disorders and disorders of speech and language commonly co-occur.
Implications for occupational therapy treatment of Developmental coordination disorder
a) Emphasize improving occupational performance across contexts.
b) Implement modifications and accommodations for written language, including keyboarding.
c) Provide support in physical education.
d) Promote safe practice of motor skills.
e) Provide support for development of a good self-concept and self-esteem.
f) For some children, provide individual intervention to master skills before being asked to perform them in front of a large group.
g) Perform assessment with the Cognitive Orientation to daily Occupational Performance.
Cognitive Orientation to Daily Occupational Performance
(CO-OP) assessment
a) The CO–OP is a client-centered problem-solving approach.
b) It is a way to coach the child through self-discovery and devise solutions for everyday life situations that are affected by motor performance.
c) The CO–OP is characterized by a cooperative relationship between the occupational therapy practitioner and the child.
d) The child helps to formulate and select goals and work on ways to generalize skills to other contexts.
e) The outcome of the intervention is skill acquisition, generalization, transfer, and positive gains in self-efficacy and independent strategy development.
Diabetes is a metabolic condition that involves the pancreas producing insufficient amounts of insulin. There are two types of diabetes, Type I and Type II
Type 1 Diabetes
a) Onset is usually around age 10.
b) Presentation tends to be more acute and requires the administration of insulin.
c) Diet and exercise are also a part of treatment.
d) Early symptoms include weight loss, thirst, polyuria, and dehydration.
e) Children with Type 1 diabetes are at risk for developing retinopathy leading to blindness, nephropathy, and peripheral nerve damage.
Type 2 Diabetes
a) Onset is usually around age 40.
b) Type 2 diabetes can be controlled by diet, exercise, and insulin.
storch Infections
Infections transmitted from mother to child are known as “STORCH” infections: syphilis, toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes simplex virus–2
Congenital syphilis
this is a STORCH infection transmitted during the third trimester of pregnancy or during delivery. The infant requires isolation and is treated with penicillin. Early-state congenital syphilis leads to hepatitis, failure to thrive, and neurologic involvement. After the infection is treated, the child may develop osteochondritis at the joints and other bone abnormalities, dental anomalies, and visual and auditory deficits.
this is a STORCH infection contracted through handling of cat feces or eating raw meats. Stillbirths are commonly associated with this condition. However, children born with toxoplasmosis have intellectual disabilities, hydrocephalus, and chorioretinitis. Other common comorbidities include cerebral palsy, seizures, cardiac and liver damage, and gastrointestinal problems.
this can be a STORCH infection can be very harmful if it is contracted in the first trimester. Many fetuses will not survive the duration of the pregnancy. When babies are born after their mother has contracted rubella, they often have intellectual disabilities, hearing loss, microcephaly, congenital heart defects, seizures, and problems with their liver and spleen.
Cytomegalovirus or (CMV)
this is a STORCH infection transmitted before, during, or after birth. Because the virus may be dormant, therapists need to use universal precautions when working with children who have been exposed to CMV. Children exposed to CMV may have low birth weight, hearing loss, microcephaly, spleen and liver damage, and neurologic deficits.
Congenital herpes
this is a STORCH infection contracted during delivery. Infants will often develop skin lesions within 1 week to 10 days of birth. Internal organ lesions and central nervous system damage may develop. Early red flags include fever, lethargy, poor feeding, and vomiting. Cesarean sections can often be used to stop transmission.
AIDS as a STORCH infection
a) AIDS is caused by the human immunodeficiency virus (HIV).
b) HIV is transmitted to infants by perinatal contact with the mother, mostly in utero.
c) HIV can be diagnosed between ages 1 and 6 mo.
d) The rate of progression from HIV to AIDS varies greatly.
e) Laboratory tests are required around every 3 mo for children who test positive for HIV.
f) Other illnesses, including colds, are monitored closely for the impact that they may have on the immune system.
g) Common infections that may be contracted include otitis media, urinary tract infections, and oral candidiasis.
h) Treatment involves antiretroviral drugs.
i) If the disease progresses, chronic respiratory illness, skin infections, and diarrhea are common; ataxia, spasticity, rigidity, tremor, and seizures are also common.
j) Developmental delays may include speech and language, motor, and independent skills.
k) Occupational therapy intervention includes developmental assessment and educational support.
this is an inflammation of the brain.
a) It is caused by bacteria, spirochetes, or a viral infection.
b) The condition could be localized or include the spinal cord or the meninges.
c) Summer onset is common.
d) Signs and symptoms include fever, headache, dizziness, stiff neck, nausea, vomiting, tremors, and ataxia.
e) Diagnosis is based on how the infection was contracted, clinical findings, and laboratory tests.
f) Encephalitis can ultimately lead to brain damage, ranging from mild to severe.
g) Neurorehabilitation is used to limit disability and teach compensatory strategies.
this is an infection of the tissue that covers the brain and the spinal cord.
a) It most commonly has a bacterial cause.
b) The presentation is similar to encephalitis; symptoms include headache, fever, and stiff neck.
c) Diagnostic procedures include lumbar puncture and analysis of cerebrospinal fluid.
d) Neuromotor, visual, and auditory disturbances; seizures; and learning disorders may all persist after the meningitis has resolved.
