PAEDIATRIC

OCCUPATIONAL
THERAPY
MADE A BIT EASIER

By Paula Barnard
I would like to extend thanks to:
 Betsy Coville for her time, expertise and contributions to the
generation of the booklet.
 Adoreé Louw for contributing to the booklet.
 The staff of the Occupational Therapy Department of the University
of the Witwatersrand for supporting and contributing to the
booklet.
 VONA Du TOIT’s MODEL OF CREATIVE ABILITY APPLIED TO PAEDIATRICS

MOTIV- ACTION KEY COMPONENTS

ATION LEVEL
LEVEL
 Birth to ± 5 months
destruct
 Movements are irregular and uncoordinated
 Survival responses for needs to be met by the care giver
Tone

Pre-

 Dependent on care giver

-ive

 ± 5 months to ± 9 months
differentiatio

 Sensory experiences are the primary activity focus (feeling, rubbing, chewing, biting,
Destructive

tasting, looking).
 Child throws, tears, and pulls at objects.
 Starts to recognise parents, smile responses. Communication is mostly receptive.
Self

 10 months to ± 2 years old

 Aware of self as an entity (separate from mother and environment)
differentiation

 Interaction is short-lived (1 step) & outcomes are unplanned and immediate

 Objects are manipulated more (holding, placing or rubbing) but no tool handling or
Incidental

skill
 Repetitive movements
 Communication is limited. Responds to “known” people. Limited expressive
Self

vocabulary, one word sentences

 ± 2 years to ± 5 years old
 Starts to control interaction with environment
 Materials are explored to determine its properties
Self presentation

 Products still largely unplanned but with step-by–step approach 4 – 5 step product
can be successfully made. No norms of quality / speed
 Develop a task concept and tool manipulation is explored and tested
Explorative

 Development of basic concepts occurs

 Explores social boundaries. Seeks approval from others. Communication now two-
way but more for the child’s benefit (egocentric). Does not fully understand
situations, and oblivious to the subtleties of body language and innuendo
 Fantasy play and role-modelling is enjoyed
 School going child (pre and primary)
 Interaction is product centred with a consolidated task concept but external
Passive participation

motivation / stimulation still required. Step or sequence prompting occasionally

required.
 Tool handling more product centred and practice leads to some levels of skill
 Product evaluation is a need of the child, but negative evaluation is not well
Experimental

accepted.
 Active learning, but not self-directed. Do not like to participate in unfamiliar
situations. More comfortable in familiar situations and sequences previously
experienced. Practice.
 Relationships are less dependant and more self maintained. Development of peer
acceptance and norming is a focus, but selected peer groups may vary frequently
 Early Adolescent
 Task participation is product centred and self fulfilment orientated, but initiative still
limited.
participation

 Experienced at a variety of tool and material handling.

 Works well from a model and evaluation of performance becomes comparative
Imitative

Imitative

instead of quality centred.

 Socially conforming. Tries to imitate (be identical) the peer group in all spheres of
life. Susceptible to peer pressure
 Behaviour is acceptable / appropriate to most situations

2
3
 SENSORY INPUT

Sensory input is the information that the brain receives about the environment through the
senses. It marks the beginning of the sensory-perceptual-cognitive-performance (S-P-C-P) process.
The brain is continually bombarded with this information, but chooses to discard the irrelevant
information (sounds of birds outside) and focus on the relevant information (the voice of the
person speaking to the child). The brain processes and perceives this information by relating it to
previous experiences. A motor output is generated in response to the processing phase (child
replies verbally to the question). The S-P-C-P process allows for development and learning to
occur, through feedback of the outcomes as sensory input. This is significant in treatment as the
occupational therapist exposes the child to sensory input in order to initiate the S-P-C-P process.
The OT then guides the process in order to achieve the desired response or outcome. This allows
for appropriate sensory feedback and thus improved outcomes in future.

Cognitive Processing

Sensory Processing & Motor Output

Input Perception

Sensory Feedback

There are seven senses that the OT can make use of to initiate the S-P-C-P process. They are
proprioception, vestibular sensation, vision, hearing, touch, taste, and smell. Taste and smell are
however very seldom incorporated and will thus not be discussed in this text.

VESTIBULAR STIMULATION
Definition: Vestibular stimulation is a specialised “proprioceptive” sensory input received by the
semicircular canals, utricle and saccule of the vestibular apparatus. This stimulation sends
information to the brain regarding the position (utricle and saccule) of the head relative to the
environment and rate of movement (semicircular canals) of the head over the earth’s surface. The
brain integrates sensory information from the vestibular system and the proprioceptive, tactile
and visual systems in order to create an image of the body relative to the environment (body
scheme). A child swinging on a swing will receive the vestibular input of the back and forth motion
of swinging and from the fact that the child is sitting upright (head vertical). Proprioceptive input
is gained from the movements of the legs to maintain the motion, from the arms and hands
pulling against the ropes of the swing, and the neck and trunk as it accommodates to the
movements.
Vestibular stimulation is a primary stimulus for the development and maintenance of postural
tone. Linear stimulation (utricle and saccule) results in tonic contraction of the postural muscles
and via integration with the visual and proprioceptive systems generates normal equilibrium.
Angular acceleration (semicircular canals) results in phasic contraction of the postural muscles
and via integration with the visual and proprioceptive system generates normal protective
extension.
The vestibular system has marked effects on a child’s levels of arousal. Linear stimulation has an
inhibitory influence on arousal and angular acceleration has an excitatory influence on arousal. Be
very careful of using vestibular input during treatment unless you are trained to detect
the effects that the stimulation is having on the arousal system!!

Methods of stimulation:
Linear:
 Changes of head position. Many children spend the majority of their waking hours with the
head vertical. Other positions are prone, supine, laterally to the left or right, and inverted.
Inversion is a strong driver for extensor muscle tone. Be cautious of maintaining an
inverted position for longer than 1 minute.

4
 Continuous or rhythmical movement. Swinging back and forth slowly on a hammock. Being
pulled around a room on a scooter board.
Angular:
 Acceleration and deceleration of movement. Starting and stopping a movement. Going down a
ramp on a scooter board (starting) and crashing into a wall of foam blocks (stopping).
 Irregular movements. Funfair rides.
 Rotary movements. Spinning on a merry-go-round, doing summersaults, rolling sideways down
a hill.

