Ot Guidelines Child Specific

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Clinical Guidelines of Occupational Therapy to Children with Specific Learning Disabilities

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, Hospital Authority 2004

1

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

List of contributors: Magdalene Poon, Kwai Chung Hospital Rita Ng, Yaumatei Child Psychiatric Centre Shiren Wong, Castle Peak Hospital Sanne Fong, Princess Margaret Hospital Catherine Fung, Princess Margaret Hospital Sally Choy, Kowloon Hospital Pheobe Chan, Kowloon Hospital Winnie Fok, Tuen Mun Hospital Rosita Yip, Tuen Mun Hospital Kitty Lai, Pamela Youde Nethersole Eastern Hospital Jenet Wan, Northern District Hospital Rebecca Chan, David Trench Rehabilitation Centre Phoebe Cheung, Queen Mary Hospital Linda Yau, United Christian Hospital Cecilia Leung, Queen Elizabeth Hospital Barbara Chan, Prince of Wales Hospital Ingrid Ngan , Prince of Wales Hospital Carol Chan, Alice Ho Miu Ling Nethersole Hospital

Statement of Intent This guideline is not intended to be construed or to serve as a standard of medical care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made in light of the clinical data presented by the patient and the diagnostic and treatment options available. However it is advised that significant departures from any local guidelines derived from it should be fully documented in the patient's case notes at the time the relevant decision is taken. Co-ordinating Committee in Occupational Therapy, Hospital Authority

2

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

CHAPTER ONE INTRODUCTION Specific learning disabilities (SLD) (sometimes referred to as “specific learning difficulties” and “learning disabilities”) is a generic term that refers to a heterogeneous group of disorders that covers a variety of disorders in area of spoken and written language, mathematics, perceptual motor skills and the social and emotional components of learning. It is developmental in nature and may impact to varying degrees on all aspects of the affected children’s lives at school, at home and at play. Unless given intervention appropriately and systematically, SLD problems may persist to adulthood (Scientific Committee of the Working Party on SLD 1999). In Hong Kong, Leong (1999) estimated that there are about 15% of the students having these problems. Occupational therapists often encounter these children when they had numerous functional problems in visual perception, writing, reading, managing academic work and other daily living tasks. The most common SLD subgroup cases referred for occupational therapy intervention includes developmental dyslexia (DD) (sometimes written as dyslexia) and developmental coordination disorders (DCD) (also known as developmental dyspraxia or clumsy child syndrome). Developmental dyslexia (DD) is the largest SLD subgroup. It refers to children who show measurably below-age reading and written language development despite average or above-average intelligence, intact emotional adjustment and instructions. According to ICD 10, DD is included under the specific reading disorder (World Health Organization 1992). There are about 10 to 20% of children being affected with specific reading difficulties (Lam 1999). On the other hand, DCD and developmental dyspraxia refers to children who show inefficiencies in visual, tactile, kinesthetic and/or vestibular related motor processing. These difficulties can be manifested in either or both fine and gross motor areas such as balance, postural control and graphomotor skills. In ICD 10, these two diagnoses are under the branch of specific developmental disorder of motor function (World Health Organization 1992).

Functional Problem of Children with SLD Occupational therapists are concerned with the role performance of the children and its related dysfunction. Children with SLD interfere the most basic and familiar tasks in writing, reading, playing and activities of daily living. These domains of occupational performance are the scope of practice of occupational therapy. Specifically, children with DCD are not only unable to complete some tasks, but also have difficulties in quality of motor production and task completion (Coster and Haley 1992). Handwriting and Reading Skills Handwriting skills are fundamental to children while they learn and study at school. McHale and Cermak (1992) found that 31 – 60% of the children’s school day consisted of fine motor activities 3

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

and of these tasks, much time was employed in paper and pencil tasks. The prevalence of children with handwriting problems was 10 – 34% (Rubin & Henderson, 1982; Smits-Engelsman et al., 1995; 2001). Difficulty in mastery of the mechanical aspects of handwriting may interfere with higher order processes required for the composition of text (Berninger & Graham, 1998). It is also significantly related to fluency and quality of composition. Children may forget the ideas and plans held in memory when they write too slow. They may have low performance at school, stressful feelings and loss of self-confidence. Handwriting problems of the children with SLD may include: -

poor accuracy; poor readability of letters, words and sentences;

-

inappropriate spacing between letters or words; incorrect or inconsistent shaping of letters;

-

poorly graded pencil pressure; letter inversions; and

-

mixing of different letter forms. In addition, there are also specific demands in writing Chinese characters which are square

shaped and occupied a uniform area in text. The structure of the characters is usually in left-right, top-bottom, circular and semi-circular structures. Thus, in writing Chinese characters, it demands much pen-lifts, sharp turns, following specific stroke sequences, attention to details of character formation and writing within confined space (Tseng and Hsueh, 1997). Reading is basically involving two steps: auditory process in retrieving meaning from graphic symbols and conversion to sound and auditory acquisition to relate the written word to its pronunciation as well as meaning (Woo and Hoosain, 1984). McBride-Chang and Chang (1995) suggested two basic cognitive functioning related to reading, the phonological memory and orthographic memory, in which reading Chinese characters required the latter skills more. In addition, Chinese words generally consist of two or more characters. And the same Chinese character can have multiple meanings and pronunciations, depending upon context, thus, it demands the person’s metacognition (strategies readers use to comprehend and on how they plan, monitor and repair their comprehension). Huang and Hanley (1995) conducted a study between children’s reading ability in China, Hong Kong and Taiwan and concluded that reading Chinese depended less on phonological awareness skills than English but more closely related to visual skills. Thus, Chinese children with visual perceptual problems should have more difficulties in reading than children studying in English. Children with reading problems often have difficulties in recognizing and memorizing Chinese characters. Therefore, they experience great difficulties in comprehension of the passage with unrecognized words in between which seriously affect the learning process. In addition, they usually perform poorly in dictation for they cannot memorize the Chinese characters.

