Module Two

C. Fluctuating.
Athetoid cerebral palsy, also called dyskinetic cerebral palsy, affects 10 to 25 percent of all people with this condition. This type of cerebral palsy is the result of brain damage to the basal ganglia, located in the midbrain region. It is characterized by abnormal regulation of tone, abnormal postural control, and coordination deficits. Abnormal movement patterns may increase with stress, excitement, or purposeful activity. Muscle tone is usually normal or can be decreased during sleep.

As a form of athetonia, athetoid cerebral palsy is characterized by involuntary slow and writhing movements, which usually affects the hands, feet, arms and legs. In some cases, this type of cerebral palsy can also affect the facial muscles, causing grimacing or drooling. While spastic cerebral palsy is characterized by increased muscle tone and tension, this type of cerebral palsy causes mixed muscle tone, where some muscles are too tense, while others are too relaxed. Sometimes this involuntary muscle activity affects the whole body at once. The symptoms of athetoid cerebral palsy tend to diminish completely during sleep, though they often heighten during times of waking stress.

C. Position the child’s elbow at 90 degrees of flexion and the shoulder at 0 degrees of internal rotation. To facilitate effective grasp and release, the easiest position to start with is to have the child’s elbow at 90 degrees of flexion and his shoulder at 0 degrees of internal rotation. This is the most functional position especially for self-feeding.
Pre-positioning of the prosthesis involves moving the prosthetic units into their optimal position to grasp an object or perform a given activity. All prosthetic components must be pre-positioned in a proximal-to-distal order. Pre-positioning of the prosthesis involves placing the TD in the optimal position to approach an object. For example: Approaching a glass, the hand should face in toward the midline to grasp the glass as a normal hand would. The fingers of the hand should not be positioned downward because a normal hand does not approach a glass in this position.

B. Swinging for vestibular input.
Treatment techniques that are used to treat children with autism include sensory integrative techniques, such as swinging or animal walks to provide specific types of sensory input, and visual structure to help compensate for deficits in other sensory areas, such as visual schedules and timers. 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.

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.
There is an overlap with ADHD and SPD, and they may occur co-morbidly. The Sensory Profile is designed to help the OT understand a child’s sensory processing patterns in everyday situations. Involving the caregiver in your data collection fosters increased collaboration and understanding of the child’s special needs.
Results, when considered with other evaluation data, help support more effective diagnostic and intervention planning.
Age Range: 3 years to 10 years 11 months.
A child with a sensory processing disorder or general sensory challenges may be distracted by the input their body craves and/or the overwhelming input that they are constantly bombarded with. This sensory inattention may be a result of underlying issues going on that distracts them from the task at hand. For example: Children with sensory hypersensitivity over-respond to sensory input. They may have an overly sensitive response and may overreact to bright lights and loud noises and be overly distracted by noises in the classroom.

Other strategies to help students who easily become distracted in the classroom 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

C. Palmar Supinate Pencil Grasp.
Palmar Supinate – The crayon or marker is held in the palm (“palmar”) with the thumb on top in a slight forearm-up (“supinated”) position. This is considered a “primitive” grasp and typically accompanies the “scribbling” stage. Scribbling movements are typically initiated by the shoulder and elbow, which involve larger muscle groups and a relatively low level of precision.

D. Dynamic tripod grasp.
After a child has mastered the static tripod grasp, the OT can work on dynamic tripod grasp.

D. The most appropriate type would be a soft sponge-tipped toothette.
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. Turn pencil over to erase
Complex rotation is a movement involving rotation of an object that requires isolated, independent movements of the fingers and thumb. The movement is further described as manipulating the object with finger pads to turn it between 180-360 degrees An example of this movement would be to turn over a pencil to use the eraser.
At 2.5 years old a child develops simple rotation. The turning or rolling of an object held at finger pads approximately 90 degrees or less (unscrewing a small bottle cap).
At 6-7 years old a child develops complex rotation. The rotation of an object  between 180 and 360 degrees (turning a pencil over to erase).

https://ot.eku.edu/sites/ot.eku.edu/files/files/In%20Hand%20Manipulation.pdf

A. Standing upright and writing on a chalkboard.
The remedial approach uses compensation to allow the student to utilize existing skills to complete a task. Since the student has limited wrist extension, writing vertically on a chalkboard will facilitate wrist extension. Writing on a vertical surface naturally places the wrist in extension, the ideal position for handwriting. In contrast, a flexed wrist limits finger mobility and pencil control. The vertical reach and resistance of the chalkboard will help to strengthen the student’s upper extremity as he writes.

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

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D. Sideward parachute (protective extension sideward).
Sideward parachute (protective extension sideward): Prevent fall; increase support (arm extension) on side opposite force- stop from falling to side.Tip infant off-balance to side. Arm extension and abduction to the side. 7 mos→ Persists

B. Place 3 coins in the child’s hand and ask him to post the coins into a piggy bank, one coin at a time.

In-Hand Manipulation refers to the ability to move and position objects within one hand without the assistance of the other hand.