PROPRIOCEPTION
Definition: Proprioception is sensory input received by the receptors in the joints, and muscle
tendons and mechanoreceptors of the skin. These receptors detect changes in the position of the
limbs, trunk, and neck through compression or stretch (traction). The information is sent to the
brain so that there is constant re-adjustment of the brains mental picture of the body, allowing for
stimulation of appropriate postural muscle tone for maintenance of the new positions. This further
allows the development of body scheme, which acts as the starting reference point for all
movements. Proprioceptive input has a normalising influence on hypotonic muscles.
Proprioception assists in the cognitive process of judging the rate and force of a movement, in
order to ensure the successful outcome of the action.

Methods of stimulation:
 Any heavy work applies traction or compression of the joints, tendons and skin resulting in
proprioceptive input. (e.g. Carrying heavy objects, pushing a loaded wheelbarrow, catching a
heavy ball)
 Weight-bearing positions allows for joint compression (e.g. wheelbarrow walking, crawling,
handstands).
 Joint traction through holding up the body weight as in hanging (e.g. swinging on monkey bars,
climbing a rope ladder)
 Adaptation to changes of the surface density that the child is moving over (e.g. crawling over
mats of varied thickness and softness. Jumping on the trampoline to jumping on the floor)
 MOVEMENT!! All purposeful movement where there is control of the rate and force of the
movement.

TACTILE STIMULATION
Definition: Tactile stimulation is the sensory input received by the receptors in the skin. This
information is received by the post-central gyrus and interpreted through reference to prior
knowledge and integration with information received by the other senses. You feel a spider crawl
over your arm, and even before looking at it you flick it off. Tactile stimulation may be light touch,
deep pressure, changes in temperature, a level of pain or discriminatory in nature.

VISUAL STIMULATION
Definition: Visual stimulation is the sensory input received by the retina of the eye. This
information is received by the occipital lobe and interpreted through reference to prior knowledge
and integration with information received by the other senses. You see a dog (know this from
seeing dogs before) opening and closing it’s mouth, and hear the barking sound, which confirms
to your brain that the dog is barking. The stimuli may be static or moving, of high contrast in
colour, or low contrast (blending), and of differing size. These factors will influence the child’s
interpretation of the stimulus.

AUDITORY STIMULATION
Definition: Auditory stimulation is the sensory input received by the cochlea of the inner ear. This
information is received by the temporal lobe and interpreted through reference to prior knowledge
and integration with information received by the other senses. You hear the sound of thunder
(prior knowledge tells you it is not a gun shot) and you look out the window and see the large
clouds and the start of rainfall, confirming that it was in fact the sound of thunder. The stimuli
may be of various tones, pitches and differing loudness or softness.

SENSORY PROCESSING & PERCEPTION

5
POSTURAL TONE
Definition: Postural tone is the level of tone in the musculature that supports posture. It allows for
the natural maintenance of anti gravity positions, and is thus mostly of extensor muscles. Postural
tone plays a significant role in equilibrium and protective extension, and is largely stimulated but
the vestibular and proprioceptive systems.

Development: New-born babies have low postural tone. This is normal and expected of all new-
borns. Their posture is flexed and dependent on the direction of gravity, thus needing full support
from the environment. By being placed in various positions and moved around by the parent, the
baby’s vestibular system is exposed to a variety of stimuli due to the change in the direction of
gravity, and movement of the head. Postural tone develops cephalo-caudally from the attainment
of neck control through to dynamic standing balance. A child’s postural tone is usually fully
developed by 3 ½ years old. Postural tone relies on the integration of the tonic labyrinthine reflex
and on the appearance of the midbrain reactions (both vestibular and proprioceptive input has
significant importance during this developmental phase).

Implications of dysfunction:
 Low postural tone results in early fatigue. The child thus may respond by reducing their active
participation in the environment. A cyclical effect is then generated as the passive child is not
stimulating the vestibular or proprioceptive systems and is thus not generating postural tone.
 The opposite may also occur. As the child’s body naturally seeks vestibular / proprioceptive
input in order to generate more postural tone, the child may present as over active, but with
the movements lacking goal direction or meaning. These movements are often repetitive
(bouncing, swaying or rocking). The child may be considered hyperactive.
 Postural alignment is often poor. In standing the child may lock the knees to gain stability. The
pelvis may tilt anteriorly leading to hyperextension of the trunk and chin protrusion. In sitting
the pelvis may be posteriorly tilted leading to thoracic kyphosis.
 Low postural tone often occurs in conjunction with delayed integration of the brainstem
reflexes. This in turn influences the emergence of the midbrain reactions. The midbrain
reactions are important for the development of trunk rotation and dissociation (thus  bilateral
integration and midline crossing). The midbrain reactions also facilitate orientation of the head
and body to the environment (eyes level with the horizon). This initiates the development of
equilibrium.
 Poor proximal stability and poor co-contraction are common manifestations resulting in
seeking of distal stability (resting head on hand with the elbow on the table) or the use of
fixation (active muscle contraction) to compensate for the lack of postural stability.
 Hand function is more mass grasp orientated than intrinsic and isolated finger movement
based, thus lacking in-hand manipulation.

Principles of treatment: (Normalise postural tone)

 Use active movements to generate proprioceptive feedback.
 Give proprioceptive inputs through the vertebral column and surrounding musculature
through traction (hanging), and joint approximation (jumping).
 Use effort in heavy work (resisted tasks).
 Change the density of the surfaces thus providing increased proprioceptive feedback.
 Sustained weight shift requires active control of posture, which normalises tone of
postural muscles.
 Slow brushing of the erector spinae muscles to stimulate active contraction of these
muscles.
 Slow linear vestibular input (anterior – posterior) facilitates use of postural mechanisms,
which in turn has a normalizing effect on postural tone.
 Inverted positioning (head below the body). NB do not use with any child who has a
history of Epilepsy or seizures.
 Tasks that require equilibrium and balance demand higher levels of postural stability and
thus activate postural tone.
 Maintain postural alignment.
 Watch for the use of trick postures and fixation.

BRAINSTEM REFLEXES
6
Definition: The Tonic Neck reflexes (ATNR & STNR) and the Tonic Labyrinthine reflex are the
brainstem reflexes that have the most impact on development. See Fiorentino for further defining
and development. Assessed in Clinical Observations.