4

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Activities of Daily Living Children with DCD, in particular, may also have self care development and associated problems in use of chopsticks in eating and the motor clumsiness may also affect the child’s organization of work in performing other self care activities such as buttoning, zipping, shoe tying and cutting nails. In managing school work, children with SLD will have difficulties in packing school bags and maintaining a well organized place for study. Thus, they need help to maintain notebooks for assignments, records of their work and drafts of their assignments (Cermak and Larkin 2002). Play Skills DCD children were reported to have poor performance of various gross motor skills such as balancing, throwing and catching a ball, skipping, hopping, or jumping. They also found to have difficulties in engaging ball games and group sports such as soccer, basketball, and baseball. Some of these children were unable to maintain their own personal body space and as a result, they bump into other people and objects easily. One study by Puderbaugh and Fisher (1992) examined play skills of children with developmental dyspraxia between the ages of 12 and 54 months. They examined the qualitative aspects of play and found that the children with motor coordination delays had poorer play skills than typical peers in the areas of motor skills (including skills such as reaching, moving, and manipulating objects) and in process skills (including skills such as sequencing, organizing and investigating objects and actions). Clifford (1985) noticed that they often have history of quitting community-sponsored physical activity programs. May-Benson (1999) found that 50 % of children with dyspraxia had problems riding a bicycle, 67 % had poor ball skills and 71 % had difficulty with sports. Social Skills Social skills was defined as a child’s ability to develop and maintain appropriate peer relationships is considered to be an important predictor of positive adult adjustment and behavior (Cowen, Pederson, Babigan, Izzo and Trost, 1973). Research documented that children with SLD exhibited deficits in social skills. Factors contributing to the social skills deficits included social perception, behavioral problems, problem solving ability, and verbal communication (Cermak & Aberson ,1997). McConaughty and Ritter (1986) examined the social competence and behavioral problems of boys with SLD ages 6-11 by using CBCL. Parental reports indicated that boys with SLD displayed significantly more behavioral problems in comparison to the normative sample. LaGreca and Stone (1990) concluded that children with SLD had significantly lower peer acceptance, fewer positive nominations, lower feelings of self worth and more negative self perceptions regarding social acceptance. Other literature also indicated that children with SLD had been found to have deficits in social perception and are less attuned to nonverbal communication than typical peers (Axelrod, 1982; Jackson et al., 1987; Sisterhern & Gerber, 1989). Studies also showed that a child’s difficulty in social 5

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

skills may relate to problems reading non-verbal cues, which were due to visual perceptual problems (Harnadek & Rourke, 1994). Self-esteem /Emotion control O’Dwyer (1987) found that 11-year-old boys with motor coordination problems were less outgoing, less emotionally stable, less tough-minded and self-reliant, less shrewd and calculating, less self-assured, and more introverted, and had lower self-esteem and poorer peer acceptance than their more coordinated peers. Schoemaker and Kalverboer (1994) also found that clumsy children were more anxious, had low self-concept, were more insecure and isolated, and were less competent in social and physical skills than their peers. Koomar (1996) found that anxiety co-occurred with dyspraxia for 5- and 13- year-old children, with a greater degree of anxiety manifesting with more severe dyspraxia.

Comorbidity In addition, a variety of disorders may co-exist in a significant percentage of children with SLD such as attention deficit and hyperactivity disorder (ADHD). SLD was present in 70% of children with ADHD and children with such co-morbidity had more severe learning problems than children with SLD but no ADHD (Mayes,Calhoun & Crowell, 2000). Furthermore, among the children with disabilities, children with SLD had more problems in perceived competence than those with physical or visual impairment. They tended to perceive themselves as lacking in competence and consider failure as an indication of their own lack of competence and thus as threat to their self-esteem (Weisz & Stipek, 1982). They either hid their emotions, or reacted aggressively in achievement situations and following failure. According to Child behavioral checklist (CBCL) and Teachers report form (TRF), the dyslexic group had significantly more behavioral problems than the control group. They had higher scores on total behavioral problems, internalizing and externalizing sub-domains and the subscales attention problem (Heiergang, Stevenson, Lund & Hugdahl, 2001). For adolescents who were diagnosed with DCD at younger age, research indicated that reading problems were associated with some increases in disruptive behavior in their teenagers.

6

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Conclusion SLD affects the children in many aspects. Outcome studies showed that the problem affects the children’s educational attainment, mental health and adult social functioning. Lam (1999) commented that these negative outcomes were the result of inadequate effective help and intervention in early years of the children. She suggested that early identification and intervention against the negative effects of SLD were therefore essential. A survey done in paediatric and child psychiatric settings in Hospital Authority in 2003 found that it was among the five most common diagnoses referred to occupational therapy service (Child and Adolescent Working Group, OTCOC, 2003). Occupational therapists provide individual and/or group treatment in children in day and out patient services aiming at improving their functional skills in learning and coping with daily activities. This clinical guidelines aim at streamlining occupational therapy service provision for children in SLD within different settings in Hospital Authority so as to improve the quality of service to these children and ensure maximal independence in their daily lives.

