Module Two

A. Incorporate opportunities for movement into the curriculum.
D. Implement sensory modulation strategies such as providing options for dynamic sitting.
E. Provide set rules and routines for the student to follow.

A. Allow for movement. Allow the student to move around, preferably by creating reasons for the movement. Incorporate opportunities for physical action into the curriculum.
D. Staying in a seat for any length of time can be difficult for students with ADHD. Adapt the environment to meet the student’s needs by implementing sensory modulation strategies such as using dynamic sitting on a stability ball. A stability ball acts on the CNS and is intended to help the body attain its optimal state of arousal required for learning.
E. Rules and routines are important for these students as they provide structure. Changes to daily routines can be very unsettling, so if there is going to be a change, explain what’s going to happen in advance. Rules for all the students in the classroom can be posted in the classroom. Rules should be short, simple and visible.

A. Plan an activity night that focuses on hobbies and special interests so that the students can discover what they have in common with one another.
An activity night that focuses on special interests will allow students to interact with their peers who have the same interests as themselves.

A. The OTA should mark the child’s gender as “girl”.

There are 2 issues in this scenario:
1. Writing down the child’s gender on the document.
2. Using gender norms to base the assessment results on.
Adhering to the Principle of Autonomy which expresses the concept that clinicians have a duty to treat the patient according to the patient’s desires, the child should be referred to as a girl, as that is the gender the child identifies with. Writing down the child’s gender and referring to the child as a girl is indicated.
In terms of scoring the assessment, until proper norms are available for transgender and nonbinary individuals, clinicians should consider the stage of transition an individual is in (pre-hormone treatment vs. post-hormone treatment) and how this may impact results. At this stage, the child being only 6-years-old, it is unlikely that any hormonal treatment will have been started. However, as the child was born a boy the OTA should score the assessment using the norms of a boy because developmental benchmarks in standardized assessments follow the norms of the inherent gender.

https://www.pacificu.edu/sites/default/files/documents/Code%20of%20Ethics%202015.pdf
https://www.apadivisions.org/division-44/publications/newsletters/division/2016/04/nonbinary-populations

A. The OTA should tell Miley’s mother not to be concerned because Miley is still too young to start learning how to tie her shoes.

The OTA should tell Miley’s mother not to worry because Miley is too young to start learning how to tie her shoes. Children typically develop the skills necessary to learn shoe tying between the ages of 5 and 6.

D. Walks with hand being held.
By 11-months of age, an infant typically develops the ability to walk with their hand being held.
Milestones at 11-months include:
– Cruising with one hand for support
– Walks with hand held
– Stands independently for a short time- 2 seconds, legs wide, arms up/out

D. Drinking from a straw.

Typical progression:
6-9 months: holding spoon and moving it in different directions
9-13 months: finger feeding Cheerios and crackers
15-18 months: scooping pudding and yogurt and bringing it to mouth
18 months: drinking liquid out of a cup and through a straw
2.5 years: feed self with a fork

C. Between 18-24 months a child can walk up stairs with support.
Between 18-24 months a child can be expected to walks up and down stairs while holding your hand. Muscle strength, weight shifting, balance, and co-ordination are some of the key elements needed for climbing stairs. These only become well developed once a child is standing up against gravity and starting to move. At 12-18 months, a child will typically start walking independently and manages stairs by crawling up the stairs and creeping back down.

When it comes to milestones, it is important to remember that a stipulated age is merely a general guideline. There is a range of ages, for meeting developmental milestones. For example, the usual age range for a child to start walking is from 10 – 15 months

B. Place 3 coins in the student’s hand and then have the student put the coins in a piggy bank.
Have the student hold 3 coins and then put them in a piggy bank. In-Hand Manipulation skills refers to the ability move and position objects within one hand without the assistance of the other hand.

C. Tactile Defensiveness
Progression of TX for tactile defensiveness: brushing; firm, consistent touch; light moving touch as tolerated.
‐ Don’t apply: light touch, or light brushing; this provokes defensiveness.
‐ Icing: unpredictable results.

B. 3-4 years.
Scissor Skills
2-3 yrs Show interest in scissors, hold and snip scissors, open/close in controlled fashion
3-4 yrs Manipulate scissor in forward, coordinates lateral direction, cuts in straight forward line, cuts simple geometric shapes
3 ½ – 4 ½ y Cuts circles
4-5 yrs Cuts simple figure shapes
5-6 yrs Cuts complex figure shapes

D. Conduct disorder.
Conduct Disorder
A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:
Aggression to people and animals
• often bullies, threatens, or intimidates others
• often initiates physical fights
• has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
• has been physically cruel to people
• has been physically cruel to animals
• has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
• has forced someone into sexual activity
Destruction of property
• has deliberately engaged in fire setting with the intention of causing serious damage
• has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft
• has broken into someone else’s house, building, or car
• often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
• has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Serious violations of rules
• often stays out at night despite parental prohibitions, beginning before age 13 years
• has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
• is often truant from school, beginning before age 13 years
The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

https://www.pediatriconcall.com/calculators/dsm-5-conduct-disorder

 D. Sensorimotor play.
In sensorimotor play children engage in motor movements beginning with early reflexes and moving toward more intentional actions. These early actions are initially the result of trial and error; children learn through their actions that their behavior has an effect on the environment. As children develop, their actions become more sophisticated and as a result more deliberate. For example, sensorimotor play includes the reflexive behavior of an infant grasping a rattle placed in her hand, as well as the intentional behavior of an older infant picking up and shaking a rattle to make sound. The sensorimotor stage typically occurs from infancy through age two.