Implications of dysfunction:
Poor integration of brainstem reflexes causes a child to use mass movement patterns for longer
than developmentally appropriate. This influences motor control and development of skill that
requires selective control of movement.
Poor integration of the ATNR:
 This often impacts on the development of bilateral co-ordination as the ATNR promotes
incidental unilateral hand use. This may then also impact on the development of midline
crossing.
 Head movement during fine motor tasks may influence the tone of the dominant arm, thus
affecting motor control.
Poor integration of the STNR:
 The STNR may not integrate in children who do not crawl as weight bearing on the arms and
hands in the crawling process has marked integrating effects.
 Poor integration may result in poor shoulder girdle stability, possibly through the lack of
muscle strength (as the child has not spent much time in the crawling position) or through
hypotonia of the trunk and arms (ineffective proprioceptive input).
 Head movement during fine motor tasks may influence the tone of the arms, thus affecting
motor control. Especially if the child is copying work off the board thus extending the neck to
look up and flexing to look down.
Poor integration of the Tonic Labyrinthine reflexes:
 The child may have more difficulty with the development of anti-gravity postures. Postural
alignment may be poor. The child may seem gravity bound as they sit slouched in their chair
(the body is moulded into the chair and is fully supported).
 Low postural tone is a common repercussion of poorly integrated Tonic Labyrinthine reflexes.

Principles of treatment: (Integrate brainstem reflexes / Facilitate selective control of movements)

 Promote use of normal movement patterns.
 Remember: Avoiding a reflex does NOT integrate it!
 STNR: Use weight bearing positions with controlled movement over the base of support.
 ATNR: Activities should involve trunk rotation, bilateral integration and crossing of
midline.
 TLR: Facilitate the maintenance of anti gravity postures within the child’s fatigue levels.

BODY SCHEME
Definition: Body scheme is the first component of body awareness to develop. It is the mental
(minds eye) view that a person has of their body. With each movement the mind is able to picture
what the body looks like, and how it is related to the current environment. It is dependent on
tactile, vestibular, proprioceptive and kinaesthetic input, and assists a person interact with the
environment.

Development: Body scheme primarily develops through the first and second year of life. A toddler
is constantly moving and interacting with their physical environment. This allows for maximal
tactile, vestibular, and proprioceptive input. The toddler thus develops a sensory “map” of the
body and how it works. Body concept begins to emerge as body scheme becomes more
established.

Implications of dysfunction:
 The control and accuracy of movements may be influenced as a child has difficulty monitoring
the motor act through reference to his body scheme.
 Praxis relies on body scheme. Poor body scheme may result in a child having difficulty ideating
movements as s/he has to understand their body and know its position in the environment in
order to decide on the next movement.
 Spatial perception is poor in children with immature body scheme as they do not receive
adequate feedback regarding their participation in the physical environment.

7
Principles of treatment: Improve body scheme
 Provide repeated proprioceptive input of all forms.
 Provide deep pressure tactile input to whole body surface to establish the body
boundaries.
 Provide light touch tactile input to whole body surface. (Precaution: be aware of children
who may become over-aroused)
 Provide vestibular input to reinforce the child’s awareness of their physical relationship
to the environment.
 Allow for self-guided exploration of familiar and unfamiliar environments. (Precaution:
Containment of over-active children may be necessary)
 Provide visual and auditory feedback of movements (a wall mirror, therapist reflecting
actions)

PROXIMAL POSTURAL STABILITY AND CO-CONTRACTION

Definition: Proximal postural stability is the ability of the postural muscles to stabilise the
shoulder and hip girdle (through tonic contraction) to allow free use of the hands and feet.
Vestibular and proprioceptive inputs are the primary stimulators of proximal postural stability. Co-
contraction is the simultaneous reciprocal tonic contraction (reciprocal innervation) of the
agonist and antagonist muscles around a joint in order to stabilise the joint (mostly elbow and
wrist) during skilled tasks of the hands. Thus as the agonist muscle releases slightly so the
antagonist increases its tonic contraction.

Development: Proximal postural stability develops from full external support  proximal mobility
on distal stability  distal mobility on proximal stability. This can be seen in that the baby first
gains stability from the surface he is in contact with. He then learns that while the distal parts are
stabilised on a surface the proximal joints can be mobile (rocking back and forth while in four-foot
kneeling). From practising this proximal mobility the child learns that these joints can also be held
still, which allows for freeing of one or more limbs from the stabilising surface for activity
participation (lifting one hand off the floor in four foot kneeling to hold a rattle). This leads to the
development of mobility through proximal stability (crawling can occur as the child can move a
hand or leg forwards by stabilising the shoulders and hips). This occurs in each developmental
position and during transfers from one position to the next. Co-contraction develops after proximal
stability and is activated first through weight bearing, and then resisted movement, finally by free
movement for skill.

Implications of dysfunction:
 The child may use the skeletal system to compensate for stability (e.g. locking the knees into
extension in standing).
 Active fixation of the joints (by tensing the phasic muscles around the joint) is a common
compensatory technique, which may result in increased levels of fatigue.
 The child may rely on distal stability or external support for maintenance of positions, as can
be seen in the child who lies on the desktop during fine motor tasks.
 The child may develop postural insecurity.

Principles of treatment: Improve proximal stability and co-contraction

 Discourage fixation (active muscle contraction) of muscles around the joints for stability.
 Improve muscle strength of the shoulder and pelvic girdles.
 Movements should be free and fluid.
 Provide proprioceptive inputs in the form of joint approximation, joint traction and use of
active weight-bearing positions.
 Tasks that require equilibrium and balance demand higher levels of postural stability
(such as vestibular inputs)
 Use activities that actively demand co-contraction of the specific muscle groups that you
are requiring to enhance. E.g. simultaneous contraction of the shoulder girdle and
extensors of the neck when pulling self up on a rope.

BODY RIGHTING REACTIONS

Definition: Body righting reactions are the midbrain reactions, which are responsible for
orientating and aligning the body and the head to each other. These reactions are stimulated by
8
the proprioceptive system and are protective in nature. Mature body righting reactions result in
the ability to rotate the trunk during motor tasks (dissociation between the shoulder and hip
girdles).

Development: As a baby learns to roll the neck righting reaction allows the body to follow the
movement of the head. This is initially seen as log rolling. As the baby develops with more active
rolling and pivot sitting the body-on-body reactions develop allowing for segmental rolling and
dissociation of the hip and shoulder girdle.