7

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

CHAPTER TWO CONCEPTUAL FRAMEWORK AND COMMON TREATMENT APPROACHES Treatment Approaches for Children with SLD In treating children with SLD, the model of practice frequently adopted by occupational therapists is the Canadian Model of Occupational Performance (CMOP). Under this model, it defines “occupational performance” of a person as the result of a dynamic relationship between persons, environment, and occupation over a person’s lifespan. It refers to the ability to choose, organize and satisfactorily perform meaningful occupations that are culturally defined and age appropriate for looking after one’s self, enjoying life, and contributing to the social and economic fabric of a community (Canadian Association of Occupational Therapy 1997). Specifically, we may consider playing and learning being the major occupations of children. Occupational therapists introduce environmental change aiming at enhancing occupational performance, or enabling persons to restore, develop, maintain, or discover their occupational potential in their environment. The process of occupational therapy practice is divided into seven stages: Stage 1: Name, validate and prioritize occupational performance issues related to self-care, productivity and leisure Stage 2: Select theoretical approach(es) Stage 3: Identify occupational performance components and environmental conditions Stage 4: Identify strengths and resources Stage 5: Develop action plan with clients Stage 6: Implement plans through occupation Stage 7: Evaluate occupational performance outcomes (Canadian Association of Occupational Therapy 1997). There are a number of treatment approaches in which occupational therapists will adopt during the treatment of children with SLD. These approaches assist in focusing the core problems of children for remedial therapy and adaptation to daily life activities. Perceptual Motor (PM) Approach Perceptual motor approach focus on the person’s ability in perceiving sensory information from environment, then responding with judgment and executing a coordinated motor response (Hong, 1984; Folio & Fewell, 1983). Perception is needed for all activities. Different from sensation, it has to be learned. It means that the child has to interpret what he sees, hears, feels and smells from the environment. Perceptual motor theorists all have similar assumptions that motor learning is a foundation for perceptual development (Kephart, 1971, Frostig, 1973 and Getman, 1965). They contended that learning problems occurs mainly because children fail to acquire normal perceptual-motor development. 8

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

The PM approach is a kind of bottom up intervention. It involves a variety of different intervention procedures based on the assumption that a causal relationship existing between motor abilities and that underlying perceptual qualities (Mandich et al., 2001; Sigmundsson et al., 1998). Perceptual motor dysfunction is regarded as a sensory input disorder which results in maladaptive motor responses (Parush & Hahn-Markowitz, 1997). The goal of the PM training programs is to remediate the underlying component of perceptual motor dysfunction which results in learning deficits. Sensory Integration Therapy Sensory integrative approach is one of the most frequently used approaches to treat children with SLD that have sensory integrative dysfunction (Mandich, Polatajko, Macnab & Miller, 2001; Vargas & Camill, 1999; Chu, 1996; Cemak, 1985). Evidences supported that sensory integration therapy is effective in remediation of these children (Vargas & Camilli, 1999; Kaplan, Polatajko, Wilson & Faris, 1993; Wilson, Kaplan, Fellowes, Gruchy & Faris, 1992; Polatajko, Law, Miller, Schaffer & Macnab, 1991; Humphries, Wright, Snider & McDougall, 1990; Densem, Nutall, Bushnell & Hoen, 1989). Sensory Integration (SI) is a theory of brain-behavior relationships. SI refers to the ability to organize, integrate, and use sensory information from the body and the environment. The concept of SI arose from a body of work that was developed by Jean Ayres (an occupational therapist and licensed clinical psychologist) based on studies in the neurosciences, physical development, and neuromuscular function. Sensory integration theory has three components. The first pertains to development and describes typical sensory integrative functioning; the second defines sensory integrative dysfunction; and the third guides intervention programs. SI intervention procedures are based on the premise that plasticity exists within the CNS. Therefore, therapy was designed to effect changes in the brain by improving the efficiency with which the nervous system interprets and uses sensory information for functional use. The control of tactile, vestibular, and proprioceptive sensory inputs is believed to enhance nervous system function. Biomechanical Approach Biomechanics is a system of assumptions about forces affecting the human body. It is based primarily on the mechanics of musculoskeletal system with the use of direct strengthening techniques involving the application of resistance. It is commonly applied to impairments of the musculoskeletal, cardio-pulmonary, integumentary, and nervous systems with its goal to increase strength, endurance, and joint range of motion. In treating children with SLD, the application of biomechanical approach mainly concerns the ergonomic of the children and the related compensatory techniques in writing. The treatment considerations include: stabilities of posture, shoulder and wrist and the environmental adaptations in the furniture arrangements and the development of the pencil grip. In addition, the strength and endurance of the child’s musculoskeletal function of the hand will also be emphasized. 9

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Other Approaches During the treatment intervention, there are numerous treatment approaches which the therapist may apply. These include developmental approach, cognitive approach, compensatory approach, adaptive approach, functional approach and behavioural approach. Developmental and cognitive approaches are always fundamental to the treatment to children. Therapists will consider the developmental sequences and establish their performance skills the children have or can develop at their current level of function. Cognitive approach focuses on examining the underlying cognitive deficits of the children. The investigation of the cognitive deficits in relation to the children with SLD and plan related training activities is very essential. Therapists need to update themselves with recent neurological studies and the relationship with these children’s problems. Compensatory and adaptive approaches need to be considered as the children still show residual symptoms after an intensive course of training. When adopting these approaches, therapists may consider the prescription of aids and adaptive devices together with the other human and non-human environmental considerations. Throughout the process, the therapist will also apply the biomechanical approach to ensure that the decisions made are practical to the children. Very often, the treatment intervention involves teaching learning, thus, the incorporation of behavioral approach is common. The behavioral theory based on the premise that most behaviors are learned and the interaction between the human beings and the environment attributed to the learning of behavior. Thus change of behaviors can be resulted by monitoring the environment through the application of various learning principles. The techniques based on operant conditioning had been widely adopted for treating children with SLD. Shaping which included breaking down the target behavior such as hopping in sequence into steps and reinforce for achieving certain step of the target such as imitate hopping for once only or reinforce for approximation to the target behavior such as praising for touching a throwing ball instead of really able to catch the ball. Children with SLD often faced frustration when performing tasks which they had difficulties in doing. Shaping lowered the level of the tasks and thus effectively set a more achievable target for the children. Positive reinforcement is also a frequently used technique to increase or maintain the desired behaviors. The reinforcers used may include either immediate positive feedback from the therapist or through a token system. Behavioral contract and token economy can be designed to increase the compliance and motivation of home program prescribed during training. Time out and response cost procedures are designed to decrease or eliminate undesirable behaviors by removing reinforcing events from the child’s environment. In particular, the children with SLD comorbid with ADHD may need these procedures in order to maintain the disciplines and group orders so as to ensure effective treatment. Therapist could remove the child from the activities to time out in a corner when the child is overly impulsive, non-compliance, temper tantrum during training. In response cost, therapist could give tokens to specific behaviors such as remain seated, asked permission before acting out and child would lose the token once he or she cannot achieve the specific behaviors. In addition, inappropriate behaviors such as hyperactivity or tantrum could also be reduced by stimulus control, that is by avoiding situations that produce conflict, by avoiding the over stimulating activities and by engaging the child 10

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

in individual training instead of group training. All in all, occupational therapists always consider the functional level of the children in daily lives. Thus, the functional deficits at school, home and play, the three major areas of the children are essential to the formulation of treatment plan of these children.