C. The girl may have difficulty with visual perception. Visual perception is the ability to see and interpret (analyze and give meaning to) the visual information that surrounds us. The process of “taking in” one’s environment is referred to as perception. Figure-ground perception is a visual perceptual skill which gives one the ability to focus on one specific piece of information in a busy background.

A. Visual acuity refers to the sharpness and clarity of the girl’s vision which does not appear to be affected in this scenario.
D. Difficulty in fine motor skills is incorrect because she can clearly grab the the markers and color the paper.

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. The term “sensorimotor” was used by Piaget, because he believed that infants were dependent on their senses and their physical abilities to understand their world. Because they can see, hear, taste, and smell from birth, they combine these senses with their emerging physical abilities to interact with objects by grasping, shaking, banging, and tasting them. During their early experiences, infants are only aware of what is immediately in front of them. Because they don’t understand how things react, they are constantly learning about the world through trial and error by shaking or throwing things and putting things in their mouths. 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

C. The MVPT-3 assesses visual perception independent of motor ability.
The MVPT-3 assesses an individual’s visual perceptual ability without any motor involvement needed to make a response. It is especially useful with those who may have learning, motor, or cognitive disabilities. As the student has an intention tremor and the focus of the assessment is on evaluating his visual perceptual skills, this is the most appropriate test to use in this scenario. It is important to first establish the student’s visual perceptual skills before testing his visual motor integration.

A. The DTVP-3 can be used to assess children from 4-0 to 12-11.
B. The MVPT-4 is the most recent revision of the only non-motor visual perceptual assessment that can be used throughout the lifespan. Data for this version was collected from 2012–2014.
D. Typically the MVPT-3 takes 25 mins and the DTVP-3 takes 30 minutes to administer.

The Motor-Free Visual Perception Test (MVPT-3) is a widely used, standardized test of visual perception. Unlike other typical visual perception measures, this measure is meant to assess visual perception independent of motor ability. It was originally developed for use with children, however it has been used extensively with adults. The MVPT can be used to determine differences in visual perception across several different diagnostic groups and is often used by occupational therapists to screen those with stroke or head injury. The MVPT-3 was published by Colarusso and Hammill in 2003 and is intended for individuals between the ages of 4-95 and takes approximately 25 minutes to administer.

The Developmental Test of Visual Perception (DTVP-3): The DTVP-3 is the most recent revision of Marianne Frostig’s popular Developmental Test of Visual Perception. Published in 2013. New normative data were collected in 2010 and 2011. Used with children age range: 4-0 through 12-11. Testing Time: 30 minutes.
The results of the five DTVP-3 subtests are combined to form three composites: Motor-reduced Visual Perception, Visual-Motor Integration, and General Visual Perception (combination of motor-reduced and motor-enhanced subtests).

https://www.proedinc.com/Products/13700/dtvp3-developmental-test-of-visual-perception–third-edition.aspx
https://www.proedinc.com/Products/14216/motorfree-visual-perception-testfourth-edition-.aspx

B. The Rehabilitation Act of 1973.

Section 504 of this act includes provisions for providing accommodations for students with disabilities in public schools, including occupational therapy services, as long as the student has a medically diagnosed condition.

B. Discuss new interventions with the special education teacher to be implemented in the classroom. If the student’s progress has plateaued, then the NEXT stage would include discussing new interventions with the special education teacher to be implemented in the classroom to yield more progress towards the student’s goals.

A. and D. The goals for the student’s IEP have already been established and remain the same. The only change is what the OT recommends to achieve these goals. This is part of the OT process and involves grading or changing the recommendations that will help the student achieve their IEP goals. There is therefore no indication that amending the IEP or changing the goals of the IEP are necessary.
After this NEXT step, if the goals need to be changed, in certain circumstances, when minor changes to a student’s IEP are required, an IEP team member may discuss the required changes with the student’s parents and other team members without calling a meeting to review the IEP. If the team agrees, changes to the IEP may be made by completing the appropriate forms and documenting communication with other team members.
C. Continuing to work on the strategies given in the current IEP until the next IEP meeting is not an option as it has already been identified that the current strategies that have been implemented are no longer helping the student and therefore have to be changed to be of any benefit.

A. The child splays his legs out toward the ground when the therapist pulls him on a scooter board and picks up speed.
B. The child hugs the rope ladder tightly as he climbs and stops after advancing 1 rung above the floor.
E. The child becomes nauseous and pale.
These behaviors, demonstrated during the activities, are indicative of a child who has reached his sensory threshold. A threshold refers to a certain level at which a child responds to sensory information. For some children, they may be hyper-responsive and therefore take on a low sensory load to effectively respond to their environment. For others, they may be hypo-responsive and can take on a higher sensory load of information before they react.

All the other activities produce an adaptive play response that is optimal and appropriate for the child.

Ayers, Jean A. (20056). Disorders involving the vestibular system and tactile defensiveness checklist, Sensory Integration and the Child (25^th Anniversary Edition, pp 7,77, and 113). Torrance, CA: Western Psychological Services.

http://www.infantva.org/documents/copa-conf2008-sensory-koontz.pdf

C. By age 16. IDEA 2004 mandates that the IEP must include documentation addressing transition planning by the age of 16 at the latest. Individual states are allowed to set the age at which transition planning begins earlier, but not later than age 16. 