Implications of dysfunction:
 The child tends to move the body as a whole, rather than using trunk rotation. This may lead
to poor equilibrium reactions,  bilateral integration and  midline crossing.

OPTICAL/VESTIBULAR RIGHTING, EQUILIBRIUM REACTIONS & PROTECTIVE EXTENSION

Definition: The optical and vestibular righting reactions are the midbrain reactions which are
responsible for orientating the body in relation to the environment, and often results in vertical
alignment of the head. These reactions do not have weight shift as a component but rather
actively align the body within the position.
Equilibrium reactions may be reactive to the displacement of the surface the person is on or
compensatory to large movements of the person within the base of support (e.g. reaching for an
object). These serve to bring the child’s centre of mass back into the middle of the base of support
if it moves out of the base of support. Equilibrium reactions are characterised by tonic contraction
of the postural extensor muscles of the downhill side of the body for weight shift to that side. The
head maintains its position through trunk rotation.
Protective extension is a normal mechanism for prevention of injury when falling. If the
displacement of the surface was too great to be corrected by equilibrium reactions, then
protective extension takes over and “breaks the fall” by increasing the size of the base of support.

Development: Righting and equilibrium reactions usually develop within the first year and persist
throughout life. The development of these may be hindered by poor integration of the brainstem
reflexes. Righting reactions emerge first in each developmental position followed by equilibrium
reactions and protective extension, which seem to develop simultaneously. Righting reactions of
the next developmental position emerge while the equilibrium reactions and protective extension
of the current developmental position are being refined.

Implications of dysfunction:
Delayed development of righting reactions:
 Trunk rotation with dissociation of the hip to the shoulder girdle is a product of mature righting
reactions. Rotation is important for the development of equilibrium reactions as it forms a
component of weight shift to the down hill side. Rotation further aids the development of
bilateral integration and midline crossing.
 Poor stable balance developmentally relates to poor righting reactions, but may also be due to
a biomechanical problem.
 Delayed righting reactions may influence a child’s neutral balance in poor stabilising of the
head position during reaching.
Delayed development of equilibrium reactions:
 Immature equilibrium reactions are often compensated for with the use of fixation of the
proximal joints. The response lacks weight-sift, with poor rotation of the trunk. These children
thus commonly present with poor proximal stability.
 Although some equilibrium reactions are required for stable balance, they play a significant
role in neutral balance. The control of neutral balance is refined through equilibrium reactions,
which allows for postural stability.
 During dynamic balance activities, children with poor equilibrium tend to increase the speed of
the movements in order to compensate for the diminished control. Fixation and exaggerated
movements may also be evident.
Delayed development of protective extension:
 These children often overcompensate by frequently changing their base of support, even when
it does not seem necessary.
 They may have many bruises and scrapes as their response times may be slowed.
9
Principles of treatment:
Improve righting reactions
 Encourage the adaptation to new positions by providing a variety of position experience.
 Alter the rate of change of body position relative to the earth’s surface.
 Provide a variety of vestibular and proprioceptive stimuli.
 Tasks should involve trunk rotation and dissociation of all body segments.
Improve equilibrium reactions
 Stimulate weight shift to the down-hill side of the moving surface.
 Maintain postural alignment.
 Promote trunk rotation, but be aware of over-rotation.
 Provide opportunities for unpredictable changes in surface (alter the densities of the
surfaces).
 Provide visual stabilising points (target on the wall) initially, then grade to not having a
visual stabilising point.
 Grading:
i. From supine  prone  sitting  four-foot kneeling  upright kneeling  half
kneel  stand  mobility
ii. Minimal displacement to maximal displacement
iii. Movements in anterior-posterior plane  lateral  rotary  irregular
iv. Stable surfaces  moveable surfaces
v. Low centre of mass (COM) to high COM
vi. Wide base of support (BOS) to small BOS
vii. Maximal external support to minimal
Improve protective extension
 Normalise muscle tone
 Improve child’s cognitive awareness of the need to extend for protection when falling

BILATERAL INTEGRATION and CO-ORDINATION

Definition: Bilateral integration is the brain’s ability to interpret information from, and
constructively use, both sides of the body during interaction with the environment. It is thus a
brain process. The result of bilateral integration is bilateral co-ordination.
Bilateral co-ordination is the motor output component. Tasks are performed with both sides of
the body working together to control the activity. (e.g. star jumps)

Development: Through the integration of reflexes, the development of rotation, righting reactions
and equilibrium, the brain starts to use the limbs of both sides in activity in each developmental
position. The limbs first work symmetrically (holding a bottle, jumping two feet together), then
reciprocally or alternately (crawling, marching). Midline crossing and asymmetrical use of limbs
(the one limb adopts a supportive role while the other adopts the skill role) follows reciprocal
bilateral co-ordination.

Implications of dysfunction:
 There may be delayed development of midline crossing and hand preference.
 Right – Left discrimination is often poor in children with poor bilateral integration.
 Poor co-ordination of sequences often occurs in conjunction with poor bilateral integration, and
the child may have difficulty adapting sequences to the changing environment.
 Sporting ability is often poor as the child has difficulty with timing their responses and many
sporting acts require bilateral co-ordination.

Principles of treatment: Improve bilateral integration

a. Gross motor bilateral integration
 Provide timing and rhythm requirements within the activity
 Grade from symmetrical  whole body reciprocal  opposite UL/LL reciprocal 
asymmetrical movements
 Activities should involve trunk rotation
 Sequencing of tasks and fluid repetition of sequences should be inherent in the
task
 Grade the child’s interaction with the environment as follows:
10
 1. Child stable – environment stable
2. Child moving - environment stable
3. Child stable - environment moving
4. Child moving - environment moving
b. Fine motor bilateral integration
 Tasks should involve both upper-limbs (this should be inherent in the task – not
contrived)
 Ensure that underlying fine-motor components have been addressed.

MIDLINE CROSSING
Definition: Midline crossing is the ability to perform purposeful activity with the hand in the
contralateral hemispheric space, thus requiring integration of the left and right hemispheres of
the brain. This is a spontaneous and automatic function, not requiring conscious thought. All
children can actively cross their midline on request. It appears to be dependent on mature
myelination of the corpus callosum.

Development: Midline crossing develops out of mature rotation, dissociation, equilibrium and
bilateral co-ordination. It tends to precede the development of a preferred hand.