C. “New exercises can be scary because you don’t know what’s going to happen”.
The statement “New exercises are scary because you don’t know what’s going to happen,” reflects back the feelings the child has expressed. Reflective listening is a special type of listening that involves. paying respectful attention to the content and feeling expressed in another persons’ communication. Reflective listening is hearing and understanding, and then letting the other. know that he or she is being heard and understood.
Reflecting is the process of paraphrasing and restating both the feelings and words of the speaker. The purposes of reflecting are:
– To allow the speaker to ‘hear’ their own thoughts and to focus on what they say and feel.
– To show the speaker that you are trying to perceive the world as they see it and that you are doing your best to understand their messages.
– To encourage them to continue talking.
Reflecting does not involve you asking questions, introducing a new topic or leading the conversation in another direction. Speakers are helped through reflecting as it not only allows them to feel understood, but it also gives them the opportunity to focus their ideas. This in turn helps them to direct their thoughts and further encourages them to continue speaking.
Two Main Techniques of Reflecting:
1. Mirroring
Mirroring is a simple form of reflecting and involves repeating almost exactly what the speaker says.
2. Paraphrasing
Paraphrasing involves using other words to reflect what the speaker has said. Paraphrasing shows not only that you are listening, but that you are attempting to understand what the speaker is saying.

https://www.skillsyouneed.com/ips/reflecting.html

B. Shift.
Turning the paper with one hand as you use the scissors to cut with the other hand involves the in-hand manipulation skill of shift.
Three Types of In Hand Manipulation Skills
1. Translation- Allows you to move objects from the palm of the hand to the fingertips and vice versa using only one hand. An example of translation is moving coins from your palm to your fingertips to put the coins in a bank.
2. Shift- This is the ability to move objects between the fingers. Some examples of shift are when you use your fingertips to try and separate two pieces of paper that are stuck together or when you move your fingers to the bottom of a pen to get ready to write.
3. Rotation- There are two types of in hand manipulation skills when it comes to rotation, simple and complex. Simple rotation is the ability to roll a small object between the thumb and finger tips. An example of simple rotation is using the finger tips and thumb to open a small jar. Complex rotation is the ability to turn an object end over end. An example of this is flipping a pencil over in one hand to use the eraser instead of writing with the tip of the pencil.

A. Long-handled sponge, soap on a rope, towel with handles.
Patients with arthrogryposis have lack of range of motion. Arthrogryposis, also called arthrogryposis multiplex congenita (AMC), is a term used to describe a variety of conditions involving multiple joint contractures. The cause is unknown, although arthrogryposis is thought to be related to inadequate room in utero and low amniotic fluid. The patient may have an underlying neurological condition or connective tissue disorder. Symptoms in patients with arthrogryposis can vary greatly. In most cases, both the arms and legs are involved. Muscle contractures of joints commonly take place in the wrist, hand, elbow and shoulder on either side of the body. Lower extremity involvement is also common involving the hips, knees and ankles. There is also muscle weakness throughout the body. Spine curvature may develop in some patients.

https://www.hopkinsmedicine.org/health/conditions-and-diseases/arthrogryposis

D. Poor core stability. When a student cannot sit upright in a chair to work on handwriting, a more stable position may help the student free up the writing hand. Prone on elbows is one position that helps stabilize the core.
A. If this position was used to address poor upper extremity strength, the student would not be able to “free” one hand to use for writing. With poor upper limb strength, the student would have to remain in a static posture, supporting their weight on both their forearms.
B. Limited attention to task is best addressed with structuring the environment and task. Examples: special seating e.g. ball seat, using a quiet space, allowing intermittent break periods, provide child with a fidget.
C. Impaired visual tracking can on be addressed by using visual exercises.

B. Progressive desensitization techniques. Some children who are born with specific malformations such as esophageal/duodenal or anal atresia, are not able to eat orally until the malformation has been corrected surgically. The student is not used to eating food, therefore it is important to use desensitization techniques to get her used to the different types and textures of food.

C. Redirect the child to another activity. It is important to find another activity that will distract the child. The session should be client centered, so it is necessary to find activities that interest the child and which will motivate them to remain in the session.

B. There are no IEPs or special education in college.
There are no IEPs or special education in college, however, most colleges do have a disability services office for students with learning and physical difficulties. Colleges are under no obligation to provide the same level of support and services that a student might have received in high school. For example, they don’t have to provide specialized instruction or tutoring. They do however have to follow federal civil rights laws which includes Section 504 of the Rehabilitation Act and the Americans with Disabilities Act. These laws have a different goal than IDEA. Their purpose is to ensure equal access for people with disabilities and protect them against discrimination. Colleges provide accommodations to students who are eligible under ADA. Some may also provide support services like tutoring or coaching for a fee. They don’t typically provide 504 plans the same way high schools do. If a student can provide evidence that they need a specific accommodation, they will be eligible to get it in college.

https://www.understood.org/en/school-learning/special-services/special-education-basics/understanding-special-education

B. A modification is a change of what is being taught or what is expected from a student.
An accommodation is a change that helps a student work around their disability or learning challenge.

Modifications and accommodations are both ways of helping the student, but it is important to determine which is the most appropriate strategy and identify it correctly on the IEP plan. Typically, a modification is a change of what is being taught or what is expected from a student. On the other hand, an accommodation is a change that helps a student overcome or work around their disability or learning challenge. An example of an accommodation might be for a student to be allowed to provide the answer to a test question orally or typed versus handwritten.

http://www.occupationaltherapy.com/articles/iep-and-ifsp-101-everything-5079-5079.

C. Bathing.
OT goals added to the IEP should address skills used in school only. IEP goals and objectives are written by the educational team and do not constitute the occupational therapy treatment/intervention plan. In addition to the IEP goals/objectives addressed by the occupational therapy practitioner, a separate occupational therapy treatment/intervention plan should include intervention approaches, types of interventions to be used, outcomes, and any additional occupational therapy goals not listed in the IEP.