Neoplastic disorders
a) A neoplasm is a new or abnormal tissue growth or tumor.
b) Neoplasty is a surgical procedure to remove the growth and reform or restore the body parts that were affected
Benign neoplasm
a growth that does not spread, metastasize, or infiltrate tissue
Histoid neoplasm
a type of neoplasm in which the growth resembles the tissue around it
Malignant neoplasm
a growth that does spread, metastasize, and infiltrate other tissue (cancer)
Mixed neoplasm
a growth that is made up of two layers
Multicentric neoplasm
a growth that comes from several distinct cell groups
Organoid neoplasm
a growth that is similar to an organ in the body
Unicentric neoplasm
a growth that originates from one group of cells

Visual impairment defined
visual impairment is the loss of vision or visual deficits as a result of pathology or the processing of visual information.
a) Children with developmental disabilities are likely to have visual impairments.
Difficulties with visual skills that develop as a result of the central nervous system
a) Fixation
b) Tracking, pursuits
c) Saccade
d) Accommodation
e) Convergence
f) Binocular vision
g) Stereopsis (binocular depth perception)
Common conditions of visual impairments
a) Cortical visual impairment
b) Retinopathy of prematurity
c) Microphthalmia
d) Anopthalmia
e) Childhood glaucoma
f) Retinoblastoma
g) Congenital cataracts
Common postural and motor presentation in children with visual impairment include
a) Hypotonia
b) Shoulder and pelvic instability
c) Pronounced head tilt to one side
d) Hyperextended neck
e) Maintenance of wide base of support
f) Tendency to move in straight planes
g) High guard posture when walking
Visual impairment Implications for occupational therapy intervention
a) In infancy, caregivers may need support to respond to their baby’s cues and to establish sleep routines, and the infant may not display typical attachment behaviors (such as imitating social smiles).
b) Play exploration may need to be supported to promote development in all areas.
c) Learning may not be affected because cognition may be intact; however, accommodations and modifications may need to be made to tasks and the environment.
Interventions the occupational therapy practitioner should focus on
a) Provide opportunities for children to learn to use their other senses.
b) Use sensory integrative therapy.
c) Support social participation.
d) Support development of self-care skills.
e) Develop tactile and proprioceptive abilities.
f) Improve fine motor manipulation skills.
g) Maximize functional use of vision.
Red flags related to visual problems
These can be physical, behavioral, performance, and social.
Physical red flags releated to problems
a) Eye shake
b) Excessively large or small pupils
c) Eyes not in alignment
d) Pupils not black; appear to have an opaque film over them
Behavioral red flags releated to problems
a) Need to move closer to objects or surfaces that need visual attention
b) Squinting, straining, frequently rubbing eyes, closing one eye, excessive head movements
c) Complaints of headaches
d) Avoidance of work tasks with a strong visual component, seemingly short attention span, or both
Performance red flags releated to problems
a) Appearing clumsy
b) Difficulty locating needed items
c) Trouble learning alphabet and recognizing spatial concepts
d) Difficulty with drawing, writing, or reading
e) Difficulty copying
Social red flags releated to problems
a) Lack of interest
b) Anxiety
c) Decreased self-confidence
Risks for hearing impairment
a) Prematurity and neonatal intensive care unit stays
b) Delayed speech and language skills
c) In utero infections
d) Craniofacial anomalies
e) Syndromes associated with hearing loss
f) Neurodegenerative disorders
g) Postnatal infections
h) Head trauma
i) Chemotherapy
Hearing impairment
a) Distinguishing between hearing loss and behavioral difficulties is a concern.
b) Vestibular dysfunction is common and results in decreased balance, low muscle tone, difficulty with visual development, and delayed reflex maturation.
Common collaborators in treatment for hearing imparirment
a) A speech–language pathologist, to address speech and language issues
b) An audiologist, to address hearing issues
c) Educational personnel, to address concerns at school
Hearing impairment Implications for occupational therapy intervention
a) Use sensory integrative therapy.
b) Support vestibular function.
c) Maximize use of residual hearing.
d) Encourage age-appropriate self-care skills.
e) Enhance fine motor coordination and skills.
f) Maximize oral–motor coordination.
g) Maximize visual processing, integration, and perception.
h) Encourage socialization and peer interaction.
i) Use backward chaining
j) Use forward chaining
Backward chaining
teaching/intervention technique in which the therapist performs the first several steps of the task and allows the child to complete the last step of the task
Forward chaining
teaching/intervention technique in which the therapist encourages the child to complete the first step of the task, and they practice this step until it is mastered. In the meantime, the therapist completes the rest of the task.
Visual perception
the process of being able to understand what is being seen.