Implications of dysfunction:
 Delayed development of a preferred hand, or lack of the non-preferred hand taking the
supportive role.
 Poor right - left discrimination and thus possible letter reversals.
 Poor spatial perception.

Principles of treatment: Improve automatic midline crossing

 Grade from bilateral integration with rotation to fine motor midline crossing.
 Midline crossing must be an inherent aspect of the task and NOT contrived through
inappropriate structuring
 Cognitive induced midline crossing does not effectively promote automatic midline
crossing (eg asking child to only use their right hand neglects the supportive role of the
non-preferred hand)

MOTOR CONTROL
Definition: Motor control is the smoothness, co-ordination and accuracy of a motor output. The
motor output is well graded with appropriate force and trajectory. It may be on a gross motor
(large extrinsic muscle groups) or fine motor (small extrinsic and all intrinsic muscles) level. Motor
control requires mature postural mechanisms. The brain (cerebellum) integrates the timing of the
contraction of agonist and antagonist muscles and between muscle groups throughout the body.
This allows for synchronised movements of the limbs on a stable postural base.

Development: Through the integration of reflexes, the development of righting reactions and
equilibrium, and bilateral co-ordination the brain uses the limbs in activity within each
developmental position. As a movement is practiced the better the motor control of the
movement.

Implications of dysfunction:
 Delayed development of motor skill is the primary implication.

Principles of treatment: Improve motor control

 Ensure that any underlying components have been addressed (proximal stability, muscle
strength etc)
 Facilitate control of movement by guiding movements at proximal joints.
 Provide structural demands for accuracy of movement which can be graded (big target
on the wall for throwing a beanbag at – upgraded to a small target farther away to throw
a tennis ball at.)

TACTILE DISCRIMINATION
11
Definition: The ability to interpret touch information from the skin. This involves the ability to
identify where on the body the touch has occurred, the type of touch that occurred and attribute
significance to the touch if necessary. For example if someone draws a picture on your back you
can feel that it is light touch, that it is on your back, and more specifically the path of the drawing
on your back to enable you to identify what is drawn.

Development: Tactile discrimination starts to develop in the womb, especially around the mouth
and hands, but is present though out the body. After birth it is the changes of tactile experiences
that are most noticed (lying on mom’s stomach to lying on a furry blanket or the cool air to the
warm water of the bath). As an infant experiences a wider variety of tactile input, some
information will be perceived as safe and calming, while others as alerting or threatening. This is
the beginning of attributing meaning to the tactile experience. As concepts develop so the child is
able to identify the type of touch experience, it’s location on the body and whether a response to
the experience is necessary.

Implications of dysfunction:
 Delayed development of in-hand manipulation.
 Poor motor planning, as tactile discrimination provides important feedback of motor execution.
 Poor development of gross and fine motor skills, primarily fine motor skills.

Principles of treatment: Improve tactile discrimination

 Provide a variety of tactile experiences.
 Be aware of not over-stimulating a child by giving too much light touch.
 Encourage manipulation of objects to gain tactile and proprioceptive information.
 Do activities with vision occluded to enhance the need for tactile discrimination for the
suscess of the activity.

INTEGRITY OF THE HAND

Definition: The integrity of the hand considers of the physical structure of the hand, and
biomechanics of the hand. It comprises of normal tone, appropriately developed muscle strength,
mature hand arches, and grips and grasps.

Development: Babies are born with flat hands (lacking arches), and their fingers are mostly flexed.
As a baby experiences more reflexive grasp the muscle strength in the hand develops, improving
selective control of grasps, but the hand moves as a unit with limited isolation. With movement
the ulnar side becomes the stabilising side of the hand for grasps and the radial side becomes the
manipulative side for pinches. With this dissociation the transverse metacarpal arches develop, as
does controlled release of grasp.

Implications of dysfunction:
 Poor in-hand manipulation.
 Poor motor control during fine motor tasks.

Principles of treatment:
Improving control of reach
a. Improve dissociation of arm movements
 Provide proximal stability for movement
 Provide cognitive cues regarding use of dissociation (“Use your fingers to draw,
not your whole arm”)
 Activities should provide opportunities to practice dissociation of movements in
order to build up the movement pattern pathways (motor engrams)
b. Improve control of movement throughout full range of motion
 Provide proximal stability especially at the ends of the range.

Improve grip strength.

 Use materials of graded resistance for manipulation
 Provide exploration of properties of materials
 Grade from transient to sustained grasp (endurance)
 Grade from strengthening mass grasp (proximal) to tip pinches (distal)
12
  Control trick movements
 Use repetition of movements
 Provide cognitive and environmental feedback

Improve grips and grasps

 Ensure that you are specific about which grip / grasp you wish to improve and ensure
that the child is not using trick grasps to compensate.
 Provide a variety of material properties for improving control of each grip / grasp
 Ensure forearm positioning and stability (wrist extension to 30) e.g. If improving lateral
pinch objects should be presented in line with the shoulder, rather than the midline as
this encourages neutral forearm positioning.
 Grade from large to small objects thus mass grasps to tip pinches.
 Compensate for loss of grasp through adaptation (built up sponge handles)
 Grade from objects with rough surface to smooth surface
 NB! Practice strategies for grasp  sustained carrying (moving the object from one
point to another)  controlled release.

IN-HAND MANIPULATION
Definition: In-hand manipulation is the ability move, adjust or change the orientation of an object
in the hand without the use of the other hand (e.g. picking up and pencil and turning it to position
for gripping the pencil). This requires appropriately developed integrity of the hand, isolation of
finger movements, dissociation of ulnar and radial sides, and control of the transverse metacarpal
arch. Translation (finger to palm / palm to finger) and precision rotation on distal finger tips also
forms an integral part of in-hand manipulation.

Development: An infant uses bilateral manipulation in order to rotate or move objects to explore
them. This leads to the manipulation where the one hand assists the hand being primarily used.
Dependence on the assisting hand reduces as in-hand manipulation improves.

Implications of dysfunction:
 Fine motor skill will be the predominant area affected by poor in-hand manipulation. Tool
usage is likely to be poor (e.g. cutting with scissors, drawing with a pencil).
 Poor hand preference may influence the development of in-hand manipulation, but may also
be affected by it. A child with poor in-hand manipulation may swap hands regularly during a
task due to muscle fatigue, or the perceived lack of accuracy of that hand.