A. Allow the child to place the orthotic on her large teddy bear. By having the child “take over the situation” and having the bear “demonstrate” anxiety through pretend play, the child is empowered and is able to take small steps toward managing her (and the bear’s) symptoms.

C. Spina bifida occulta.
Spina bifida, which literally means “cleft spine,” is characterized by the incomplete development of the brain, spinal cord, and/or meninges.
There are four types of spina bifida:  occulta, closed neural tube defects, meningocele, and myelomeningocele.
Occulta is the mildest and most common form in which one or more vertebrae are malformed. It is sometimes called “closed” spina bifida. In most cases, spina bifida occulta causes no problems. The name “occulta,” which means “hidden,” indicates that a layer of skin covers the malformation or opening in the vertebrae. Many people who have spina bifida occulta don’t even know it, unless the condition is discovered during an imaging test done for unrelated reasons.
Closed neural tube defects make up the second type of spina bifida.  This form consists of a diverse group of defects in which the spinal cord is marked by malformations of fat, bone, or meninges.  In most instances there are few or no symptoms; in others the malformation causes incomplete paralysis with urinary and bowel dysfunction.
In the third type, meningocele, spinal fluid and meninges protrude through an abnormal vertebral opening; the malformation contains no neural elements and may or may not be covered by a layer of skin.   Some individuals with meningocele may have few or no symptoms while others may experience such symptoms as complete paralysis with bladder and bowel dysfunction.
Myelomeningocele, the fourth form, is the most severe and occurs when the spinal cord/neural elements are exposed through the opening in the spine, resulting in partial or complete paralysis of the parts of the body below the spinal opening.  The impairment may be so severe that the affected individual is unable to walk and may have bladder and bowel dysfunction.

https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Tethered-Spinal-Cord-Syndrome
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Spina-Bifida-Fact-

B. Sensory Craving.
The student is demonstrating a sensory modulation disorder. She is actively seeking/craving sensory stimulation.

Sensory Modulation Disorder- Difficulty regulating responses to sensory stimuli.
3 Subtypes:
1. Sensory Over-Responsivity
Individuals with sensory over-responsivity are more sensitive to sensory stimulation than most people. Their bodies feel sensation too easily or too intensely. They might feel as if they are being constantly bombarded with information. Consequently, these people often have a “fight or flight” response to sensation, e.g. being touched unexpectedly or loud noise, a condition sometimes called “sensory defensiveness.” They may try to avoid or minimize sensations, e.g. withdraw from being touched or cover their ears to avoid loud sounds.
2. Sensory Under-Responsivity
Individuals who are under-responsive to sensory stimuli are often quiet and passive, disregarding or not responding to stimuli of the usual intensity available in their sensory environment. They may appear withdrawn, difficult to engage and or self-absorbed because they do not detect the sensory input in their environment. Their under-responsivity to tactile and deep pressure input may lead to poor body awareness, clumsiness or movements that are not graded appropriately. These children may not perceive objects that are too hot or cold or they may not notice pain in response to bumps, falls, cuts, or scrapes.
3. Sensory Craving
Individuals with this pattern actively seek or crave sensory stimulation and seem to have an almost insatiable desire for sensory input. They tend to be constantly moving, crashing, bumping, and/or jumping. They may “need” to touch everything and be overly affectionate, not understanding what is “their space” vs. “other’s space.” Sensory seekers are often thought to have Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD). A key factor with Sensory Craving is that when the individual receives more input it does not regulate him/her; in fact, those with true craving disorders become disorganized with additional stimulation.

https://www.spdstar.org/basic/subtypes-of-spd#sensorymodulation

C. Difficulty climbing over a pile of large foam blocks preferring to climb around them.
Due to difficulty with visual processing as a result of cortical blindness, the child will demonstrate difficulty with gross motor movements because of fear of movement requiring the need to seek the ground. Therefore, the child may demonstrate poor bilateral integration for reciprocal movements necessary to climb over uneven and unsteady surfaces.

A. Although gross-motor delays are expected, muscle fatigue with constant use of upper extremity support is unlikely due to the trunk control she has gained for unsupported sitting balance by this age.
B. It is likely that the child will be able to sustain her attention.
D. It is likely that the child will demonstrate some dependence and use of her other senses to compensate for her visual difficulties. She would therefore not be aversive to tactile stimulation.

https://nei.nih.gov/faqs/cortical-visual-impairment-cvi
Reed, Kathlyn. (2001) Quick Reference to Occupational Therapy. Gaithersburg, MD: Aspen Publishers, pp 241-248.

D. Divided plate.
Athetoid cerebral palsy, also known as dyskinetic cerebral palsy, is a subtype of cerebral palsy (CP). Athetoid cerebral palsy is defined by abnormal postures and movements which present as impaired muscle tone, impaired movement control, and impaired coordination. A divided plate will allow the child to use the walls of the plate to scoop up food and he will be able to load the food onto the utensil without the need to stab the food.

A. Dycem will prevent the plate from moving, but it will not prevent food from falling off of the plate. The child is struggling with placing food on the utensil, not with the plate moving on the table.
B. A Rifton chair will place the child in proper positioning for feeding but will not improve his ability to place food on the utensil.
C. A spork would require the same control as any other utensil and does not address the problem.

A. ATNR
When a baby’s head is turned to one side, the arm on that side stretches out and the opposite arm flexes at the elbow. This is often called the “fencing” position.

B. Moro – The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his or her head, extends out the arms and legs, cries, then pulls the arms and legs back in.

C. Rooting. This reflex begins when the corner of the baby’s mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and “root” in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding.