Visual–perceptual skills
a) Shape, letter, object, and color identification and recognition
b) Visual–receptive functions
c) Visual-cognitive functions
Visual-reception functions
a) Saccades or visual scanning
b) Acuity
c) Accommodation
d) Binocular fusion
e) Stereopsis
Visual–cognitive functions
a)Visual attention: alertness, selective attention, visual vigilance, divided or shared attention
b) Visual memory: integrating visual information with past experiences
c) Visual discrimination: recognition, matching, and categorization
d) Object perception: form constancy, visual closure, visual–figure ground
e) Spatial perception: position in space, depth perception, topographic orientation
f) Visual imagery: the ability to imagine people, objects, or experiences
Warren’s model for assessment
this is a developmental framework for intervention that is a hierarchical model with each skill building on the preceding skill.
1) Primary visual skills: oculomotor control, registration of the visual fields, and visual acuity
2) Visual attention
3) Scanning
4) Pattern recognition
5) Visual memory
6) Visual cognition
Visual–perceptual problems
a) Visual–receptive dysfunction
b) Refractive errors
c) Visual–cognitive dysfunction
Visual–receptive dysfunction
a) Difficulty completing work tasks in a timely manner
b) Avoidance of reading or writing tasks
c) Visual fatigue
d) Distraction or inattention to visual material
Refractive errors
this is the inability of the eye to adjust to different lighting conditions, visual-field problems, accommodations, and other oculomotor functions
a) Presbyopia: when accommodation for near objects is poor
b) Strabismus: when one eye turns in, out, up, or down as a result of muscle imbalance; can result in blurred or double vision
c) Phoria: a tendency for one eye to move slightly in, out, up, or down without overt misalignment
Visual–cognitive dysfunction
a) Difficulty with visual attention
b) Difficulty with visual memory
c) Difficulty picking out a figure from the background
d) Difficulty with depth perception
Functional implications related to problems in visual–perceptual skills
a) Problems with reading
b) Problems with spelling
c) Problems with handwriting and visual–motor integration
d) Problems with mathematics
Evaluation of Visual–receptive functions
a) Observation of how well the eyes work together
b) Determining where visual control is most efficient and effective
c) Identification of which types of eye movements are quick, fluid, and accurate
d) Determining whether the child moves the head excessively while reading or skips lines when reading
Evaluation of Visual–cognitive functions
a) Bruininks–Oseretsky Test of Motor Proficiency
b) Jordan Left–Right Reversal Test
c) Developmental Test of Visual Perception
d) Componential Assessment of Visual Perception
e) Motor-Free Visual Perception Test–Revised
f) Test of Pictures–Forms–Letters–Numbers–Spatial Orientation and Sequencing Skills
g) Visual–motor integration assessments (e.g., Developmental Test of Visual–Motor Integration)
Intervention strategies for Infants
a) Dim lights
b) Stimulation of other body senses to influence distance sense
c) Emphasis on the human face
d) Softer, simpler three-dimensional forms
e) Mobiles hung 2 feet above the infant
f) Toys that reflect light or flash with sound
Intervention strategies for Preschool and kindergarten students
a) Multisensory approach using different textures and media
b) Activities that encourage body-in-space concepts
c) Emphasis on imitation
d) Shared storybook reading
Intervention strategies for Elementary school
a) Organize the environment so that it is less visually distracting.
b) Alternate positions for visual–perceptual activities.
c) Modify work to enhance visual attention to attributes of the assignment (e.g., bold line to enhance page margin; reorganizing worksheets).
d) Reduce other sensory input.
e) Teach strategies, for example, a routine for searching in “Where’s Waldo”–type activities; scanning routines
f) Use of chunking, maintenance rehearsal (repetition), and mnemonic devices
g) Use color coding
h) Use directional cues for writing
i) Games to support visual spatial concepts
j) Use computers to support development of skills and as an accommodation.
k) Identify learning styles (e.g., kinesthetic learners may benefit from games such as bingo, dominoes, or card games, which allow them to move while reviewing skills)
Development of prewriting and handwriting in young children
1) Age 10–12 mo: Scribbles on paper.
2) Age 2 yr: Imitates horizontal, vertical, and circular marks.
3) Age 3 yr: Copies a vertical line, horizontal line, and circle.
4) Ages 4–5 yr: Copies a cross, right oblique line, square, left diagonal line, left oblique cross, some letters and numbers; possibly can write their own name.
5) Ages 5–6 yr: Copies a triangle, prints own name, copies most letters.
Prerequisites for handwriting
a) Small muscle development
b) Eye–hand coordination
c) Ability to hold writing utensil
d) Ability to form basic strokes
e) Letter identification
f) Print orientation
Other factors for handwriting readiness
Integration of visual, motor, sensory, and perceptual systems
a) Kinesthesia
b) Motor planning
c) Visual–motor integration
d) In-hand manipulation skills
Benbow’s developmental classification of factors that are the basis of skilled hand use
a) Upper-extremity support
b) Wrist and hand development
c) Visual control
d) Bilateral integration
e) Spatial analysis
f) Kinesthesia
Occupational therapy intervention to support the development of handwriting readiness skills
a) Activities incorporated into therapy sessions and into the child’s classroom
-Fine motor control
-Isolated finger movements
-Prewriting lines and shapes as mentioned earlier
-Left–right discrimination
-Print orientation
-Letter discrimination
b) Early exposure to technology for children with more significant cognitive or physical disabilities
Typical pencil grasp progression
1) Primitive grip: The whole hand or extended fingers and a pronated forearm are used to hold writing utensil; the writing movement comes from the shoulder.