Principles of treatment: Improve in –hand manipulation

 Ensure optimal positioning of the child with appropriate proximal stability (even if this
needs to be external).
 Present objects in the child’s midline
 Provide tactile discrimination experience
 Ensure that the integrity of the hand is appropriately developed
 Provide visual cues of movement accuracy and requirements
a. Improve isolation of finger movements
 Activities should require individual finger movements of flexion, extension,
abduction and adduction.
 Provide repetition of movements
 Activities should require manipulation of objects within the finger tips
b. Improve translation
 Provide tactile discrimination and proprioceptive activities to provide awareness
of the palm and fingertips.
 Activities should require manipulation of objects from palm  finger tips and back
with functional grasp
 Grade from using objects that are large and irregular shaped to small, smooth
objects
 Grade from having one object in the hand to more than one object in the hand at
a time.

LATERALISATION, LATERALITY and HAND PREFERENCE

13
Definition: Lateralisation is the brain process of one hemisphere becoming superior to the other
for a specific function (e.g. the left hemisphere is lateralised for language processing). Laterality
is the innate awareness that there are two sides of the body. Hand preference is the
establishment of a dominant hand through lateralisation of the appropriate hemisphere for skilled
hand function (writing, eating and brushing teeth is performed mostly by the right hand in a child
with right hand preference). Dominance is the observed superiority of one side of the body for a
specific skill over the other side where there are paired parts symmetrical to the midline (eyes,
ears, hands and legs). Kicking a ball is smoother and easier with the right foot than the left in a
right foot dominant child. In many texts this is referred to as “laterality”.

Development: Lateralisation and laterality develop from infancy throughout childhood and
adolescence. They develop from body scheme and play a role in bilateral integration, midline
crossing, dominance, and left – right discrimination. As these develop dominance and hand
preference emerge. They begin to be noticeable at about three years old, but become more firmly
established by six years old.

Implications of dysfunction:
 Poor development of lateralisation and laterality will hinder the development of dominance
and hand preference.
 Spatial perception is commonly seen to be poor in children with poor hand preference, which
relates to the possible presence of poor bilateral integration and midline crossing as
underlying factors for the delayed dominance.
 Right - left discrimination is commonly poor.

Principles of treatment:
Treatment of eye and ear preference is not a function of occupational therapy.
Consolidate hand preference
 Grade activities from bilateral  midline crossing  unilateral skill with other hand in
supportive role
 In the younger child, aspects of a task must be completed with the hand that initiated
the aspect.
 Unusual tactile input from the tools used provide unilateral tactile feedback and a form
of “sensory memory” for that side.
 Increase cognitive awareness of hand used
 Laterality is established when a child consistently uses one hand to perform a particular
task.

Consolidate foot preference

 Provide opportunities to select and practice unilateral foot use.

PRE-WRITING SKILLS
Definition: These are skills, which prepare a child to be able to master handwriting. It includes
grasping the writing instrument appropriately, being able to apply appropriate pressure with the
instrument and control the instrument (colouring / tracing / drawing)

Development: An infant initially scribbles with a thick crayon and is satisfied merely making a
mark on the paper. Scribbles develop into drawings of circles and lines, which develop into
pictures. Scribbles can also develop in to colouring by initially colouring over a whole page with
some very dark parts, and many gaps where no crayon is evident. The thickness of the crayon
reduces as the child gains more control of the colouring and becomes more selective of parts of
the picture being coloured in specific colours. By six years old a child should be able to colour in a
picture from a colouring book with even pencil pressure, staying within the lines of the picture,
selecting appropriate colours and using pen width wax crayons. Pre writing skills are usually
developed by 7 years old.

Implications of dysfunction:
 Poor handwriting, which influences academic performance.

14
Principles of treatment: Improve pre-writing skills
 Provide opportunity to practice these skills (colouring in, tracing, copying).
 Give verbal encouragement and structure for the task.
 Grade the level of the skill required.

Pencil grip
Definition: Pencil grip is a specific form of in-hand manipulation. Normal tone, muscle strength,
hand preference and isolation of finger movements are essential components of a mature pencil
grip. A tripod grip (pencil rests on the middle finger, the index finger is on the shaft of the pencil
with the thumb in opposition supporting the side of the pencil), just above the sharpened area of
the pencil is considered to be a mature pencil grip. This allows for maximal finger movement
during writing.

Development: An infant holds a crayon with a full cylindrical grasp and forearm pronation, with
the movement generated at the shoulder. As the grasps progress from full static palmer to
dynamic radial tripod grasp the movement becomes more distally generated (shoulder  elbow 
wrist  isolation of fingers).

Implications of dysfunction:
 Unevenness and difficulty staying in the lines during colouring.
 Poor letter formation and untidy handwriting.
 Slow writing speed with muscle fatigue (due to using excessive strength to hold the pencil/
from generating the movement at the shoulder).

Principles of treatment: Improve pencil grasp

 Improve the underlying components if there are deficits in any of these (muscle strength,
isolation of finger movements etc)
 Using a pencil grip is beneficial for some children, as they do not require as much muscle
strength to grasp; it guides the finger position, and gives tactile and proprioceptive
feedback.
 Verbally reinforce the use of the correct grip, but don’t become overly fixated on it so that
it becomes a major issue for the child.

EYE MOVEMENTS AND CO-ORDINATION

Definition: The intrinsic eye muscles are responsible for focussing vision on a specific object, and
controlling the amount of light that enters the eye. The extrinsic eye muscles allow for movement
of the eyes in order to scan the environment. This requires co-ordinated movements so that the
eyes move together and are able to stop simultaneously.
Types of movements (extrinsic) are:
 Pursuits (focussing on and tracking a moving object)
 Saccades (quick movement of the eyes with interspersed fixations in order to look at
various aspects of an object – reading across a line of words)
 Convergence (Bringing the eyes closer to the midline in order to focus on a near object)
 Divergence (Moving the eyes away from the midline in order to focus on a far object)

Development: Movements of the intrinsic muscles start to develop from birth, where the new-born
distinguishes contrasts of light and dark. This develops throughout the first year to allow
observation of objects and their characteristic features. During this phase extrinsic eye
movements are less refined with the infant using head movements in order to locate objects. As
the movements become more refined the head movements and eye movements become more
dissociated, allowing for independent movement of the eyes from the head. By five years visual
pursuits should be refined and saccade movements are refined by seven years old.