11

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

CHAPTER THREE TREATMENT INTERVENTION FOR CHILDREN WITH SLD Occupational therapy intervention to children with SLD mainly related to three sets of training activities based on perceptual motor approach, sensory integrative approach and the functional skills training. Occupational therapists will first identify the child’s major problems in the daily activities, mostly related to their academic difficulties. Then, therapists will assess the related performance components of the problems. For detail of the assessments done to the children, please refer to Appendix 1. The treatment programs given will either be in individual or group format or both. Parent involvement is very important throughout the treatment.

Common Treatment Intervention Perceptual Motor Intervention Perceptual motor (PM) programs require the child to perform specific tasks so as to increase perceptual motor skills necessary for optimize functioning (Parush & Hahn-Markowitz, 1997; Sellers, 1995). It aims to ameliorate the process that results in learning deficits by treating the underlying component deficits (Schaffer et al., 1989). Occupational therapists would manipulate and structure the environment by a sequence of activities with specific task instruction in the way that to elicit positive visual perceptual response from the child. Different from general educational program used in school, PM program put more emphasis on skills teaching. Therapists would direct the child to do the tasks, starting from simple tasks and move on to more complex tasks (Kephart, 1971; Platzer, 1976). The approach also believes that repetitive practice would help the child to master skills (DeGangi et al, 1993; Seller, 1995). Home program is suggested to encourage child to practice their skills at home. Besides, parents were encouraged to participate in the program, and the therapist assisted them to identify and understand their children’s difficulties. Perceptual motor training can be provided in group session or individual session. The activities that are commonly employed in PM programs include fine and gross motor tasks, visual-motor tasks, visual perceptual tasks, eye-hand coordination tasks and visual perceptual tasks. Examples of therapeutic activities that can be used are putty games, sponge stamp art, drawing maze, etc. Sensory Integration Intervention Sensory Integration treatment for children with SLD using a SI frame of reference initially focuses on facilitating improvement in the functional support capabilities (FSCs) (Cermak & Larkin, 2002). Deficits in functional support capabilities are viewed as key components contributing to poor praxis (Ayres, 1985). And poor praxis is one of the weakness area found in children with SLD. The functional support capabilities are mainly physical capabilities that underlie and support praxis and other abilities. They help integrating the two distinct types of sensory systems input, alert/arousal, and discrimination, through providing avenues for modulation of alert. Arousal input and avenues 12

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

for interpretation of discriminative input. Treatment is aimed at underlying deficits rather than specific behavior or skill development. The purpose of using a sensory integration approach is to build a repertoire of motor responses based on good or improved functioning of the functional support capabilities, which support the child’s improvement in the process of motor planning (versus a particular motor skill). Sensory integration relies on the building of motor patterns by using multiple contexts, and changes in the surface characteristics of the task. For example, an activity that includes challenges to proprioception and balance would help improve functioning in those areas as well as increase muscle tone and cocontraction, all in preparation for an activity demanding more difficult motor planning. Hopping ball is one of the activities that provide proprioceptive stimulation along with a variety of balancing challenges. This activity can be incorporated with different kinds of tossing activities and obstacles. Functional support capabilities are also incorporated into therapeutic activities aimed specifically at improving praxis. The child with tactile discrimination problem may lead to poor fine motor coordination (for writing, cutting, eating, fastening clothing, etc.). The child cannot locate where his body is being touched. His/her performance is much like someone trying to pick up and put together tiny nuts and bolts while wearing gloves. The muscles and nerves are working adequately, but the sensations do not accurately direct the brain to carry out the necessary fine motor control. Thus, when attempting a task, the child’s movements may be awkward. A child with inadequate kinesthesia and proprioception awareness may lead to handwriting problems such as applying excessive pressure in writing, poor pencil control, etc. Activities that include challenges to tactile, kinesthesia and proprioception senses may improve the child’s fine motor skills and handwriting. For example, Feeley-Meeley is one of the commonly used activities that can improve child’s stereognosis. In addition, activities related to the kinesthetic abilities such as balancing on swing, scooter board, etc. All this adds multiple sensory systems and the opportunity to increase integration of those senses (SI), with adaptive responses resulting in increased support for accomplishing praxis. The types, intensity, frequency, and duration of sensory input are carefully evaluated and modified to achieve an optimal level of arousal. Functional Skills Training in Reading and Writing Reading Reading is one of the major deficits of children with SLD. It highly affects the child’s learning from books and other written references. Learning to read Chinese characters involved three basic skills included phonological process, orthographic process and semantic process. Reading training will therefore be focused on learning radicals, stroke patterns, characters with same phonetic meaning and Chinese word structure. For more advanced reading skill, learning of word types such as noun, verbal and adjectives; reading comprehension; identify key words in sentence; the understanding of what, why, when, who, where, whose and how questions would be stressed. These skills would help children with SLD to deal with functional problems in doing homework. It facilitated their understanding and reading of key words in questions. Children also learnt the techniques to search and give relevant information to questions. It increased the association between 13

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

the phonetics, orthographic and semantic meaning of a character and hence decreased the confusion for characters of similar characteristics. The child would have increased accuracy in both dictation and reading of the characters. Throughout the training process, in order to increase the child’s basic sensory and motor performance, occupational therapists will adopt multi-sensory teaching techniques: the use of tactile, visual, auditory and proprioceptive input while teaching. In addition, the children with SLD usually have poor motivation to learn owing the past failure experience, reinforcement program should also incorporated in order to improve child’s motivation, attention and compliance of the training program. Parent training is also essential as part of the program. Parent will be invited to practice the learnt skill with child at home. The content of parent training may include general guidelines on -

the choice of time for reading practice; coaching techniques in reading such as paired reading and

-

handling child’s misreads.