D. The OT can provide services to the girl through a 504 plan. Section 504 of the Rehabilitation Act of 1973 allows schools to provide adaptations to students in public schools who have a medical diagnosis that limits their functional abilities in school. An IEP does not have to be in place for services to be provided in this manner.

C. Yes, the OTA may make changes during the IEP meeting if before the IEP meeting, the OT and OTA discussed and agreed upon potential changes in goals or amount or type of service.
It is entirely appropriate for an OTA to attend an IEP meeting and present information concerning student progress and IEP goals to be addressed by occupational therapy, based on previous collaboration between the supervising OT and the OTA. If, at the IEP meeting, the IEP team requests additions or changes to the goals being addressed by occupational therapy, the supervising OT would need to review those recommendations and agree to any changes; the OTA cannot make that decision alone, without additional collaboration between the OT and OTA. If, before the IEP meeting, the OT and OTA discussed and agreed upon potential changes in goals or amount or type of service, the OTA may make the changes during the IEP meeting.

https://www.aota.org/About-Occupational-Therapy/Professionals/CY/Articles/School-consumer.aspx

A. The OT should refer the teacher to the special education director. Occupational therapy in public schools cannot be provided unless a child qualifies for special education services under IDEA 2004 or for an accommodation plan under Section 504 of the Rehabilitation Act of 1973. Since the student does not have either of these services in place, the special education director will need to observe the student and determine if an evaluation for special education services is warranted. If the student’s performance in school is significantly impacted by his speech and gross motor delays, the special education director will request permission for the evaluation from the student’s parents and will notify those members of the special education team who may need to evaluate the student.

B. Actual work tasks at Matthew’s place of employment. Transitional employment involves on-site job training for a period of 3 to 6 months. The OT practitioner would help Matthew by training him to perform actual work tasks at his place of employment. Matthew’s job would be pre-arranged by the school and would last 3 to 6 months, after which time the OT would work with Matthew’s IEP team to determine what type of ongoing employment Matthew can complete.

D. Work on swinging if it relates to an activity of improving visual motor skills. Work on swinging if it relates to an activity of improving visual motor skills. The parents are not able to change the goals in the middle of the school year. However, the OT can work on swinging if she combines visual motor skills with it.

C. The student would benefit from sitting in a quiet corner of the room.
A distraction free and structured/predictable environment is most conducive to learning for students who can become easily distracted and overwhelmed by too much input.
The student may be distracted and disturbed by the free movement of others in the classroom, i.e. other students may bump into him, his chair or table when they move about the classroom. The student may be unable to understand this contact is accidental. Personal space is important. If it is practical, establish a work area in the classroom that is uncluttered, free from distractions and not subject to ‘traffic flow’ by other students.
Structuring the classroom:
• Make sure the student has a clear and easy path to the teacher for help.
• Position the student in a quiet corner of the room where there is little chance of him being distracted by light, reflections, the door opening and closing etc.
• The student might perform better when facing a wall or window providing the view is not too distracting.

A, B and D. These are not an option as schools are required to have an IEP in place for students with special needs It is very important not to exclude or separate the student from the rest of the class, but to establish a work area that takes the student’s special needs into account.

https://www.autismhelp.info/for-professionals-teachers-employers/teaching-students-with-autism

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 is not a symptom related to cortical problems.
B. It is unlikely that her visual difficulties would result in difficulties with 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 averse 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.

A. Exploratory play.

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 the age of 6 months. Walking without support does not typically develop before the age of 10 months. Symbolic/Fantasy play is role playing or make-believe play, such as pretending to be a baby, firefighter, 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.

B, E, and F. All of these answer choices support the client-centered approach. Interventions involving both the child and family in preparation for what is expected in the receiving environment to ensure a smooth transitioning process, is also client-centered. “Strategies may include altering or modifying activities, remediating deficits, reducing environmental barriers, and preventing challenges by anticipating needs in the receiving environment. Although barriers exist to participation, practitioners can reduce such barriers through collaboration and accessing resources related to best practice in transition planning”.

Shah, N., Washko, J. and Stoffel, A. (2018, October 5). Strategies for Supporting Transition from Early Intervention to Early Childhood Special Education, OT Practice Pulse. Retrieved from

D. Heart defect and atlantoaxial instability.

Down syndrome is also known as Trisomy 21.
People with Down syndrome can have a variety of complications, some of which become more prominent as they get older. These complications can include:
• Heart defects. About half the children with Down syndrome are born with some type of congenital heart defect. These heart problems can be life-threatening and may require surgery in early infancy.
• Gastrointestinal (GI) defects. GI abnormalities occur in some children with Down syndrome and may include abnormalities of the intestines, esophagus, trachea and anus. The risk of developing digestive problems, such as GI blockage, heartburn (gastroesophageal reflux) or celiac disease, may be increased.
• Immune disorders. Because of abnormalities in their immune systems, people with Down syndrome are at increased risk of developing autoimmune disorders, some forms of cancer, and infectious diseases, such as pneumonia.
• Sleep apnea. Because of soft tissue and skeletal changes that lead to the obstruction of their airways, children and adults with Down syndrome are at greater risk of obstructive sleep apnea.
• Obesity. People with Down syndrome have a greater tendency to be obese compared with the general population.
• Spinal problems. Some people with Down syndrome may have a misalignment of the top two vertebrae in the neck (atlantoaxial instability). This condition puts them at risk of serious injury to the spinal cord from overextension of the neck.
• Leukemia. Young children with Down syndrome have an increased risk of leukemia.
• Dementia. People with Down syndrome have a greatly increased risk of dementia — signs and symptoms may begin around age 50. Having Down syndrome also increases the risk of developing Alzheimer’s disease.
• Other problems. Down syndrome may also be associated with other health conditions, including endocrine problems, dental problems, seizures, ear infections, and hearing and vision problems.