2) Transitional grip: Writing utensil is held with flexed fingers with pronated forearm and radial side down and then progresses to a supinated forearm position.
3) Mature grip: The writing utensil is stabilized by distal phalanges of the thumb, middle, and index finger; the ring finger may also be used; wrist is slightly extended, and the supinated forearm rests on the table.
Functional pencil grips for handwriting
a) Dynamic tripod: The pencil rests against distal phalanx of the radial side of the middle finger, and the pads of the fingers control the movement; the thumb is opposed to the index finger.
b) Lateral tripod: The pencil rests against the radial side of the middle finger, and the pads of the fingers control the movement; the thumb is not opposed to the index finger and rests on the distal interphalangeal joint.
c) Dynamic quadrupod: The pencil rests against the distal phalanx of the radial side of the ring finger, and the pads of the fingers control the movement; the thumb is opposed to the index finger.
d) Lateral quadrupod: The pencil rests against the radial side of the ring finger, and the pads of the fingers control the movement; the thumb is not opposed to the index finger and rests on the distal interphalangeal joint.
Handwriting evaluation
a) Occupational profile
b) Interviews of: Child, Teacher, and Parent
c) Analysis of performance
-Work samples
-File review
-Direct observation
d) Measuring handwriting performance
e) Factors restricting handwriting performance
Direct observations to look for during the Analysis of performance when evaluating handwriting
a) Writing tasks that are the most difficult for the child
b) What behaviors are evident when the child is required to write
c) Level of assistance or cueing (if any) the child needs to complete the writing tasks
d) Whether the child is distracted by any visual or auditory stimuli
e) Where the child sits in the classroom
f)The handwriting curriculum (if any) used
g) Location of the teacher when instruction is being given
h) How the writing difficulty affects learning
Measuring handwriting performance
a) Measure the Domains of handwriting
b) Measure Legibility components
c) Writing speed: number of letters or words written per minute
d) Ergonomic factors: writing posture, upper-extremity stability and mobility, and pencil grip
e) Formal handwriting assessments
Domains of handwriting
a) Writing the uppercase and lowercase alphabet
b) Copying letters, words, and numbers in manuscript and cursive
c) Copying from distal vertical surface (far point)
d) Copying from manuscript to cursive and cursive to manuscript
e) Writing words, numbers, and letters that are dictated
f) Generation of a short composition that matches grade expectations
Legibility components of handwriting
a) Letter formation: improper letter formation, poor leading in and leading out of letters, inadequate rounding of letters, incomplete closures of letters, and incorrect ascenders or descenders
b) Alignment: letter orientation to the baseline and how the writing is placed between the paper’s guidelines
c) Spacing: dispersion of words between words and letters within words
d) Sizing: size of the letters relative to the paper’s guidelines
e) Slant: angle of the words and letters
f) Word legibility formula: total number of readable words divided by total number of words written
Formal handwriting assessments
a) Children’s Handwriting Evaluation Scale
b) Denver Handwriting Analysis
c) Minnesota Handwriting Assessment
d) Evaluation Test of Children’s Handwriting
e) Test of Handwriting Skills, Revised
f) Print Tool
Factors restricting handwriting performance
a) Performance skills
b) Client factors
c) Performance patterns
d) Contextual elements
Handwriting intervention
a) Neurodevelopmental approach
b) Acquisitional approach
c) Sensorimotor approach
d) Biomechanical approach
e) Psychosocial approach
Neurodevelopmental approach to handwriting intervention
a) This approach is ideal for children who have poor postural control, poor automatic reactions, and limited limb control; children with tone issues and poor proximal stability may also benefit.
b) The approach includes preparation activities for posture and the upper extremities.
-Activities that modulate muscle tone
-Activities that promote proximal joint stability
-Activities that improve hand function
Acquisitional approach to handwriting intervention
a) Handwriting should be taught directly.
b) Handwriting should be implemented in brief, daily lessons.
c) Handwriting instruction should be individualized to the child.
d) Handwriting instruction should be adjusted on the basis of evaluation and performance data.
e) Handwriting should be overlearned and used in a functional way.
The different phases of handwriting acquisition in the acquisitional approuch to handwriting intervention
a) Cognitive phase: The child is beginning to understand the demands of handwriting and develop a cognitive strategy for the necessary motor movement.
b) Associative phase: The child continues to practice and begins to self-monitor; proprioceptive feedback and visual cues are essential at this phase.
c) Autonomous phase: The child can perform handwriting with minimal conscious attention.
Sensorimotor approach to handwriting intervention
a) Multisensory input is provided to enhance the integration of the sensory systems at the subcortical level.
b) Various sensory experiences, media, and novel instructional materials are incorporated.
c) Multiple writing tools, writing surfaces, and positions for writing should be offered.