Handwriting Handwriting is a complex skill encompassing visual motor co-ordination, cognitive, perceptual skills as well as tactile and kinesthetic sensitivities (Maeland, 1992). Handwriting problems in SLD children are often the contribution of more than one of these components. As a starting point, occupational therapists will deal with these core component skills first. Sensorimotor and perceptual skills are the two major focused areas. These include postural control, shoulder stability, ulnar stability, power and pinch strength, in-hand manipulation and dexterity, bilateral integration, oculomotor control, kinesthetic and proprioception awareness, visual discrimination, position in space, spatial relationship, visual memory, form constancy etc.. Throughout the training, biomechanical, perceptual motor and sensory integration activities are incorporated. Generalization of these core skills in functional handwriting is the key of efficient writing. Treatment plan will follow the developmental sequence of children. Skills like pencil grip and pencil control, pressure of stroke are addressed through multisensory feedback and perceptual motor activities. Sometimes assistive writing grip will be used to facilitate a functional pencil grip. Besides the mechanical aspect, writing also involves stroke control, stroke and form identification. As mentioned in last session, Chinese characters are a combination of different strokes and radicals, putting together in a specific spatial alignment. So learning of component strokes and radicals is the pre-requisite of writing. Next is the general rule of spatial alignment in Chinese characters. Visual scanning training and strategies are also included in training program. These training will facilitate Chinese characters identification as well as writing legibility, which in turn enhancing accuracy and speed. Environmental modification is another strategy that occupational therapist usually employs in handwriting treatment. Examples are ergonomic factors of chair, table with reference to the body position and use of slope table. Besides, human environment modifications such as adjustment of school demand like homework load and examination time should be made. Liaison with school and parents are crucial for the successful integration in daily living. 14

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Focus of Occupational Therapy Intervention at Different Stages of Development Individuals with SLD may need occupational therapy treatment in different age range ever since they start to learn reading and writing. Thus, specific focuses of these individuals who receive treatment at preschool age, school age and adolescence stage will be discussed below. Focus of Occupational Therapy Intervention at Preschool Children Preschool children with Specific Learning Disabilities (SLD) Children with SLD are those who exhibit difficulties in managing skills and purposive movement in the absence of abnormal intelligence, limited physical strength and gross sensory deficits using the standards and conventional neurological assessment (Gubbay, 1975; Aryes, 1979). It is a heterogeneous group although all of them show some degree of inability in performing skilled or complicated motor tasks. Very often, parents would detect their problems rather early. For examples, they might have found their children poor in hand dexterity or handwriting skills, poorly manage simple self-care tasks like buttoning, fall frequently and so forth. General characteristics of the group include poor tactile perception abilities, poor body scheme, poor gross and fine motor skills, poor coordination, difficulties in transferring skills in daily tasks; and articulation deficits (Ayres, 1979; Williams, 1983). These problems clearly create lots of distress in the children, and are associated with a high incidence of learning difficulties, school failure and psychological problems. These problems would become a major barrier as they progress to increasing academic demands. Assessment for the Pre-school children with SLD A comprehensive and thorough assessment is required to measure the different abilities level of these children (Appendix I). Using various measurements to assess these children, researchers found that these children present different patterns of strengths and weakness in terms of their abilities level (Hartlag & Telzrow, 1983; Fletcher, 1985). O’Brien, Cermak and Murray (1988) indicated that degree of clumsiness was significantly correlated with the degree of visual perceptual, visual-motor deficits, but clinical manifestations of these deficits could vary greatly among individuals. For pre-schoolers, assessment will focus more on their hand strength, eye-hand coordination and in-hand manipulation in managing simple task/play, how they get use of the simple hand tools such as chopsticks management and scissors manipulation; and their visual perceptual skills. Assessment should be conducted in relation to their age-level. Intervention for the Preschool children with SLD To design the treatment program to preschool children with SLD, various approaches have been adopted by occupational therapists. The common goal is to reduce the degree of dysfunction and to promote/ maximize the preserved skills. Both group and individual sessions can be held. Parents’ participation is also necessary for the effectiveness of the program. The focus of intervention based on the major treatment approaches are listed as follow: Perceptual motor training: Aims to remediate the underlying components of perceptual motor dysfunction which results in 15

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

-

learning deficits e.g. Eye-hand coordination training, in-hand manipulation training, pre-writing skill training,

visual perceptual training Sensory integration therapy: -

Focus on all senses, i.e. vestibular, tactile, proprioceptive, auditory, visual and olfactory. Aims to build a repertoire of motor responses which support the child’s improvement in the process of motor planning. Functional skills training of preschool children includes teaching the specific hand function

skills such as buttoning, use of knife and fork, use of scissors, shoe-lacing, etc. and also assess and train their writing skills or pre-writing skills required at nurseries or kindergartens. In general, preschool children referred are over 4 years old in which the children have started pre-writing or writing activities in their nurseries/kindergartens. Their attention is relatively short and the fine motor skills are not well developed. Thus, activities assigned will be shorter in duration and fun-based so as to minimize their negative feelings towards writing. Focus of Occupational Therapy Intervention at School Aged Children School-aged Children with SLD During school age, where children experienced loads of academic demands with new Chinese and English vocabularies, children with SLD experience many academic difficulties in all the major subjects. With frustration and frequent failures, some might have emotional, social and family conflicts (Silver, 1989). Assessment for School-aged Children with SLD Assessment for school-aged children with SLD emphasis on functional skills in writing, reading and the related core problems in visual perceptual and motor performance of the children (Appendix I). Intervention for School-aged Children with SLD Similar to the intervention for children at pre-school age, the major approaches adopted are perceptual motor, sensory integration and biomechanical approach. The goals are to promote/maximize the preserved skills and reduce the degree of dysfunction. Early intervention and detection is crucial as the common and major vocabularies are introduced in the first two years in the primary school. Both group and individual sessions can be given to the children. Parents’ participation is essential so as to ensure the effectiveness of the home programs and increase their understanding towards the children’s difficulties. Close liaison with the school teachers is also important as the children may need environmental adaptations to cope with the school work. These include cutting of demand in homework and extension of examination time for these children.