D. Suck reflex – When the roof of the baby’s mouth is touched, the baby will begin to suck. Rooting helps the baby become ready to suck.

https://www.stanfordchildrens.org/en/topic/default?id=newborn-reflexes-90-P02630

A. Practice moving coins from their fingertips to palm and palm back to their fingertips.
By improving the child’s in-hand manipulation, you will ultimately encourage the use of a functional pencil grasp which facilitates legibility, letter formation, speed and endurance. An efficient pencil grip is one in which the writing tool is controlled only through finger movements. This occurs when the ulnar side of the hand supports the whole hand against the writing surface, allowing the other fingers to hold and move the pencil. Incorporation of finger-to-palm and palm-to-finger translations are in-hand manipulation skills that address the dynamic use of the fingers. These finger movements will help progress the child’s static tripod grasp to a dynamic tripod grasp

B. Using a thicker pencil will not facilitate a dynamic tripod grasp. Smaller writing implements naturally encourage a proper grasp.
C. A scribe will not help the child become more proficient in writing.
D. Taking a writing break every 10 mins to actively range the fingers does not address pencil grasp and is a strategy used to cope with hand fatigue.

D. Time-out is being demonstrated.
Time out is a commonly used consequence for problem behavior. The timeout strategy involves removing the child from all sources of positive reinforcement as a consequence of a specified undesired behavior.
Timeouts should be:
– Used sparingly. They are only one technique in a discipline plan, so don’t over-rely on them. If you give more than one or two each day for the same behavior, that is too much.
– Brief. Research shows that timeouts’ positive effect on behavior is within the first one or two minutes (Kazdin, 2013). Extra time may satisfy your sense of justice, but it does nothing to change the behavior.
– Immediate. A timeout should follow the behavior that made the timeout necessary as soon as possible. Delayed timeouts are ineffective.
– Done in isolation from interaction with others. You can ignore your child for a brief period (where she otherwise might receive attention) or have her sit in a corner of a room (where it still might be reinforcing to see others). The key is to remove as many sources of reinforcement as possible. Attention is reinforcement because it increases the probability of the behavior it follows. Research shows that any form of attention, positive or negative, tends to increase the likelihood of the behavior occurring again (Kazdin, 2013).
– Administered calmly, not in anger or as an act of vengeance, but as an expected response to the behavior.
Administered without repeated warnings. Make clear to your child before misbehavior which behaviors will lead to a timeout and what the timeout will be. Then be consistent about using timeouts when the behavior occurs, every time. Warnings lose their effect if not followed by consequences, and are unnecessary if your child has been told what to expect before the behavior occurs.
– Praised when completed. If your child goes to the isolated spot when asked, and completes the timeout, praise the specific behavior when complete: “It’s good that you went to timeout like I asked you, and that you sat quietly the whole time, that was wonderful.” Verbal encouragement should be combined with physical contact if possible – a gentle pat, high five, or other contact. Even though it may feel strange to praise your child as part of discipline, remember that actions followed by reinforcement will be strengthened and more likely to occur in the future. You want your child to comply with timeouts when they are necessary.
– Followed by a return to the task that was interrupted by misbehavior and timeout. Timeouts should not let your child off the hook of engaging in the behavior you want to see in the first place. This also provides an opportunity to positively reinforce the desired behavior, further strengthening the likelihood that your child will choose the desired behavior over the undesired behavior next time.

https://allpsych.com/psychology101/reinforcement/
https://www.findapsychologist.org/time-out-is-extinction-not-punishment-by-dr-lorraine-m-dorfman/

A. That this is typical development.

This child is crawling, cruising, and almost walking which is typical for his age. Cruising with one hand for support,
walking with his hands held, and standing independently for a short time- with legs wide, arms up/out are all milestones an 11 month old infant can be expected to achieve. Crawling is usually achieved before 11 month.

A. He would be able to cut circles.
A forward motion can be cut when a child is 4 years old. At that age, a child can cut a square and a circle, and is beginning to be able to cut a tree.

D. 12-18 months. At approximately 12 to 18 months, a child typically begins to spontaneously scribble on paper. 
There’s a difference between marking a page with a crayon and scribbling. Peabody Developmental Motor Scales, 2nd edn – Guide to Item Administration (PDMS-2)- states that a child begins to scribble at around 14 months.
At 12 months- Scribbles after demo.
At 14-15 months- Spontaneous scribble.

A. 6-9 months, a baby masters transferring an object between hands, starts to isolate their index fingers and uses an immature pincer grasp.
B. 10-12 months, a baby develops a mature pincer grasp. The child may begin to mark a piece of paper with a crayon.
C. 18-24 months- The next pre-writing skill after scribbling, is imitating horizontal and vertical lines at 24 months.

https://theinspiredtreehouse.com/developmental-milestones-ages-1-2/#_a5y_p=2700308

D. 15 to 18 months.
With developmental milestones, remember that there is a range of “average” and many milestones do overlap. In this scenario, the baby is functioning at an age level of 12-14 months. Typically, at this age, a toddler is able to dip their spoon in food, bring the spoon to their mouth, and drink from a cup.

Self-feeding development:
5-7 months: Take cereal/baby food from spoon
6-8 months: Attempt to hold bottle, may not retrieve if falls, needs monitoring for safety
6-9 months: Holds, tries to eat (self-feed) crackers (6 ½- 7 mos), but sucks more than bites; eats soft foods that dissolve, grab spoon and bangs or sucks on end of it (9mos), imitates stirring with spoon (9 ½ mos)
9-13 months: Finger feeds self soft table foods (macaroni, peas, dry cereal), objects if fed by adult
12-14 months: Dip spoon in food, bring to mouth, spills food before reaches mouth, cup drinking with firm jaw
15-18 months: Scoop food and bring to mouth, Straw use begins at 18 mos
24-30 months: Interest in fork, stab food (canned fruit). Proficient spoon use and eats cereal w/milk or rice with gravy with utensil.