Focus of Biomechanical approach to handwriting intervention
Intervention is focused on the ergonomic factors that influence writing production.
Ergonomic factors that influence writing production in the Biomechanical approach
a) Sitting posture
-Children should be seated with feet on the floor, thus providing support for weight shifting and postural adjustments.
-The table surface should be 2 inches above the flexed elbows when the child is seated in the chair; this position allows for motor synergy and symmetry.
b) Paper position
-The paper should be slanted on the desktop so that it is parallel to the forearm of the writing hand when the child’s forearm is resting on the desk.
-Left-handed students with a supinated grip should have their papers slanted to the left.
c) Pencil grip and adjustment of the writing tool
-Adaptive equipment to support a functional grip includes pencil grips, triangular grips, moldable grips, wider-barreled pencils, and rubber band slings.
-A mature grip should be encouraged in young children; as early as second grade, changing a child’s pencil grip may be stressful.
d) Paper modifications
Psychosocial approach to handwriting intervention
a) Intervention is focused on improving self-control, coping skills, and social behaviors.
b) Emphasis is placed on communicating the importance of good handwriting to the child.
c) Opportunities to enhance self-confidence are provided.

Ayres Sensory Integration
a) Proximal senses are emphasized; these senses are thought to dominate a child’s early life experiences.
b) Distal senses are not thought to have as large an impact until later in childhood.
Neurologically based Sensory integration concerns
a) Optimal brain function is based on sensory input.
b) A lack of sensory input at critical points in development may result in learning or behavioral disorders.
c) Sensory input is akin to sensory nourishment because it is thought to feed the body’s central nervous system (CNS).
d) Too much sensory input is not necessarily a good thing.
e) Adaptive response to input
f) Ayres hypothesized that SI takes place in the lower levels of the CNS, specifically at the brain stem and the thalamus.
g) Increased efficiency in these lower levels of the CNS is thought to enhance higher levels of functioning.
h) Ayres hypothesized that “refinement of primitive functions”, especially those related to posture, balance, and tactile perception, would lead to increased functional skills, including learning, behavior, and motor skills.
i) The first 7 yr of life are a critical time for development of SI. Children search for experiences in the environment that provide them with the “just-right” challenge; they have a sense of inner drive.
Sensory diet
Wilbarger (1995) developed a concept called the sensory diet based on the principle that: Sensory input is akin to sensory nourishment because it is thought to feed the body’s central nervous system (CNS).
a) A sensory diet is an individualized plan that provides a specific child with the optimal sensory experiences that the child needs to be functional in his or her environment.
b) This intervention strategy is specific to children with sensory integrative dysfunction because children with typical CNS functions are thought to be able to seek out the sensory input that
Concept that Too much sensory input is not necessarily a good thing
a) For sensory input to be effective, it has to be matched to the child’s specific CNS requirements.
b) The child has to be able to organize and use the sensory input to respond to the environment.
Adaptive response
Children with typical CNSs will seek out the sensory input that they need to organize themselves and to help them achieve their goals.
a) SI is considered the act of organizing this information.
b) An adaptive response is the result of optimal organization and leads to efficient goal-directed action.
c) As tasks become more complicated and children continue to demonstrate adaptive response, their SI becomes more effective and efficient.
d) Adaptive responses are thought to lead to changes at the neuronal synaptic level; these changes alter the brain through a process called neural plasticity.
e) “Plasticity is the ability of a structure and concomitant function to be changed gradually by its own ongoing activity”.
Ayres hypothesis on the location of sensory integration in the brain
Ayres hypothesized that SI takes place in the lower levels of the CNS, specifically at the brain stem and the thalamus.
a) Vestibular input is processed mostly in the brain stem.
b) Somatosensory input is processed mostly in the thalamus.
Sensory modulation problems
are sensory integrative problems,
a) Sensory modulation is regulation by the CNS of its own activity.
b) Problems with modulation are characterized by children being unable to grade responses in relation to external stimuli.
c) Sensory-seeking behavior is thought to be due to hyporesponsivity to a stimulus; children may seek intense input or large quantities of input.
d) Overresponsiveness to stimuli may be the result of tactile defensiveness or gravitation insecurity.
Sensory modulation Underreactivity
also known as hyporesponsivity: Children demonstrate a pattern that looks as though they fail to orient to the stimuli.
Sensory modulation Overreactivity
also known as hyperresponsivity: Children demonstrate a pattern that looks as though they overorient to the stimuli.
Sensory-seeking behavior
this is thought to be due to hyporesponsivity to a stimulus; children may seek intense input or large quantities of input.
a) Children seeking vestibular input may appear to be reckless or risk takers; they may need a lot to get going.
b) Children seeking proprioceptive input may try to get their needs met by engaging in rough housing and other activities that provide them with deep-pressure input or muscle resistance. Children who seek this type of input may be trying to regulate their experiences of touch or movement.