16

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

The major elements in implementation of the treatment programs under different approaches are as follows: Perceptual Motor Approach Use individualized treatment program in a structured and graded way to remedy -

perceptual-motor deficits e.g. fine motor skills training, visual perceptual training and functional skills training such as

reading, writing Sensory Integration Therapy -

Use multi-sensory approach such as visual, auditory, tactile, kinesthetic or vestibular modes to reinforce learning and facilitate the process of motor planning

Biomechanical Approach Apply this approach on muscle strengthening for motor learning and processing, and compensate deficits on functional tasks such as writing. Functional skills training for the school age children, in addition to those in pre-school age, will involve more coping skills training in dealing with the academic work at school and at home. These may include strategies in packing school bags, planning homework schedule and general organization in work at home and at school. Sometimes, compensatory approach is needed where occupational therapists will advice the teachers in the amount of homework assigned and the need in lengthening the examination time for the children. As the children often comorbid with ADHD and other emotional problems, treatment provided will also emphasize the application of behavioral principles to increase motivation and facilitate learning especially on academic skills and deficits area. Focus of Occupational Therapy Intervention at Adolescence Adolescents with Specific Learning Disabilities (SLD) As experiencing a normal development, adolescents can master and integrate their neuron-developmental function (namely, physical or somatic growth, neurological, motor (gross and fine), visual, cognitive, auditory, language, kinaesthetic, psychosocial, perceptual-motor, integrative and adaptive) maturely. If deficits in one or all of these neuro-developmental domains are found, clients may have attention, cognitive and learning problems. Such problems will become more severe when they reach the adolescence stage and enter an educational setting where the environmental demands of social interactions and academic performance become more complex. They will experience serious impairment in function in one or more of the following areas: mathematical reasoning or calculation, expressive (written or oral) or receptive language (listening and comprehension), basic reading skills or comprehension, sustained attention, and goal directed behavior. Problems in attention can affect eye-tracking ability and thus impact their reading ability (Pratt, 2002). Therefore, it is important to have intervention for the clients with SLD.

17

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Assessment for the Adolescents with SLD Comprehensive assessment should be done and recorded (App.1) in order to provide important clues to designing effective treatment intervention. Additional screening and assessment may be necessary to assess the clients’ self esteem and problem solving abilities since they have been exposed to the SLD dysfunctions for a prolonged period. Intervention for the Adolescents with SLD The treatment goal for the adolescents with SLD is minimizing disability and maximizing potential. Both individual and group treatment sessions can be held. Home program will be provided as well. As it is mentioned before, SLD is a life long problem to the clients from childhood to adulthood. Their learning skills may reach a plateau in the adolescent stage. As a result, their ability may not able to meet the demand of a complex society. Their self-esteem and self confidence may be affected. In order to maximize their residual ability and prepare for the social and vocational life in future, the intervention for the adolescents with SLD should not only be focused on special teaching technique, skill training, but also emphasized more on the compensatory technique. Furthermore, the intervention on psychosocial aspect of the clients e.g. social skill, life goal / expectation adjustment, self-confidence development etc. will be addressed to as well. The following recommendations are listed as reference: 1. Skills training: -

Fine-motor training, transfer of skill training, problem solving skill training can be provided to adolescents with writing, mathematics problems.

2. Adaptive / compensatory intervention: Extend exam time limit, use type writers / computers to lessen the stress caused by fine motor -

deficits Use aids like ruler or bookmark as a place holder to focus attention

3. Advice parents/teachers in the teaching techniques to the adolescents: Teach concepts or comprehension skills through direct instruction -

Provide specific intensive courses / tutors in reading, arithmetic and writing etc. Improve memory skills by teaching through repetition, cue cards etc.

-

Tape recording of lectures to allow slow learners to have repeated revises on the lectures Goal / expectation adjustment to both the client and parents if necessary

4. Evaluation on the need for pre-vocational skill development by vocational assessments and vocational exploration assessments. Advices on the vocational choice or areas for further studies can also be given 5. Self-confidence, motivation and self-esteem establishment through the successful experience gain from the treatment session

18

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

CHAPTER FOUR GLOSSARY OF TERMINOLOGIES Area

Terminology

Definition

Visual Perception Visual attention Alertness Selective attention

It is reflective of the child’s natural state of arousal It is the ability to choose relevant information while ignoring the less relevant information

Visual vigilance

It is the conscious mental effort to concentrate and persist at a visual task

Shared attention

It is the ability to respond to two or more simultaneous tasks

Visual memory Short term memory

It is the location necessary for newly acquired data perceived from the environment. The information gathered by visual short-term memory disappears if it is not processed further

Long term memory

Visual memories that endures for days and years

19

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Area

Terminology

Visual Object/form Discrimination perception

Definition Object/form recognition

It is the ability to identify the object by its features

Object/form matching

It is the ability to note the similarities among specific objects

Form

It is the recognition of forms and objects as the

constancy

same in various environment, position and sizes

Figure ground It is the differentiation between foreground and background forms and objects. It is the ability to separate essential important data from distracting surrounding information Visual closure It is the identification of forms or objects from incomplete presentations. Spatial

Spatial

It is the ability to understand how to place one

perception

concept

object in relation to another. For example: in, on, under, out of, together, away from, up top, apart, toward, around, in front of, high, in back of, next to, beside, bottom, backward, forward, down, low, behind, ahead of, first, last, etc.