D. A mechanical toy with a chin-controlled on/off switch.
An adaptive toy will encourage play and will allow the child to control the toy with his chin thus reinforcing cause and effect. /em>

D. Keep the child’s hips and knees flexed and neck slightly flexed, with him facing away from the caregivers.

Flexion of the neck and lower extremities will inhibit lower extremity extensor tone and will help make carrying the child easier. He will be more centered for proper body mechanics while lifting and transferring him.

B. Treatment is child directed.
D. Tactile, vestibular, and proprioceptive processing are typically the main focus of SI therapy.
E. Treatment should provide a “just right challenge”.

The goal of sensory integration intervention is to improve the processing and integration of sensory information to allow participation in childhood occupations, including activities of daily living, school work, extracurricular activities, and play.

General Principles
1. The focus of treatment is primarily on tactile, vestibular, and proprioceptive processing. These three systems form the base for other sensory processing.
2. Treatment should provide a “just right challenge” – an activity that is challenging but at the same time realistic for the child to achieve.
3. The treatment environment should be enticing, encouraging the child to actively engage in play.
4. Treatment is child directed. The child directs treatment by giving behavioral cues that the therapist observes and reads. The therapist adjusts treatment based on these cues that indicate what the child wants and will find enticing.

PTOT Module 2. Topic: Sensory Integration

D. Ways to balance free time and structure so the student can direct his own actions.
A treatment strategy for a child with inattention and hyperactivity should include an environment that provides a balance between structure and freedom so the child can direct his own actions.
ADD is the term commonly used to describe symptoms of inattention, distractibility, and poor working memory. With ADHD, the added feature is hyperactivity. Strategies to help students who easily become distracted include physical placement of the student in the classroom, increased movement, and breaking long stretches of work into shorter chunks.

Chunk classwork into small manageable steps. Give the student a certain task to complete and then allow the student to choose a preferred activity, preferably one that includes movement.
Giving them a ‘brain break” can be very beneficial. According to research, brain breaks are simple physical and mental exercises that are designed to restore attention. The theory is that learning through movement increases oxygen into the bloodstream, which leads to improved concentration. Many studies have proven that brain breaks have a positive effect on students’ academic performance.

https://www.educationandbehavior.com/strategies-for-studentren-with-adhd/
https://www.teachhub.com/5-teaching-strategies-getting-students-focus

A. Rubber coated spoon.
The definition of a tonic bite reflex is a reflexive, sustained jaw closure, accompanied by increased abnormal tone in the jaw muscles, in response to stimulation of the teeth or gums. It is difficult to release, and its force can damage the teeth or an object placed in the mouth.
Rubber coated spoons provide a smoother surface than that of a regular stainless steel spoon and will protect the child’s teeth from injury. Biting on a plastic spoon, could result in the plastic breaking and would therefore become a choking hazard.

A. Adapted teaching techniques. As the child is intellectually disabled, he has learning difficulties. Therefore, the OT must establish an appropriate teaching method such as the use of shaping, cueing, and chaining.
B, C and D- are more appropriate for physical limitations.

B. Replace the Velcro straps with shoelaces and shoelace locks, and apply stickers of her favorite animal or cartoon characters. This would prevent her from removing the splint. The cartoon design is fun and appealing and she is more likely to keep the splint on, to show the design to her peers and loved ones.

https://www.mitchmedical.us/extremity-splinting/splinting-the-pediatric-patient.html

D. Raking grasp. This grasp develops at about age 7 months. An infant will use the fingers to “rake” objects toward himself. This grasp is often seen when infants first attempt to feed themselves finger foods.

C. Sensorimotor.
Piaget’s Theory of Cognitive Development is a description of cognitive development as four distinct stages in children:
1. sensorimotor
2. preoperational
3. concrete
4. formal
The first stage, sensorimotor, begins at birth and lasts until 18 months-2 years of age. This stage involves the use of motor activity without the use of symbols. Knowledge is limited in this stage, because it is based on physical interactions and experiences. Infants cannot predict reaction, and therefore must constantly experiment and learn through trial and error. Such exploration might include shaking a rattle or putting objects in the mouth. As they become more mobile, infants’ ability to develop cognitively increases.

A. Preoperational. One of Piaget’s stages of cognitive development. It involves the development of language, memory, and imagination. 2 to 7 years old.
B. Trust vs. mistrust is the first stage in Erik Erikson’s theory of psychosocial development. This stage begins at birth continues to approximately 18 months of age. During this stage, the infant is uncertain about the world in which they live and looks towards their primary caregiver for stability and consistency of care.
D. Unoccupied play. This is one of the stages of play developed by Mildred Parten Newhall. In unoccupied play, the child learns about and discovers how their body moves, no toys are involved.

https://resources.saylor.org/wwwresources/archived/site/wp-content/uploads/2011/07/psych406-5.3.2.pdf

A. Tier 1 intervention. Tier 1 intervention includes changes in the classroom that benefit all students, including those considered to be “at risk”. Tier 1 intervention is the first step of the Response to Intervention, or RTI, process. RTI Tier 1 interventions are the “first line of defense” for supporting students. Response to Intervention (RTI) was designed to help prevent students from needing special education assistance. Tier 1 instruction is delivered to the whole class.

https://www.understood.org/en/school-learning/special-services/rti/at-a-glance-3-tiers-of-rti-support
https://studyskills.com/spedadhd/rti-tier-1-interventions-4

/

C. New exercises are scary because you don’t know what’s going to happen”. This reflects back the feelings the child has expressed.
Reflective listening includes:
Listen actively: Turn toward the child, sit or kneel at his level or hold him, and look directly at him.
Listen for expressions of feeling: Words such as “scared,” “happy,” “excited,” “sad,” and “afraid.” Try to identify and understand feelings rather than just words or facts.
Reflect back: Restate the feelings the child has expressed and try to state the probable reason (“because”) behind the feelings.