A, B and C – are associated with complications of prematurity.

http://www.mayoclinic.org
http://www.marchofdimes.org

B. 2-3 years.
Children between the ages of 2 and 3 become aware that they need to use the bathroom and can verbalize it, but do not always make it to the bathroom in time. The following developmental stages occur between the ages of 19 months and 4 years:
19-24 months: Urinates regularly
2-3 years old: Achieves regular toileting with occasional accidents; verbalizes when need to go to bathroom
3-4 years old: Goes to bathroom independently; may need help with wiping/fasteners/difficult clothing

D. An OT determines that the child’s oral-motor skills are age appropriate.
Oral Motor skills and feeding at 3-7 months
By 4 months of age, most infants have gained fair head control and are able to remain in an upright position with support, and parents are beginning to introduce puréed foods. By this time, the anatomical structure of their jaws and tongues have dropped forward to support munching patterns. They also may open their mouth when a spoon is presented and are able to manage thin purees with minimal difficulties.

Oral Motor skills and feeding at 7-9 months
Between 7 and 9 months of age, infants are now moving into unsupported sitting, quadruped and crawling. This development supports jaw stability, breath support and fine motor development for self-feeding skills. Infants at this age now begin to be able to successfully manage “lumpy” purees, bite and munch softer foods, and the development of rotary chewing begins.

https://www.theottoolbox.com/2018/08/development-of-oral-motor-skills.html

A. 24-36 months.
Every child progresses differently with self-feeding, which is why there is such an age range regarding utensil use development. The consensus is that by 36 months, a child can use a fork to pierce soft foods and bring it to their mouth.

B. Sitting with arms at sides, for support.
This is the sequence of the progression of developing independent sitting:
1. Sitting forwards, propping self on arms (forwards), hands not free to play.
2. Sitting with a more upright posture and supporting self with arms at sides, hands not free to play.
3. Finally sitting independently and hands are free for play.

B. 12-14 months, which is age appropriate.
The child is functioning at a development age of 12-14 months, which is appropriate for his corrected age as he was born 3-months prematurely.
In more detail: This child was born at 28-weeks gestation, which is equivalent to being born 3-months prematurely. Until a child reaches the chronological age of 2-years-old, the weeks of prematurity should be taken into account and subtracted from the chronological age in order to calculate their corrected age.
In this scenario:
Chronological age = 15-months
Gestational age: 28-weeks = (40 – 28 = 12 weeks) 3-months prematurely.
Corrected age: Chronological – prematurity = 15 – 3 = 12-months
With developmental milestones, remember that there is a range of “average” and many milestones do overlap. In this scenario, the child 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 months
24-30 months: Interest in fork, stab food (canned fruit). Proficient spoon use and eats cereal w/milk or rice with gravy with utensil.

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.

B. Replace the Velcro straps with shoelaces and shoelace locks, and apply stickers of her favorite animal or cartoon characters. Shoelaces for attachment rather than Velcro straps are often more challenging for removal. “Bow Biters,” little plastic critters that tie on the lace and then clamp down on the bow after it is tied, can also be used to secure the lace, therefore making removal more difficult. 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.

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

B. Place objects in different directions so the student has to move his arm while maintaining his grasp.
Once the student has developed the ability to grasp objects of different sizes, it is important to have him use his newly developed skill for functional tasks.

B. The child is demonstrating goal-directed behavior. The girl is initiating the task by being spontaneous, and despite using a crayon, she has a goal to comb her hair. Piaget believed that as babies begin to grow and learn about their environment through their senses, they begin to engage in intentional, goal-directed behaviors. In other words, they begin to think about what they want to accomplish, how to accomplish it, and then they do it. Purposeful activities are defined as goal-directed behaviors and guided by client centered goals

C. The OT would identify a need to develop the girl’s dressing skills.
Myelomeningocele Spina Bifida (SBM) is the most severe form of spina bifida. The physical impairments in SBM include motor and sensory deficits of the lower limbs leading to difficulties with stance and locomotion, as well as urinary and bowel dysfunction. Upper limb function, as well as lower limb function, is impaired in two thirds of children with SBM. Upper limb motor deficits in SBM include motor weakness and impaired hand and finger dexterity, motor speed, motor planning, and bimanual coordination. This affects development of eye-hand co-ordination which may interfere with activities of daily living (ADLs), such as buttoning a shirt or opening a lunchbox. Difficulties with spatial relations, body image, and development of hand dominance may also be evident. A variety of cognitive impairments in perception and cognitive development have also been documented.
Other common symptoms are:
– Weakness or paralysis in the lower limbs
– Urinary and bowel incontinence
– Type 2 Arnold-Chiari malformation- an abnormal brain development involving the cerebellum.