Directionality

Spatial

It is the ability to determines the position of

relation

objects relative to each other, the ability to determine the direction of forms It refers to the way print is tracked during reading and lay down during writing

20

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Area

Terminology

Definition

Sensory Motor Sensory

Tactile

Tactile input is received through tactile receptors that are found throughout the skin and, are activated by externally applied stimuli such as touch, pressure, pain, and temperature

Vestibular

Along with the visual and proprioceptive system, it is responsible for detecting changes in the direction and rate of rotary head movements, linear head movement and head tilt

Proprioceptive/Kinesthesia

Those receptor mechanisms, most noticeably in the joints, muscles, and tendons, that signal information about the posture and movements of the body as a whole. It referred to the awareness of where the body parts are in space and the position, force and extent of their movement that arise from information from the muscles, joints, and skin. It promotes awareness of extent, weight, timing, force and direction of movements

Motor Planning/Praxis

It is the process of organizing a plan for action.

It

involved the choosing of starting point, the direction, the speed, and the exact time to change direction, and the place to terminate the movement

21

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Area

Terminology

Definition

Motor

Postural motor Joint stability It refers to the contraction of muscles around a joint control to hold it steady. It includes balance reactions; trunk control against gravity; shoulder cocontraction and joint stability; arm and hand strength; and the ability to isolate movement of the arm from the shoulder and the trunk Muscle strength

It is essential for the development of the development of well-formed hand arches, which in turn are important for efficient pencil grips

Muscle tone Fine motor skills

It is the resistance of a muscle in passive elongation or stretching

In-hand It is defined as an adjustment of an object in hand manipulation after grasp Eye-hand It is the development of highly refined fine motor coordination skills. Its development is based on the integration of sensorimotor control mechanism that can locate the hand and object in visual space and bring them together Bilateral hand It involves a sequence of bimanual movements in coordination which the child simultaneously controls arm and hand stabilization and movement. These movements can be asymmetric and dissociated when performing the task with both hands

Sequence and timing

Reaction and Reaction time analyzes important information movement about the speed and accuracy of sensory time

information processing, the translation of that processing into a plan of action and the initiation of an overt response. Movement time is a measure of the speed of movement execution and can be viewed as an indirect indicator of the efficiency of motor system function

22

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

APPENDIX I OCCUPATIONAL THERAPY DEPARMENT Occupational Therapy Assessment Report Date of Assessment : Date of Report :

Gum Label

I.

History

Birth/Medical History (only applicable for cases with history with very low birth weight) Gestation Period :

Weeks

Mode of Delivery: • NSD Birth Weight :

• CS kg

• Vacuum

• Others________

Complications : Social History Family Background: Major care taker

Time spent with child on homework________

Siblings: EB/ES/YB/YS

EB/ES/YB/YS

EB/ES/YB/YS

EB/ES/YB/YS

Age:

Age:

Age:

Age:

Education level:

Education level:

Education level:

Education level:

Academic performance: Academic performance: Academic performance: Academic performance:

Parent’s concern and attitude: Major complaints and concern

Expectation

Current strategies in handling

23

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Schooling: School name Grade Hx of repeat Academic performance (performance in Chinese, English & other major subjects)

Peer relationship

Special Service • At school

• At Special Education

• Educational Manpower

• Other rehabilitation

Dept

Bureau

services

II. General Behaviour

III. Clinical Observation Postural Stability Muscle tone:

Sitting tolerance:

Fine Motor Skills Hand dominance: Power grip: (unit ___)

R

L

Pinch grip:

R

L

(unit ___)

_______

24

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Tripod grip: (unit ___)

R

L

Dexterity/in-hand manipulation:

Bilateral coordination:

Copying and writing skills Pencil grip: Pencil control: (Tension on pencil, pressure on paper, pencil manipulation)

Legibility: Accuracy: Stroke Sequence: Speed:

Self Care

25

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

IV. Assessment Results** Movement Assessment Battery for Children (Movement ABC) Motor Score

Percentile(HK/US norm)*

Manual Dexterity Ball Skills Static and Dynamic Balance Total Impairment Score

* Remarks : < 5 percentile = severe; 5-15 percentile = borderline; > 15 percentile = no problem

**Select specific assessments where appropriate

26

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Brunininks-Oseretsky Test of Motor Proficiency (BO Test) Gross Motor Composite Subtest

Standard score (mean = 15, S.D. =5)

1.Running Speed and Agility 2.Balance 3.Bilateral Coordination 4.Strength Gross motor composite

Standard score

Percentile

(subtest 1-4)

(mean = 50, S.D. = 10)

(US norm)

Fine Motor Composite Subtest

Standard score (mean = 15, S.D. =5)

5.Upper limb coordination 6.Response speed 7.Visual motor control 8.Upper-limb and dexterity Fine motor composite

Standard score

Percentile

(subtest 6-8)

(mean = 50, S.D. = 10)

(US norm)

Standard score

Percentile

Complete Battery Subtest

(US norm)

Upper limb coordination Gross motor composite

(mean =15; S.D. = 10)

Fine motor composite Battery composite

(mean= 50; S.D. = 10)

(mean= 50; S.D. = 10)

(mean= 50; S.D. = 10)

27

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Peabody Developmental Motor Scales Development Motor Gross motor subtest

(mean =100; S.D. =15)

Quotient Mean

S.D.

Mean

S.D.