Sensory integration Overresponsiveness
Overresponsiveness to stimuli may be the result of tactile defensiveness or gravitation insecurity.
a) Tactile defensiveness is an extreme reaction or overreaction to tactile input; light touch may be particularly noxious; children may be extrasensitive on their face, abdomen, and palmar surfaces of their hands.
b) Gravitational insecurity is an overresponsivity to vestibular input; children with this type of dysfunction may be extremely scared of movement and may move carefully; in addition, they may prefer to have their feet stay on the ground.
c) Overresponsivity may be present in any of the other senses as well.
Sensory discrimination and proprioceptive problems
a) Difficulty with tactile discrimination and perception is one of the most common types of sensory integrative dysfunction.
b) Difficulty with proprioception is characterized by children appearing gawky and awkward and having difficulty grading force.
c) Visual–perceptual problems are common in children with other types of SI dysfunction; children may have difficulty with form and space perception, figure–ground perception, spatial orientation, depth perception, and visual closure.
d) Vestibular–proprioceptive problems are characterized by poor bilateral coordination and difficulty sequencing actions.
e) Praxis problems, or dyspraxia, involve difficulty with any of the three parts of praxis: ideation, planning, and execution.
Tactile discrimination and perception problems
a) It is characterized by difficulty making sense of, or interpreting, tactile input.
b) Fine motor manipulation skills may be delayed as a result.
c) Children may also have difficulty grading force or pressure.
d) Being able to feel objects and use them efficiently is an important part of child development. When children have difficulty interpreting what they are feeling, they may experience delays.
e) Children may have difficulty with visual–motor tasks and motor planning in general.
f) Children with this type of dysfunction should be taught to compensate for motor skills by using visual guidance.
Proprioception sensory problems
Difficulty with proprioception is characterized by children appearing gawky and awkward and having difficulty grading force.
a) Children with this type of dysfunction may not be getting the information that they need from their muscles and joints
b) Cognitive strategies can be used to help them compensate.
Vestibular–proprioceptive problems
these problems are characterized by poor bilateral coordination and difficulty sequencing actions.
a) Projected action sequences involving children having to be able to move their bodies in relationship to changing environmental conditions (e.g., a child responding to a ball being kicked to him or her) are difficult for children with vestibular–proprioceptive problems
b) Common presentations include decreased equilibrium reactions, poor posture, lower-than-average tone, and delayed gross motor skills.
Praxis problems
also known as dyspraxia, involve difficulty with any of the three parts of praxis: ideation, planning, and execution.
a) Dyspraxia is also known as developmental dyspraxia and somatodyspraxia.
b) Children with dyspraxia have difficulty with motor planning.
c) Children also experience difficulty with tactile perception and discrimination.
Interviews and caregiver questionnaires during the assessment of sensory integration
these are used to gain an understanding of how sensory problems influence participation in daily activities
a) Sensory Profile
b) Sensory Processing Measure
c) Touch Inventory for Elementary-School-Aged Children
Informal observations used during the assessment of sensory integration
a) Observations occur in the child’s natural settings, such as at home, at school, and in the community.
b) The occupational therapy practitioner looks for the ways in which the child responds to typical events as well as to novel ones.
c) Children without sensory integrative dysfunction will demonstrate adaptive responses; children with sensory integrative dysfunction will not consistently demonstrate adaptive responses, if at all.
Formal observations used during the assessment of sensory integration
a) Clinical observations are a specific set of observations that allow the occupational therapy practitioner to make some inferences about how the child’s CNS is functioning.
b) Examples of clinical observations are crossing the body at midline, equilibrium reactions, muscle tone, prone extension, supine flexion.
Standardized tests used during the assessment of sensory integration
a) Sensory Integration and Praxis Test (Ayres, 1996)
-Requires 90–120 minutes to administer
-Subtests measure tactile, vestibular, and proprioceptive processing, visual–motor coordination and forms and space perception, bilateral integration, and praxis.
-Requires specialized training.
b) Miller Function and Participation Scales
c) Bruininks–Oseretsky Test of Motor Proficiency
d) School Function Assessment.
Ayres Sensory integration treatment
The guiding principles of Ayres Sensory Integration treatment are as follows:
a) Sensory input can be used systematically to elicit an adaptive response
b) Registration of meaningful sensory input is necessary before an adaptive response can be made
c) An adaptive response contributes to the development of sensory integration
d) Better organization of adaptive responses enhances the child’s general behavioral organization
e) More mature and complex patterns of behaviors involve consolidations of more primitive behaviors
f) The more inner directed a child’s activities are, the greater the potential for the activities to improve neural organization.