https://clinicalgate.com/spina-bifida-a-congenital-spinal-cord-injury/
https://www.medicalnewstoday.com/articles/220424.php
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075008/

C. Wrist extension for pencil grasp. Using a slanted board has many benefits, one of which is, it forces the wrist and hand into tenodesis (wrist extension and finger flexion). Writing with an extended wrist automatically places the hand into a functional position and allows the hand to pull the radial digits into opposition. Maintaining radial digit opposition to the thumb is necessary for promoting an efficient grasp on the pencil. By improving the student’s pencil grasp, he can develop the skill of handwriting

Other benefits:

• Helps with stabilizing the paper
• Promotes good shoulder positioning for handwriting
• Helps with visual tracking during writing and reading tasks

D. Figure Ground.
Refer to “Handwriting” in Study Materials Module 2. Figure ground refers to a child’s ability to distinguish an object against its background. The best choice is Figure ground because the student is not able to recognize the shapes within a picture.

A. Visual discrimination is the skill a child uses to see subtle differences between objects or pictures. This visual perceptual skill can be described as “paying attention to detail”.
B. The ability to recall or remember the visual details of what you have seen is referred to as visual memory.
C. Spatial orientation refers to the ability to identify the position or direction of objects in space.

B. The most helpful compensatory technique would be to introduce side-lying.
By using side-lying, the boy’s body will be fully supported by the floor/bed. He will therefore be able to use his hands freely to dress himself.

A. Give the student a smaller crayon (crayon that’s been broken in half).
The student is using a static tripod grasp, therefore the next step is to work on using a dynamic tripod grasp. Smaller crayons allow a child to manipulate the pencil more easily, which discourages them from using too many fingers to maintain a grasp on the crayon. By giving the student a crayon that’s been broken in half, it will naturally encourage them to “pinch” the crayon between their thumb and index finger, moving them into a more mature and skilled grasp pattern. The reason is that it’s hard to use all their digits to grasp on a short crayon.

A. To provide proprioceptive and vestibular input.
Tactile Defensiveness is a sensory processing issue, where the child’s neurological system is “hypersensitive” to light touch sensation. Light touch tends to be alerting and arousing whereas deep tactile pressure is a firm, consistent touch which tends to be calming and organizing. The theory behind inhibition is that because multiple sensations and multiple pathways interact with each other in the CNS, by providing one kind of input, it may reduce/inhibit the sensation of the other.
The vestibular and proprioceptive systems are interrelated and have some common functions. The proprioceptive system plays an important regulatory role in sensory processing as proprioceptive input can assist in controlling responses to sensory stimuli. Rolling in a yoga mat provides the child with both proprioceptive and vestibular input. Being encased in the mat, gives constant deep pressure (proprioception) and the act of rolling stimulates the vestibular system.

D. 6. The question asks at what age can a child use a spoon, knife and fork- to scoop food, spread butter, cut food with a knife and fork.
By age 6 a typically developing child will have acquired all of the skills needed to use the utensils pictured, including the ability to cut food with a knife.
4 to 5 Years: Can spread soft substances with a plastic/child-safe knife.
5 to 6 Years: Can cut foods with a knife under supervision (dull knife or slightly serrated, not sharp)
5 1/2 to 6 1/2 Years: Can cut with a fork and knife (entire process of holding utensils, controlling and cutting food, and bringing to mouth)

Pass the OT. Module 2. https://passtheot.com/developmental-progression-of-oral-motor-skills-self-feeding-skills/

A. Dipping the spoon in apple sauce.
Typically a child progresses from banging a spoon, to dipping a spoon into food, to scooping food with spoon, to piercing food with fork, to using a knife with some assistance, to eventually using a knife and fork with skill.
Developmental norms:
10-12 Months: Holds spoon to play, bang, mouth, drop
13-15 Months: Dips spoon in food. Brings spoon to mouth, turns spoon over but obtains some food
By 36 months: Can use a fork to pierce soft foods and bring to mouth
By 6 Years: Can cut with a fork and knife (entire process of holding utensils, controlling and cutting food, and bringing to mouth)
As the OT is working on utensil use, finger feeding would not address the treatment goal.

https://mamaot.com/when-can-kids-feed-themselves-mealtime-milestones/

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.

C. The next developmental step would be to drink using a straw.
Typical developmental sequence:
6-9 months: grabbing spoon and banging it
9-13 months: finger feeding self soft table foods
15-18 months: scooping food and bringing it to mouth
18 months: straw use

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

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, Motor-Free Visual Perception Test, and Miller Assessment for Preschoolers meet this requirement. 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. The Allen Cognitive Level Screening Tool does have specific instructions, but is more complicated to administer because scores need to be validated by observed performance.