Implications of dysfunction:
 Poor pursuits and saccades usually manifest in reading difficulties as the child may skip words,
or become confused as to which line is being read.
 A midline crossing difficulty may cause a jump in pursuits across the midline. This will in turn
lead to possible reading difficulties.

15
 Copying work off the blackboard is affected when convergence / divergence difficulties are
present as the child is required to focus on the blackboard (far) and then on their paper (near)
and back again to the blackboard.

Principles of treatment: Improve eye movements

 Refer to an optometrist.
 Provide opportunities to track objects in the environment (play ball games)
 Active movement within the environment provides opportunities for visual tacking.

VISUAL DISCRIMINATION
Definition: This is the ability to focus on characteristics/features of objects in order to identify, or
match the object and isolate the similarities and differences between similar objects.

Development: Discrimination develops from the ability to focus vision on an object through use of
intrinsic muscles. It develops throughout the pre-school years and is usually refined by five years.

Implications of dysfunction:
 All other visual perceptual skills may be influenced by poor visual discrimination, especially
form constancy.
 The child may have difficulty reading as some letters may appear to be the same (e.g. “q” and
“g”, “a” and “o”), and some texts print letters slightly differently (e.g. “a” vs. “ a”). Even
differences in bold or italics texts may be confusing.

Principles of treatment: Improve visual discrimination

 Reinforce focus on the details of objects
 Expose to similarities and differences
 Grade from simple forms to complex and intricate designs / forms

VISUAL FIGURE-GROUND PERCEPTION

Definition: Figure-ground perception is the ability to interpret visual information in distinguishing
the meaningful object in the foreground from the background. (e.g. looking at a bird in a tree – the
bird is the figure and the tree and surrounding environment are the ground). Aspects of form
constancy are often required in higher levels of figure – ground perception in order to decide on
what aspect of the stimuli is the ground.

Development: Figure-ground perception develops from the ability to focus vision on an object, and
discriminate the object as being separate from the background. Light intensity and contrast of
colour initially stimulates figure-ground perception. As it becomes more refined (approximately
five years old) the child is able to determine objects from distracting and similar backgrounds.

Implications of dysfunction:
 Form constancy may be delayed as a result of poor figure-ground perception.
 Figure-ground perception problems may interfere with a child’s ability to find and keep their
place during reading if there are many lines on a page.
 Reading of maps and doing geometry may be difficult for a child with figure-ground perception
difficulty.

Principles of treatment: Improve figure-ground perception

 Provide opportunities to explore foreground and background
 Grade from:
o high contrast to low contrast
o uniform to diffuse and busy background
o clear object boundaries to overlapping background (bird in a tree, some leaves are
in-front)

BASIC CONSTANCY
Definition: Constancy refers to the ability to identify similar characteristic of objects or drawings
in order to recognise, classify or match them. Constancy is the perception of the form/ colour/

16
size/ number etc. Constancy does not require attaching language (naming) to the form, colour
etc.

a) Colour
Definition: Colour constancy is the ability to recognise and match a colour regardless of the
environment in which it is seen, the shade, or object representing it (A red pencil and red water
paint still represent the same colour).

Development: Colour constancy develops from visual discrimination and figure-ground perception.
By two years old a toddler is able to match one primary colour. By three years old the child is able
to match most primary and secondary colours. By five years a child is able to match shades of
colour an sequence them from lightest to darkest.

Implications of dysfunction:
 Difficulties with sorting / grouping coloured objects.
 Inappropriate use of colour in drawings and paintings (a purple river).
 Delayed colour concept development.

Principles of treatment: Improve colour constancy

 Provide opportunities to match, sort and group objects by colour.
 Provide opportunities to explore shades of colour

b) Form
Definition: Form constancy is the ability to recognise and match a form (table, book) or shape
(circle, rectangle) regardless of the environment in which it is seen. That is it may be different in
terms of size, colour, and orientation in the environment, but still retains the characteristics that
categorise the object as a particular form (The desk top and the door are both the shape of a
rectangle).

Development: Form constancy develops from visual discrimination and figure-ground perceptionn.
By two years old a toddler is able to match objects that s/he is exposed to regularly (different
colour spoons from a pile of cutlery). By three years old the child is able to match basic shapes. By
seven years old form constancy is usually refined.

Implications of dysfunction:
 Development of visual closure and space perception may be poor.
 Delayed development of form concepts.
 Delayed symbol recognition which influences reading and mathematics skills.

Principles of treatment: Improve form constancy

 Provide opportunities to match, sort and group objects by form.
 Provide opportunities to explore the properties of different forms, and have discussions around
these properties. (“It has three sides, three corners and is flat.”)

c) Size
Definition: Size constancy is the ability to recognise and match objects of the same size, or tell
different sizes apart. Often sequencing objects according to size is considered an indication of size
constancy, but remember that the child must have sequencing concepts to be able to do this.

Development: Size constancy develops from visual discrimination and form constancy. Body
awareness plays a role in the development of size constancy as the child uses the self as the first
reference to size.

Implications of dysfunction:
 Sequencing may be affected.
 Spatial perception may be influenced as size is often used to indicate distance and the
relationship of one object to another.

Principles of treatment: Improve size constancy

17
 Provide opportunities to match, sort and group objects by size.

d) Number
Definition: Number constancy (conservation) is the ability to recognise how many objects are
in a group and whether or not there are objects missing or more added over a period of time.
(Being able to tell that there are three sweets without actually counting them).

Development: Low level space perception, body scheme and concept, form and size constancy
contribute to the development of number constancy. Usually by two years old a child has
constancy of two objects. Number constancy is usually integrated by nine years old.

Implications of dysfunction:
 The primary implication is on basic arithmetic, which in turn impacts on the learning of
mathematics
 Sequencing, form constancy and space perception at higher levels may in turn be affected.

Principles of treatment: Improve number constancy

 Provide opportunities to interact with a group of objects, allowing the child to determine if all
the objects are present and to find missing ones.
 Match groups containing the same amount of objects

DIRECTIONALITY
Definition: Directionality is the ability to perceive, outwardly project and adapt to changes in
direction. This may by the directions of the child’s movements, or that of others. It may also be on
a two dimensional level, such as changing direction at the corners when drawing a triangle.