D. Optic righting. Also called labyrinthine, this reflex automatically orients the head to a new optical or visual fixation point, depending on the body position change. The visual fixation point allows the head to correct its position to upright, regardless of the position of the body. This reflex is one of the reflexes the body uses to change positions.

A. Equilibrium Reactions. These reactions develop after righting reactions and allow children to maintain standing and walking posture.

D. Soft sponge-tipped toothette. Children with oral hypersensitivity are usually reluctant to use traditional manual or electric toothbrushes. The soft sponge on the toothette is more comfortable on the gums and not as threatening to children with this condition.
Encouraging a child to use a soft sponge-tipped toothette is typically indicated in the child with oral hypersensitivity. We have sensory receptors in our mouths that allow us to recognize information about temperature, texture and taste. Children with healthy oral sensory systems can tolerate eating foods that have mixed textures like cereal and milk, spaghetti and mince or vegetable soup. They manage tooth brushing and visits to the dentist with minimal complaints. Some children struggle with processing and responding to the oral sensory information they encounter in everyday life. They may be over responsive or have increased sensitivity to oral input, causing them to be resistant to oral sensory experiences like trying new foods or brushing their teeth. A soft sponge-tipped toothette, is typically indicated in the child with oral hypersensitivity/defensiveness as the bristles of a regular toothbrush cause discomfort to those with sensory challenges.
http://www.jeanekolbe-ot.co.za/tipsandtricks/2016/9/26/oral-sensory-processing

D. Tactile defensiveness. Children who have tactile defensiveness are sensitive to touch sensations and can be easily overwhelmed by, and fearful of, ordinary daily experiences and activities.

Often, children with tactile defensiveness will show signs of aversion to the following:
– textured materials/items
– “messy” things
– vibrating toys, etc.
– a hug
– a kiss
– certain clothing textures
– rough or bumpy bed sheets
– seams on socks
– tags on shirts
– light touch
– hands or face being dirty
– shoes and/or sandals
– wind blowing on bare skin
– bare feet touching grass or sand

Follow the facility’s policies regarding reporting abuse to child protective services. All healthcare workers, including COTAs®, are required by law to report suspected abuse to the appropriate local agency. Most facilities that provide occupational therapy services, including clinics and schools, have policies in place regarding what to do to report suspected abuse. The COTA® should follow his facility’s established policy when reporting the abuse to child protective services.

B. Neck-righting. Also referred to as Neck on Body Right Reaction (NOB)
Onset age: 4-6 months
Stimulus: Place infant in supine and passively turn head to one side.
Response: Body rotates as a whole to align the body with the head- Log rolling of the entire body towards the same side, to maintain alignment with head.
Relevance: Maintains head/body alignment; initiates rolling

A. Tilting response
i. Prone tilting
Onset age: 5 months
Stimulus- After positioning infant in prone, slowly raise one side of the supporting surface
Response- Curving of the spine toward the raised side (opposite to the pull of gravity), abduction/extension of arms and legs
Relevance- Maintain equilibrium without arm support; facilitate postural adjustments in all positions

ii. Supine Tilting and Sitting Tilting Responses
Onset: 7 to 8 months
Stimulus: After positioning infant in supine or sitting, slowly raise one side of supporting surface.
Response: Curving of the spine toward the raised side (opposite to the pull of gravity); Abduction/extension of arms and legs
Relevance: Maintain equilibrium without arm support; facilitate posture adjustments in all positions

C. Forward parachute reflex.
Onset age: 6 to 9 months
Stimulus: Suddenly tip infant forward toward supporting surface while vertically suspended
Response: Sudden extension of UE, hand opening, and neck extension
Relevance: Allows accurate placement of UE in anticipation of supporting surface to prevent a fall

D. Body righting.
Onset age: 4-6 months
Stimulus: Place infant in supine, flex one hip and knee towards the chest and hold briefly.
Response: The infant will rotate the head in the direction in which the body is rotated. The body will initiate segmental log rolling of the upper trunk to maintain alignment.
Relevance: Facilitates trunk/spinal rotation

A. Push the tongue down with the spoon. Tongue-thrust is the forward protrusion of the tongue which usually is an indication of improper tongue control and poor bolus control when moving food to the back of the mouth to swallow. Pressing down on the middle of the tongue can help suppress tongue-thrust and improve the child’s ability to move food to the back of the mouth.

D. Conduct Disorder.
Conduct disorder is a range of antisocial types of behavior displayed in childhood or adolescence. These behaviors can continue into adulthood and may result in consequences such as drug addiction or arrests for criminal acts.

A. Is the student fidgeting because their feet can’t touch the floor. It is always important to start by FIRST establishing why the student needs sensory seating. Sensory cushions, regardless of shape, are all designed to be filled with air. This creates a moving surface for the child to sit on. Before suggesting a wobble cushion, it is important to check that the child is not fidgeting because their feet can’t touch the floor. If the child’s chair is too high for them, they will find sitting still in their chair very difficult. The cushion will make them even higher and even more unstable. Also, children with poor core stability and balance might find the cushions very difficult to sit on. This is because the cushion is unstable and therefore harder to stay seated on compared to a harder surface. Sensory seating (chair or movement cushion) helps children get the extra movement they are ‘seeking’ whilst sitting in a classroom. The ultimate aim of sensory chairs and fidget cushions is to help children with their attention and ability to focus. It is thought that children who move about are doing this to help keep themselves regulated and/or alert. Some children might move in order to help themselves to focus while others may move because it helps keep their body and/or thinking more organized. The idea is that the motion of the sensory movement decreases other distracting or unsafe movements that the child may be doing to help keep themselves alert and focused. It allows these children to move about in a more appropriate way. Wobble cushions are typically recommended for children with ADHD or ASD. Within the sensory processing disorder model, these children would be called movement/vestibular seekers.