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

D. Sensory Modulation Disorder. A child with a Sensory Modulation Disorder has difficulty modulating (regulating) sensory input. Sensory modulation is the ability to respond appropriately to sensory information and remain at an appropriate level of alertness for daily activities. It includes the subtypes: 1. Sensory Over-Responsivity, 2. Sensory-Under Responsivity, and 3. Sensory Craving/ Seeking. In this scenario, Sara is demonstrating sensory-seeking behavior. The nervous system of the sensory-craver needs intense input in order for the sensation to be registered. Sensory-cravers seek out intense sensations constantly but are often disorganized due to high levels of random sensory input. They are constantly touching, crashing, and moving, and they have no awareness of personal space. The child may also: Demonstrate decreased safety due to impulsiveness and excessive risk taking behaviors.
Appears to be in constant motion but may be clumsy and awkward, frequently falling and bruising (but may not notice injury until pointed out).

https://childrenstherapy.org/what-is-sensory-modulation-disorder/

A. The OTR® should tell Miley’s mother not to worry as 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 years.

B. Observe how the child handles scissors during an art activity with construction paper.
This observation correspond to identifying motor planning and fine motor difficulties. As the parent reported being concerned with functional tasks that involve motor planning and fine motor skills, the answer should be based on tasks which involve motor planning and fine motor skills. Fine motor skills involve the use of the smaller muscle of the hands, such as when doing up buttons, opening lunch boxes or using pencils or scissors. Fine motor skill efficiency significantly influences the quality of the task outcome as well as the speed of task performance.

A, C. and D. Although it is possible that the child demonstrates behavioral problems which may be related to sensory processing disorders, it is the fine motor problems that are related to the parent’s concerns and could play a part in establishing priorities and goals should the child be eligible for IEP.

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.

C. 2 years. By the age of two, a child should begin to help pull his pants down, and will pull down elastic-waist pants by age two and a half.

B. 4 years.
At 4 years old a child can buckle shoes or a belt, fasten large buttons without assistance, pull up zipper on jacket, put on shoes and socks (not yet able to tie shoes), zip a jacket zipper, puts on socks correctly, and identify the front and back of a garment.
The question asks at what age this child can zip up her jacket independently. The word independently implies that all aspects of zipping up her zipper are included from hooking the zip at the bottom as well as pulling the zipper up. For a typically developing child, as the development chart states, from the ages of 4-5 a child can be expected to zip up their jacket independently. When looking at age norms, 4-5 indicates from the age of turning 4 to the age of turning 5. This period is considered to be the stage of the child being 4 years of age.

At least 3 references concur that age 4 is the age when a child can be expected to manipulate a zipper.
https://www.abcpediatrictherapy.com/age-child-dressing-skills/
https://www.baltimoretherapyspot.com/developmental-milestones-for-children-2-5-years-old/

C. 5-6.
At 5 years old a child can tie and untie knots as well as dress unsupervised.
Developmental milestones related to self-dressing skills. These are meant to be general guidelines for when these skills tend to typically emerge.

• By 4 1/2 years of age:
Unbuttons front-opening clothing
Buttons front-opening clothing (e.g., button-down shirt)
Puts on weather-appropriate clothing without prompting (e.g., puts on coat if cold outside)
Tightens shoelaces by pulling up or out

• By 5 1/2 years of age:
Dresses independently when asked
Tucks in shirt
http://mamaot.com/when-do-kids-learn-to-dress-themselves-developmental-progression-of-self-dressing-skills/
https://www.yourkidsot.com/blog/best-tips-for-tying-shoe-laces

A. Beery Developmental Test of Visual-Motor Integration (VMI). The Beery VMI helps assess the extent to which individuals can integrate their visual and motor abilities. The Short Format and Full Format tests present drawings of geometric forms arranged in order of increasing difficulty that the individual is asked to copy. Optional Supplemental Tests for More Detailed Evaluation
Two supplemental tests-the VMI Visual Perception Test and the VMI Motor Coordination Test- can each be administered in 5 minutes or less. They are generally given if full- or short-form VMI results indicate a need for further testing. The supplemental tests use the same VMI stimulus forms, so it easy to compare results from all 3 tests, using a profile form provided in the Test Booklet.

B. Bayley Scales of Infant & Toddler Development Motor Scale: Assesses the mental, psychomotor and behavior of infants and toddlers ages from 1 month to 42 months.
C. Beery Developmental Test of Visual-Motor Integration-Visual Perception- this is a standardized supplement to the Beery VMI and if needed, is administered after the Beery VMI. This is a timed test, where during a three- minute period the task is to identify the exact match for as many of the stimuli figures as possible. To make this as pure a visual-perceptual task as possible, the only motor requirement of the individual is to point to his/her responses.
D. Beery Developmental Test of Visual-Motor Integration-Motor Coordination- this is a standardized supplement to the Beery VMI and if needed is administered after the Beery VMI. This is a timed test, where during a 5-minute period the task is to simply trace the stimulus form with a pencil without going outside the double-lined path.

https://sites.google.com/site/darceyot/evaluations
https://www.therapro.com/Browse-Category/Visual-Perception-and-Visual-Skills/6th-Ed-Starter-Kit.html

D. Raking grasp.
Between 5-7 months of age a child will develop a raking grasp. The child consciously uses their fingers to grasp an object. They do not have finger isolation so they use all of their fingers as a whole unit to pull an object into their hand. This movement is termed “raking” and it is how most infants obtain objects of any size, small or large.