Sensory integration Intervention
a) The purpose of intervention is to alter the child’s CNS so that the child may respond more efficiently and effectively in his or her environment.
b) Intervention typically occurs on an individual basis because the occupational therapy practitioner is continually monitoring the child’s response to sensory input.
c) Therapy is child directed and guided by the child’s inner drive; the child’s active participation means that therapy will be more meaningful and effective.
d) Within this child-directed environment, the occupational therapy practitioner strives to create the just-right challenge.
e) Play and imagination are an important part of Ayres Sensory Integration treatment.
f) Suspended equipment provides the opportunity for children to gain vestibular input.
g) Other types of equipment are also used to provide different types of input. Some of the inputs that are targeted include vibration, tactile input (e.g., playing in a bin of rice or beans), and proprioceptive (e.g., pulling oneself up a rope).
h) Treatments typically last between 45 and 60 minutes 1–2 times per week and continue for about 2 yr.
i) Ayres Sensory Integration concepts have been adapted to meet the needs of children who are included in populations with known CNS differences (e.g., autism spectrum disorders, fragile X, cerebral palsy)
Useage of suspended equipment in sensory integration treatments
Suspended equipment provides the opportunity for children to gain vestibular input.
a) Linear movement is usually tolerated the best and is introduced first.
b) When providing vestibular input, the occupational therapy practitioner looks for red flags to ensure that too much input was not provided. These red flags include the child’s report of nausea or dizziness, blanching, hyperactivity, and lethargy.
c) occupational therapy practitioners may need to actively reduce the intensity of some movement to ensure that it is therapeutic.
d) Proprioceptive input may have a mediating effect on vestibular input, and the occupational therapy practitioner will often offer both types of input at the same time (e.g., encouraging the child to swing on a platform swing while “climbing” a rope with the hands).
Expected outcomes of sensory integration intervention
a) Increase in the frequency or duration of adaptive responses
b) Development of increasingly more complex adaptive responses
c) Improvement in gross and fine motor skills
d) Improvement in cognitive, language, and academic performance
e) Increase in self-confidence and self-esteem
f) Enhancement of occupational engagement and social participation
g) Enhancement of family life.
Evaluation for Children With Behavioral Disorders
a) A complete history is important for understanding the child and why the child is engaging in such behavior; it should include relevant medical information.
b) An occupational profile should be developed
c) Teachers should complete a preassessment checklist.
d) Observations should be made in the child’s natural environments with peers.
e) Assessments include
Assessments for the evaluation for children with behavioral disorders
a) Social Skills Rating System
b) School Function Assessment
Intervention for Children With Behavioral Disorders
a) Intervention should be goal directed and appropriate for the intervention context.
b) It should take place in natural environments whenever possible.
c) It should be motivating and meaningful to the child.
d) It should provide the just-right challenge and be graded appropriately.
e) It should be enjoyable for the child.
f) Intervention may be based on rational intervention (RI).
Intervention for children with behavioral disorders based on Rational Intervention
a) Any interactions between the child and the occupational therapy practitioner are considered to be opportunities for learning.
b) The occupational therapy practitioner acts with respect and caring toward the child.
c) Safety is the priority; development of decision-making skills and increased social participation are also key focuses.
d) The child should be given opportunities to make choices as often as is feasible.
e) Adults should use the least amount of control necessary so that children can make decisions.
Rational Intervention color coded zones in the treatment of children with behavioral disorders
a) The occupational therapy practitioner uses zones to classify the child’s behavior and determine whether intervention is needed.
b) Green-zone behaviors are those that are appropriate and acceptable.
c) Yellow-zone behaviors are those that are slightly problematic and require additional observations; the child may benefit from environmental adjustments, cues, or facilitation.
d) Red-zone behaviors are those that require immediate intervention (verbal or physical) because the child or others are being put at risk as a result of a negative behavior.
Rational Inervention response options for the treatment of children with behavioral disorders
a) Matching: characterized by the occupational therapy practitioner matching his or her response to the child’s behavior
b) Facilitation: characterized by observing the child and improving the child’s environmental supports
c) Monitoring: characterized by observing the child and letting the child know the occupational therapy practitioner is present; encouraging the child; and using guiding questions to prompt the child to problem solve
d) Gentle correction: characterized by altering the environment; reminding the child of the expectations, modeling appropriate behavior, and redirecting the child to another location or activity
e) Moderate correction: characterized by giving the child a break by redirecting the child
f) Strong correction: characterized by a time out, that is, time away from the activity until the child is calm; possible use of physical management if safety is an issue
Temper tantrums and other challenging behaviors
a) Tantrums are an expression of anger and can include verbal or physical behaviors; when a child has a tantrum, the child is seemingly out of control.
b) Tantrums are often characterized by crying, whining, screaming, shouting, arching, tensing the body, kicking, scratching, pinching, hitting, destroying property, and lying on the floor.
c) Typical tantrums last approximately 2 min, with the first 30 s containing the most severe behaviors.
d) During the first 3 yr of life, tantrums are likely caused by anger or frustration. A child’s lack of vocabulary may result in a tantrum. Frequent causes of tantrums include not being able to complete a task, trying to get something, trying to avoid something, difficulty communicating, being hungry or tired, being uncomfortable, or wanting attention.
e) Tantrums are a natural part of development. They occur frequently with 2-year-olds and diminish significantly by age 4, when verbal communication is typically easier for the child.
f) Children with special needs may have tantrums beyond age 4, and they may be of greater intensity.