D. Creeping on hands and knees.
The developmental milestones typically progress in following order:
Lifting the head while in prone – about 3 months of age
Rolling from side lying to prone – about 4 months of age
Sitting independently – about 6 months of age
Creeping on hands and knees – 7-8 months of age
Cruising – 9-10 months of age

C. A head pointer. When using assistive technology devices to adapt an activity, best practice recommends trying the least invasive device first to minimize the amount of change and keep task performance as similar to peers as possible. If the student is able to use a head pointer to type on a regular computer keyboard, he will not require additional equipment or software to type assignments, just some practice in using the pointer and a little extra time to complete assignments. If the student cannot use the pointer or will not use the pointer because it looks different, then the OTA can progress to trying a switch with the student.

C. Moro reflex.
This reflex has three distinct components:
– spreading out the arms (abduction)
– retracting the arms (adduction)
– crying (usually)

B. The food is placed in front of the child.
It is important that food is in front of the child when teaching a child to finger feed.

B. Pushing a large therapy ball toward a target with his right upper extremity. This constitutes a “pre-positioning activity” in which the child practices limb positioning. This stage of pre-prosthetic training will be followed by prehension training, and finally the child will undergo functional training.

D. Ask the student to place his hands in a large bowl filled with beans to find small objects that are hidden in the beans.
Asking the student to place his hand in a large bowl of beans and grabbing various textured objects will work on both his fine motor skills and tactile hypersensitivity.

A. Equilibrium reactions.
B. Sitting without support while rotating upper body.
F. Reciprocal creeping.
A 9-month-old typically demonstrates equilibrium reactions while sitting, as well as the ability to sit without support while rotating the upper body, reciprocal creeping, and the ability to engage in exploratory play.

The Moro reflex disappears in normally developing infants by age 6 months. Walking without support does not typically develop before the age of ten months.

B. Swinging for vestibular input.
C. Jumping or animal walks for proprioceptive input.
D. Use of a “first/then” schedule to encourage participation in classroom work.
Treatment techniques that are used to treat children with ASD include sensory integrative techniques, such as swinging or animal walks to provide specific types of sensory input.
For children with ASD, a visual schedule not only establishes a predictable environment where they feel safe, but it also provides motivation by helping them better understand expectations and when preferred activities will occur. A ‘first-then’ visual schedule informs the child about the sequence of events she is expected to participate in. It assists the child transition from
one activity to another as she knows what she will be doing next. It can also motivate the child to complete a non-preferred task, especially if it is followed by a preferred activity. For example, “First you do your work, then you may play on the computer “
Exposure to flashing lights or loud noises would likely exacerbate the girl’s sensory dysfunction in visual or auditory processing, rather than help to provide appropriate input. These techniques are also likely to cause the girl discomfort and distress.

A. ATNR.
C. Moro reflex.
F. Palmar reflex.
These reflexes are present until 6 to 9 months.

The Galant and Rooting reflexes usually disappear before 5 months.
The Forward parachute develops only after 5 months.

Refer to Reflex chart in Module 2 of study materials.

A. Low muscle tone.
B. Difficulty with oral motor skills during eating.
D. Poor fine motor skills.
All children born with Down’s syndrome have some degree of learning disability and delayed development, but this varies widely between individual children. The American Academy of Orthopedic Surgeons lists a number of issues affecting the muscles, bones, and joints of children with Down syndrome. The most common characteristics of Down’s Syndrome include low muscle tone with resulting in joint hyper-mobility, poor oral motor skills with impaired lip closure and a strong tongue-thrust, poor core strength with impaired postural control,impaired balance, poor fine motor skills, and deficits in visual tracking and visual perceptual skills.

A. Review of splint fit and use with the family, including any needed adjustments to prevent pressure areas.
B. Neurodevelopmental treatment activities.
E. Visual tracking activities.
Since the boy is attending an outpatient clinic for therapy services over the summer, treatment is likely to focus on the boy’s development, including neurodevelopmental treatment activities and visual tracking activities. Range of motion and splint use and fit are also likely to be addressed. Handwriting and training in the use of assistive technology are activities that the boy participates in at school and would be addressed by the school-based occupational therapist rather than the therapist at the outpatient clinic.

A. Environmental factors, such as exposure to harmful substances.
B. Poor maternal nutritional intake.
E. Insufficient intake of folic acid during pregnancy.
Environmental factors, poor nutritional intake, genetic tendencies, and insufficient intake of folic acid during pregnancy are the suspected primary causes of spina bifida. This condition is not caused by trauma or injury during pregnancy or the birth process, or maternal age.
The exact cause of spina bifida remains a mystery. No one knows what disrupts complete closure of the neural tube, causing this malformation to develop. Scientists suspect the factors that cause spina bifida are multiple: genetic, nutritional, and environmental factors all play a role. Research studies indicate that insufficient intake of folic acid—a common B vitamin—in the mother’s diet is a key factor in causing spina bifida and other neural tube defects.

Maternal age:
– The risk of chromosomal abnormality increases with maternal age. A woman’s chances of giving birth to a child with Down syndrome increase with age because older eggs have a greater risk of improper chromosome division. A woman’s risk of conceiving a child with Down syndrome increases after 35 years of age.
– Spina bifida is more commonly seen in teenage mothers. Mothers 19 years old or younger have a higher risk for having a child with spina bifida.

https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Spina-Bifida-Fact-Sheet

A. Mature grasp on pencils and crayons.
B. Ties her own shoes.
D. Rides a bicycle.
Typical childhood milestones for an 8-year-old include a mature grasp on writing and drawing tools, the ability to tie shoes, the ability to ride a bicycle, and the ability to use a telephone to make a simple phone call to parents at home.

The girl is too young to have reached the milestones of doing her own laundry or caring for a pet by herself.