D. Ataxic cerebral palsy.
Ataxic CP is derived from the word “ataxia,” meaning lack of coordination and order.

Hypotonia is diminished muscle tone. The infant or child with hypotonic cerebral palsy appears floppy — like a rag doll.
Children with dyskinetic forms of cerebral palsy have variable movement that is involuntary (outside of their control).
Spastic cerebral palsy is the most common type of cerebral palsy. The muscles of people with spastic cerebral palsy feel stiff and their movements may look stiff and jerky. Spasticity is a form of hypertonia, or increased muscle tone

C. Pad-to-pad prehension. Placing discs into a grid when playing “Connect 4” requires pad-to-pad prehension.
Precision grips can be categorized as pad-to-pad prehension, tip-to-tip prehension, and pad-to-side prehension. Each tends to be a dynamic function with relatively little static holding.
Pad-to-Pad Prehension- involves opposition of the pad of the thumb to the pad of the finger.
Tip-to-Tip Prehension- the interphalangeal joints of the finger and thumb have the range and available muscle force to create nearly full joint flexion.
Pad-to-Side Prehension- also known as key grip (or lateral pinch) because a key is held between the pad of the thumb and side of the index finger. Pad-to-side prehension differs from the other forms of precision handling only in that the thumb is more
adducted and less rotated.
https://shodhganga.inflibnet.ac.in/bitstream/10603/23416/10/10_introduction.pdf

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

A. Neck righting reflex. The first of the righting reflexes to appear is the neck righting reflex. It is present at birth and strongest at about three months of age. It is triggered by stretching of the neck muscles when there is rotation of the head. With the baby in supine, if the head is turned to one side, the whole body will follow, in what is called a log roll, until it is brought into alignment with the head.

B. STNR- When the infant’s head is flexed, the influence on tone causes their arms to flex and their lower limbs to extend. When their head is extended, the influence on tone causes their arms to extend and their legs to flex. The STNR emerges at around 4 – 6 months, and should be integrated by the latest 12 months of age. The reflex is important to help the child come into a crawling position.
C. Moro
• Onset – begins at 28 weeks gestation
• Integration – 5-6 months
• Position infant halfway between supine and upright sitting with their head in midline, support the infant’s head and shoulders with one hand. Allow the neck to drop back to allow the anterior neck muscles to stretch
• Response observed – the shoulders abduct, the elbows, wrists and fingers extend. Subsequently, the shoulders adduct, and the elbows and fingers flex
D. Labyrinthine Head Righting
• Onset – birth to 2 months
• Integration – persists throughout life
• Testing position – vertical position
• Procedure – tilt the child anterior, posterior, and lateral from the vertical
• Response observed – the head orients to the vertical position and is maintained steady

B. Postural instability.
When working with this child it is important to first address postural stability so they are in an ergonomically aligned position to eat food properly. You need proximal stability for distal ability.

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

C. Fine pincer grasp.
Typical progression of the pincer grasp, is moving from using the pads of the fingers to the tips of the fingers. to pick up small objects.

B. To stay focused and maintain alignment.
The ball seat has several benefits. It can correct a child’s posture and help meet his or her movement needs. Children with ADHD have an increased need for movement and they often seek out this movement in unacceptable ways in the classroom. Ball seats allow children to wiggle and shift position without disturbing their classmates. The seats also help correct poor posture, which facilitates proper position while working and attention to task.

C. By age 4, a child should typically be able to climb up and down stairs using a reciprocal pattern and no rail.
Walking up and down the stairs using an alternating stepping pattern without support is a milestone that can be expected from 3-4 years. As every child develops at their own pace, they may achieve these milestones at different ages.

Typical Progression:
2 years- It is typical for a child to walk up the stairs without any support from the parent or a wall/railing, but still putting both feet on each step before proceeding to the next step.
3 years- The child should now be able to walk up the stairs using a reciprocal pattern, placing only one foot on each step, without requiring the use of a railing for support.
4 years- The child should now be able to go both up and down stairs using a reciprocal pattern and no rail.

A. Oppositional defiant disorder.
Children with oppositional defiant disorder break rules and act aggressively, argue repeatedly with adults, lose their temper, feel great anger or resentment, ignore adult rules and requests, and display negative behaviors. 

C. Visual tracking. This is typically defined as the ability to efficiently move the eyes from left to right (or right to left, up and down, and circular motions) OR focusing on an object as it moves across a person’s visual field.