Skill A : Reflex Skill B : Balance Skill C : Non-locomotor Skill D : Locomotor Skill E : Receipt & propulsion Total score Age equivalent

Fine motor subtest Skill A : Grasping Skill B : Hand use Skill C : Eye-hand coordination Skill D : Manual dexterity Total score Age equivalent

Remarks: <-1.5 SD= sever deficit; -1 to –1.5 S.D. = moderate deficit; >-1 S.D. = no deficit

28

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Developmental Test of Visual-Motor Integration (VMI) Percentile

Age equivalent (US/HK norm)

Visual motor integration Visual perception Motor coordination

Developmental Test of Visual Perception II (DTVPII) Subtest

Percentile (mean = 10; S.D. =3)

1.Eye-hand coordination 2.Position in space 3.Copying 4.Figure-ground 5.Spatial relations 6.Visual closure 7.Visual-motor speed 8.Form constancy Composite

Quotients (mean = 100, S.D. =15)

General visual perception Motor-reduced visual perception Visual motor integration

29

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Test of Visual Perceptual Skills (TVPS) Subtest

Percentile Rank

Visual discrimination Visual memory Visual-spatial relations Visual form constancy Visual sequential memory Visual figure-ground Visual closure Median Perceptual Age Percentile Rank Tseng’s Chinese Handwriting Speed Test Word per minute Mean

S.D.

Legibility Error Sensory Integrative Function Sensory Modulation: Sensory Processing Tactile

Vestibulo-proprioceptive

Motor planning

30

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

V.

Interpretation of Result

VI.

Conclusion & Recommendation

Occupational Therapist

31

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Key References: American Psychiatric Association .(1994). Diagnostic Criteria from DSM-IV. Washington, DC: American Psychiatric Association. Amundson, S.J. & Weil, M. (1996). Prewriting and handwriting skills. In J. Case-Smith, A. Allen and P. Pratt (Ed.), Occupational Therapy for Children. Chicago: Mosey. Axelrod, L. (1982). Social perception in learning disabled adolescents. Journal of Learning Disabilities, 15, 610-613. Bundy, A.C., Lane, S.J., & Murray, E.A. (2002). Sensory integration: Theory and practice. (2nd ed.). Philadelphia: F.A. Davis. Canadian Association of Occupational Therapists. (1997). Enabling Occupation: An Occupational Therapy Perspective. Ottawa: CAOT Publications ACE. Cantell, M., Smyth, M., & Ahonen, T. (1994). Clumsiness in adolescence: Educational, motor, and social outcomes of motor delay detected at 5 years. Adapted Physical Activity Quarterly, 11, 115-129. Case-Smith, J. (1995). The relationships among sensorimotor components, fine motor skill, and functional performance in preschool children. American Journal of Occupational Therapy, 49, 645-652. Cermak, S.A., & Aberson, J.R. (1997). Social skills in children with learning disabilities. Occupational Therapy in Mental Health, 13(4): 1-24 Cermak, S.A., & Larkin, D. (2002). Developmental coordination disorder. Albany: Delmar Thomas Learning. Chow, S. M. K (1999). What do we know about Developmental Coordination Disorder? The Hong Kong Society of Child Neurology and Developmental Paediatrics Specific Learning Disabilities, Position Statement and Papers. Hong Kong: The Hong Kong Society of Child Neurology and Developmental Paediatrics Chu, S. (1999). Assessment and treatment of children with handwriting difficulties. In Barchers, S. (1994). Teaching language arts: an integrated approach. Minneapolis: West Publishing. Feldman, L.B. and Siok, W.W.T. (1997). The Role of Component Function in Visual Recognition of Chinese Characters. Journal of Experimental Psychology, 23, 3, 776-781. 32

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Frostig, M. (1973). Frostig program for the Development of Visual Perception: Teacher’s Guide. Chicago: Follett Henderson, A. & Pehoski, C. (1995). Hand Function in the Child. Foundations for remediation. St. Louis, Missouri: Mosby-Year. Hong, C.S. (1984). Occupational Therapy for children with perceptual motor disorder. A Literature Review. British Journal of Occupational Therapy, 47, 39-42 Lam, C. C. C. (1999). Current Practice in Specific Learning Disabilities in Hong Kong: Developmental Paediatrics Perspective. The Hong Kong Society of Child Neurology and Developmental Paediatrics Specific Learning Disabilities, Position Statement and Papers. Hong Kong: The Hong Kong Society of Child Neurology and Developmental Paediatrics Leong, C. K. (1999). Psychological and Educational Aspects of Cantonese-Speaking Children in Hong Kong with Developmental Dyslexia. The Hong Kong Society of Child Neurology and Developmental Paediatrics Specific Learning Disabilities, Position Statement and Papers. Hong Kong: The Hong Kong Society of Child Neurology and Developmental Paediatrics Mandich, A.D., Polatajko, H.J., Macnab, J.J., & Miller, L.T. (2001). Treatment of children with developmental coordination disorder: What is the evidence? Physical & Occupational Therapy in Pediatrics, 20, 2-3, 51-68. McBride-Chang, C. & Chang, L. Memory, Print Exposure, and Metacognition: Components of Reading in Chinese Children. International Journal of Psychology, 30, 5, 607-616. Paillard (1990). Basic neurophysiological structures of eye-hand coordination. In C. Bard, m. Fleury, & L. Hays (Eds.), Development of eye-hand coordination (p.26-74). Columbia, SC: University of South Carolina Press. Scientific Committee of the Working Party on SLD (1999). Definition of Specific Learning Disabilities: Position Statement. The Hong Kong Society of Child Neurology and Developmental Paediatrics Specific Learning Disabilities, Position Statement and Papers. Hong Kong: The Hong Kong Society of Child Neurology and Developmental Paediatrics Tseng, M. H. & Cermak, S. A. (1993). The Influence of Ergonomic Factors and Perceptual-Motor Abilities on Handwriting Performance. American Journal of Occupational Therapy, 47, 10, 919-926. 33

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Vargas, S., & Camilli, G. (1999). A meta-analysis of research on sensory integration treatment. American Journal of Occupational Therapy, 53, 2, 189-198. World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: World Health Organization.

34