B. Peabody Developmental Motor Scales.
C. Bruininks-Oseretsky Test of Motor Proficiency.
E. Motor-Free Visual Perception Test.
The COTA® would be allowed to administer portions of tests that are standardized and have specific, objective instructions. The Peabody Developmental Motor Scales, Bruininks-Oseretsky Test of Motor Proficiency, and the Motor-Free Visual Perception Test.
The Sensory Profile is a questionnaire style test that parents complete and the Transdisciplinary Play-Based Assessment is a non-standardized assessment that utilizes team observations, so these two tests do not meet the criteria.

B. Draw imaginary letters in the air.
C. Write letters on a wall-mounted chalkboard with chalk.
D. Write letters on paper using a weighted pencil.
Kinesthesia is an awareness of how the body is moving in space. Teaching handwriting using a kinesthetic approach allows the student to feel the physical movements involved in writing as it is being carried out. Kinesthetic activities help strengthen motor memory through body movements. ‘Air writing’ is a great way to learn about sequencing of letter strokes by encouraging children to use not only their pointer finger, but also their whole arm to draw imaginary letters in the air. The bigger the movements, the better. Vertical writing on a chalkboard, writing using a weighted pencil, and forming letters with the whole body all utilize kinesthetic activities to address handwriting.

A. Typing is a separate skill from handwriting and it does not engage the same areas of the brain.
F. Covering the pencil shaft with a fuzzy cover is an approach that uses tactile processing rather than kinesthesia.

A. Makes eye contact with the boy before giving instructions.
B. Signal to the boy to make sure his hearing aid is turned on.
E. Sits directly across the table so the boy can see her face and hands.
To ensure that the boy can understand the COTA® during treatment, she should sit directly across the table from him so that he can see her face and should make eye contact with him before giving instructions so that she knows he is paying attention. She should avoid sitting in an area that is back-lit by a window or bright light, as this can interfere with the boy’s ability to see her clearly. She should also signal to the boy to check his hearing aid before the session. The COTA® should speak clearly, but at a normal pace and volume. The boy should be able to understand the COTA® if the COTA® follows these guidelines and should not need instructions to be written.

B. Symbolic play – Pretend play, also referred to as “fantasy play” is considered to be part of symbolic play.

Play is an important element in Piaget’s theory. It is a vehicle for the child to understand the world around him as well as an indicator of the child’s cognitive development. Piaget determined that play is described in three stages: functional play (sensorimotor) such as an infant grasping a rattle; symbolic play (experience) which adds constructive concepts as well as pretend play activities; and games with rules which build social skills.

Piaget’s Stages of Play

Functional play is the use of bodily movements, with or without objects, such as running and jumping, sliding, gathering and dumping, manipulating and stacking objects, and informal games without rules.

Constructive play uses objects: blocks, Legos, Tinkertoys, or different materials (sand, modelling clay, paint, blocks) in an organized, goal-oriented way to make something.

Symbolic/Fantasy play is role playing or make-believe play, such as pretending to be a baby, fire-fighter, superhero, or monster, and make believe actions, such as driving a car by moving a pretend steering wheel, or using a block of wood as a cell phone.

Games with rules are games with peers that are controlled by pre-established rules, such as tag, Mother-May-I, checkers, Duck-Duck-Goose, and so on.

https://www.pgpedia.com/p/jean-piaget

http://www.communityplaythings.com/resources/articles/2015/constructive-play

D. Food textures. Posture is very important, but the question is asking about tongue control. If a child has an issue with tongue control, various food textures could be a choke hazard because they don’t have the ability to maneuver the food properly within the mouth.

A. Scooping applesauce with a spoon. After a child can bang a spoon, the next appropriate activity would be to learn how to scoop food onto the spoon.

A. Playing Simon Says. This game will allow the child to work on motor planning and gross motor coordination at the same time. Walking on a balance beam and riding a bike with training wheels both work on gross motor coordination and balance, with less emphasis on motor planning because they use automatic actions. Playing an active board game works on motor planning, but not gross motor skills.

A. Only hand the child one peg at a time. It is important to make the environment free from distractions and to only hand him one peg at a time so that he can focus on one task at a time.

C. The girl is likely to have the most difficulty with putting on pants.
The girl is likely to have the most difficulty with dressing her lower extremities due to partial or complete paralysis of the legs as a result of Spina Bifida Myelomeningocele.

B. Rolling down a ramp in prone on a scooter board and knocking over cones .
Rolling down a ramp in prone on a scooter board and knocking over cones requires sequencing, maintaining prone extension, and oculomotor control.

B. The child has a lack of attention for the task. The OTA can conclude that the child has a lack of attention for the task. Since the student was able to complete the task the first time without any problems, the student should be able to complete the task correctly again. The student most likely lacked attention or interest in the task.

D. Tactile defensiveness. 
Children who have tactile defensiveness are sensitive to touch sensations and can be easily overwhelmed by, and fearful of, ordinary daily experiences and activities. Sensory defensiveness can prevent a child from play and interactions critical to learning and socialization.
Often, children with tactile defensiveness (hypersensitivity to touch/tactile input) will avoid touching, become fearful of, or will be bothered by the following:
– textured materials/items
– “messy” things
– vibrating toys, etc.
– a hug
– a kiss
– certain clothing textures
– rough or bumpy bed sheets
– seams on socks
– tags on shirts
– light touch
– hands or face being dirty
– shoes and/or sandals
– wind blowing on bare skin
– bare feet touching grass or sand

A. Standing upright and writing on a chalkboard. In order to work on the student’s prone grasp and upper extremities, the OTA can have the student stand upright and write on a chalkboard. This will allow the student to raise his hand against gravity.

B. Constraint-induced therapy. Also called forced-use therapy, this intervention constrains the normal limb to force the child to use the affected limb.