A. Visual scanning is the ability to use vision to search in a systematic manner, such as top to bottom and left to right. A child needs to use visual scanning to avoid obstacles when navigating their environment. Smooth visual scanning is required for reading.
B. Visual memory focuses on one’s ability to recall visual information that has been seen. Visual memory is a critical factor in reading and writing. When a child is writing a word, he must recall the formation of parts of the letter from memory
D. Visual acuity is a measure of the ability of the eye to distinguish shapes and the details of objects at a given distance.

https://www.theottoolbox.com/visual-tracking-tips-and-tools-for/

B. Simple rotation.
The question asks what type of hand manipulation skills the child uses to open the soda. Manipulation skills are different to types of grasps and although there may be different ways of to open a screw top bottle, we always need to look at the typical grasp or type of hand manipulation. When we refer to manipulation skills vs grasps, we are looking at in-hand manipulation which is the ability to hold and move an object within one hand. In-hand manipulation skills are divided into three major categories: translation, shift, and rotation.
1. Translation is the ability to move objects from the fingertips to the palm or the palm to the fingertips such as moving coins from the palm to the fingertips to place in vending machine or picking up pennies and moving them from the fingertips to the palm.
2. Shift is the ability to move an object in a linear manner with the fingertips, such as repositioning the pencil in the fingers to position for writing or fanning playing cards in the hand.
3. Rotation is the ability to turn an object around in the pads of the fingers and thumb (simple rotation) or turning an object from end to end (complex rotation) such as flipping a pencil from writing end to eraser.
A screw top bottle is typically opened with rotation by turning the bottle top between the pads of the fingers and thumb (simple rotation) and typically develops between 2 and 3 years of age. It involves the turning or rolling of an object 90 degrees or less with the fingertips moving as one unit.
Rotation in more detail:
Rotation is defined as the movement of an object around one or more of its axes. Rotation is divided into simple rotation and complex rotation. Simple rotation is a movement that occurs when an object is turned between the finger pads and thumb pad in a repetitive movement between thumb and fingers. The movement may occur with only the index finger and the thumb or with the involvement of additional fingers. An example of this movement would be to unscrew a small bottle cap.
Complex rotation is a movement involving rotation of the object or rotation that requires isolated, independent movements of the fingers and/or thumb. The movement is further described as the object being turned between 180 to 360 degrees. An example of this movement would be to turn over a pencil to use the eraser.

Case-Smith J, O’Brien JC. Occupational Therapy for Children. 6th ed. Missouri: Mosby Elsevier; 2010: 275-312.
Exner CE. In-hand manipulation skills. In: Case-smith J, Pehoski C. editors. Development of Hand Skills in the Child. Bethesda, MD: American Occupational Therapy Association, Inc; 1992: 35-40.

B. Inner core and outer core muscles.
When swinging prone, the child assumes prone extension- the “Superman” pose. This position activates the Posterior Oblique Synergist outer core muscle group (POS = contralateral latissimus dorsi and gluteus maximus) in combination with the inner core muscles. As soon as the POS activation begins, there is a counterbalance in anti-gravity flexion as the Anterior Oblique Synergist (contralateral obliques and adductors) activate. The combination of vestibular input with inner core and outer core muscle activity creates this sustained anti-gravity posture.

https://heartspacept.com/where-is-superman/

C. Increasing awareness through sensory stimulation.
The OT should focus on increasing awareness through sensory stimulation. OT for TBI in the acute care setting includes: sensory stimulation to promote awareness, ROM to maintain joint mobility, positioning to prevent skin breakdown, and splinting to maximize hand function

B. Rett Syndrome.
All the symptoms listed are characteristic of Rett Syndrome, which primarily affects girls.

C. The most helpful would be a spork.
Spastic hemiplegia is one of the subtypes of spastic CP. The most helpful utensil would be a spork which combines a fork and spoon and is ideal for anyone who has limited movement of one hand. Self-feeding using a spoon and fork should be established by this age.

C. Have him pick up small beans one at a time and put them in a bowl.
This is a good intervention to promote pincer grasp. Simply placing his hands in a pile of rice or beans is usually used for sensory or dexterity-related development. Neither throwing a ball into a hoop or building towers out of Legos requires the boy to use a pincer grasp. Grasping a ball requires a spherical grasp, and when a child picks up and builds with Lego, they would typically use a tripod (thumb and 2 digits) grasp.

A. Blowing a paper boat across a tub of water. This is an activity that is meaningful and purposeful for a child as it involves the occupation of play. As Liam is presenting with excessive drooling, the initial intervention needs to be tailored towards his abilities and thus blowing the paper boat is the most appropriate activity as it requires the least resistance. The act of blowing requires lip pursing which will help develop lip closure and in turn assist with swallowing.
B. Playing the harmonica is a very difficult task that requires developed oral-motor control and it is too challenging for a 5-year-old. 
C. Sipping milkshake from a regular cup will not address/improve oral-motor control.
D. Drinking yogurt through a straw could be used at a later stage but at this stage the resistance of sipping the thick liquid (resistive textures) would prove difficult for the child.

D. Sensory overload

The boy is most likely experiencing the symptoms of sensory overload from the crowded, noisy room. The symptoms have likely become so overwhelming that the boy does not remember what he has been taught when he becomes uncomfortable from sensory input and he reacts by attempting to get away from the situation.

B. A visual schedule.
Since Lily has Developmental Coordination Disorder, she has difficulty planning and carrying out the teacher’s instructions within the classroom. She might have heard the teacher, but may not be able to visualize what the teacher wants her to do. A visual schedule will provide Lily with visual prompts to pair with the teachers verbal instructions, helping her brain to organize and interpret what the teacher wants her to do.