Some strategies that can reduce the occurrence of tantrums
a) Encourage the development of good communication skills.
b) Encourage the child to express anger appropriately.
c) Teach the child how to calm himself or herself down.
d) Ensure that the child’s basic needs (e.g., hunger, thirst) are met.
e) Allow time to transition between activities; give warnings when preferred activities are coming to a close (e.g., “2 more minutes of Legos and then it is time to clean up”).
f) Prepare the child for novel situations and new people ahead of time; use methods that are appropriate to the child’s developmental level (e.g., showing pictures, viewing a video, reading a story).
g) Praise the child when the child is engaging in positive behaviors and making good choices.
h) Provide the child with opportunities to make choices on a regular basis; reduce the amount of time the child is told “no” by providing the child with another option (e.g., “You can’t watch TV right now; you can color or look at books”).
i) Do not phrase directives (e.g., “Get your shoes on”) as questions (e.g., “Do you want to get your shoes on?”).
j) Consider each of the child’s requests carefully. Be permissive when possible so as not to enter into a power struggle.
k) Redirect the child when items are off limits (e.g., provide a new toy, begin a new activity, change an aspect of the environment).
l) Maintain routines whenever possible.
m) Tell the child the rules and expectations and follow them.
Treatment strategies that can promote positive behavioral outcomes
a) Limit the amount of negative attention (e.g., verbal reprimands and punishments) given to the child when the child is engaging in the nonpreferred behavior.
b) Reinforce the preferred behavior.
Reinforcing prefers behavior to promote positive behavioral outcome
a) Use rewards and incentives that are meaningful to the child.
b) Reward the preferred behavior when it is demonstrated.
c) Grade reinforcers so that tangible rewards (e.g., a cracker) are paired with nontangible rewards (e.g., a high five) and systematically reduce tangible rewards.
d) Encourage the child to delay gratification and continue to work on a given task (e.g., “Do two more, then you can have a break”).
e) Use prompts when the child requires prompts at the baseline level of performance.
f) Shape the response through Forward chaining or Backward chaining
g) Give a time out or break that is not viewed punitively.
h) Regroup by leaving the situation for a few seconds to a minute to consider whether and how the negative behavior is being inadvertently reinforced.
Prompts to use when reinforcing prefered behavior
a) Physical prompts: manually guiding the child through the activity
b) Visual prompts: visual cues or other supports to help the child remember how the task should be completed
c) Demonstration: completing the task and then having the child copy the occupational therapy practitioner
d) Modeling: having a peer complete the task and then having the child copy the peer
e) Auditory or verbal prompts: providing verbal prompts to redirect the child
Therapeutic time out/ breaks for the reinforcement of positive behavior outcomes
a) Give a time out or break that is not viewed punitively.
b) Encourage the child to request a time out or break when the child feels disregulated, increased anxiety, or sensory overload.
c) Provide opportunities for heavy work.
d) Teach the child calming strategies.
Typical Development of Skills related to dressing
-At Age 1: Assists with dressing by cooperating during the activity; pulls off shoes and removes socks.
-At Age 2: Able to doff coat after fasteners have been unfastened; removes shoes if not tied; begins to help with pulling down pants; can locate armholes in shirt.
-At Age 2½: Able to pull down pants with an elastic waistband; helps with putting on socks, coat, and shirt; able to unbutton large buttons.
-At Age 3: Able to don a pullover shirt with little assistance; able to put on own shoes (still needs help with tying); able to put on socks; able to zip zipper once it is engaged; can button large buttons.
-At Age 3½: Can distinguish between front and back of clothing items; can manage snaps and hooks; can unzip zipper completely; can button buttons and begins to buckle buckles; can put on mittens; dresses with supervision.
-At Age 4: Removes pullover garment independently; can buckle buckles; can zip zipper completely; may lace shoes (but still need assistance for tying).
-At Age 4½: Able to weave belt through belt loops.
-At Age 5: Can tie and untie knots; can dress without supervision.
-At Age 6: Can tie bows; can manage fasteners in the back of garments.
Typical Development of Skills related to toileting
-At Age 1: Expresses discomfort when diaper is wet or dirty; moves bowels regularly.
-At Age 1½: Can sit on toilet with supervision.
-At Age 2: Begins to show interest in toileting; can stay dry for 2 hr or more; can flush toilet independently; urinates regularly.
-At Age 2½: Tells someone when having to go to the bathroom; can be on a regular toileting schedule; may need assistance to get positioned on the toilet; wakes up dry at night; can wipe self after urinating; washes hands independently.
-At Age 3: Goes to the bathroom independently; may need assistance wiping, particularly after bowel movements; may need assistance fastening or managing some clothing items.
-At Ages 4–5: Independent with toileting, washing hands, and clothing management.
Typical Development of Mobility Skills
-At Age 7 mo: able to bear weight through both lower extremities; the infant also begins to transition from sitting to kneeling
-At Age 9 mo: able to stand while holding on to a surface or a piece of furniture; the infant also beings to crawl
-At Age 10 mo: taking purposeful steps while holding on to an adult’s hands for assistance
-At Age 12 mo: beginning to walk independently