Development: Directionality is an extension of laterality in that an awareness of the two sides

assists in the ability to move towards either side. It however precedes the development of left –
right discrimination.

Implications of dysfunction:
 Difficulty with following maps and directions is a directionality problem. This may manifest in
drawings by confusion at corners or where a change of direction is required.
 Poor spatial perception can be in part due to directionality difficulties.
 Progression and left – right discrimination may show delayed development.

Principles of treatment: Improve directionality

 Task must require a change of direction
 Use a variety and combinations of portraying directional information ( written,
diagrammatic, physical such as arrows on the floor, verbal etc.)
 Grade from assisted to imitated to independent directional change
 Grade from familiar to unfamiliar settings
 Grade from many cognitive & environmental cues to minimal cues.

PROGRESSION
Definition: Progression is the automatic, sub-conscious tendency to format tasks from top 
bottom, left  right and anti-clockwise from “two o’clock”. We read from the top of the page, and
across from left to right. In drawing a circle we tend to start at two o’clock and draw anti-
clockwise. Though progression should be an automatic response, many children learn this through
cognitive reinforcement (the teacher constantly reminds the class to start writing in the top left
corner) until it becomes automatic. Progression is different in some written languages.

Development: Progression is a combination of midline crossing, hand preference, directionality

and left – right discrimination. Children with poor development of any of these will have more
difficulty in developing automatic progression skills. Progression develops from top –bottom
progression to left-right progression to anti-clockwise progression. This is usually fully automatic
by seven to eight years old.

Implications of dysfunction:
18
 A child with poor progression may not start at the top – left corner of the page, resulting in
poor layout of written work.
 Letter formation may be irregular and untidy as the child may go over lines in order to
complete a letter.

Principles of treatment: Improve progression

 Ensure that spatial perception and directionailty are consolidated
 Provide opportunities to practice   and (repitition)
 Provide structural starting points / cues (dot in top left corner of the page) – grade the
amount of structural cues given
 Grade from large movements of body  simple lines  shapes  letters

SPATIAL PERCEPTION
a) Position in space
Definition: Position in space perception is the ability of a child to determine his/her own position
relative to the environment, or the position of an object relative to the child. This perception
involves both spatial orientation and spatial relations perception of the persons self related to the
environment. I am hanging up side down on a branch. I am in a box / under a table / lying on a
bed. The book is behind / in front / above / next to me. Position in space concerns the relationship
of the child to the object and the object to the child (I am on top of the table and the table is
under me). The child does not have to verbalise their position, just perceive it! Attributing the
words to the position is cognitive and language based.

Development: Body scheme is the primary base for the development of position in space
perception. Through the internal model (scheme) that the child has of his body and proprioceptive
and vestibular stimulation of interaction with the environment a sense of position in space is
generated. The use of the correct prepositions develops as basic concepts develop.

Implications of dysfunction:
 The development of spatial orientation, spatial relations and space visualisation perception will
be influenced.
 Motor planning and movements within the environment may be influenced as the child may
not be able to determine if they are able to fit through the tunnel, or under the table. The child
may misinterpret their position relative to the object they want to touch and thus plan the
movement inaccurately. (Body scheme plays a significant role.)
 Object sequencing may also be influenced by delayed position in space.
 Dressing relies heavily of position in space as the child must orientate and relate their body
parts to the clothing.

Principles of treatment: Improve position in space perception

 Ensure that the child’s body scheme has been addressed if there are difficulties in this
area.
 Provide opportunities to explore different positions in space.
 Give verbal reinforcement of the child’s position. (“you are on the table”)

b) Spatial orientation
Definition: Spatial orientation is the orientation of an object on its own axis, where the viewer is
upright in relation to the environment. The box is the right way up. The book is on its side. The
boy is hanging up side down.

Development: Spatial orientation develops from body scheme and position in space perception. Its
development is also dependant on the development of laterality, directionality (in which midline
crossing plays a role) and form constancy.

Implications of dysfunction:
 Letter reversals are a common manifestation of poor spatial orientation (p,b,d). This may lead
to inappropriate spelling and reading of words.
 The motor orientation of an object may be inaccurately carried out. (Shirt may be put on in
side out / back to front).
19
 Instructions involving the orientation of objects may be poor. (Turn your shirt around the other
way before putting it on).
 Delayed space visualisation skills.

Principles of treatment: Improve spatial orientation

 Provide opportunities for the child to explore different orientations of objects.
 Grade from manipulating the orientation of objects (3D) to paper based drawings of
objects (2D).
 Discuss the implications of the orientation of an object (if the cup it tilted the water will
spill)

c) Spatial relations
Definition: Spatial relations perception is the ability to determine the relationship of one object to
another as seen by the observer. The book is on the table. The chair is behind the desk.

Development: Spatial relations develops from body scheme and position in space perception. Its
development is also dependant on the development of midline crossing (as some of the objects
being related may not be focussed on as they are being viewed by the contralateral hemisphere)
and form constancy

Implications of dysfunction:
 Sequencing of objects may be influenced by poor spatial relations
 Sequencing of letters in a word is a common difficulty causing spelling errors (was – saw, on –
no) or of numbers causing mathematics difficulties (67 vs. 76).
 Space visualisation skills are likely to be poor.
 Instructions involving the spatial relations of objects may be inaccurately carried out. (Put the
book on the shelf between the stand and the red book.)

Principles of treatment: Improve spatial relations

 Provide opportunities for the child to explore different relations of objects.
 Grade from manipulating the relationships of objects (3D) to paper based drawings of
objects (2D).

d) Space visualisation
Definition: Space visualisation is the ability to mentally manipulate the orientation and relations of
an object without physically moving the object. You visualise whether the key will fit into the lock
before actually trying it in the lock.

Development: This develops primarily from spatial orientation and spatial relations perception,
and thus aspects involved in their development will also influence the development of space
visualisation.

Implications of dysfunction:
 Problem solving often depends on space visualisation. (Will the book fit into the space left on
the shelf? How much space is needed on the paper to draw a house?)

Space visualisation is a high level perception, and is usually not directly treated as the underlying
spatial perception takes focus.

VISUAL CLOSURE
Definition: Visual closure is the ability to determine what an object will look like complete if only
part of the object is visible. The child must have prior knowledge of the complete object (a mental
image of it) to use as a reference.

Development: Form constancy is a primary necessity for the development of visual closure, but
visual memory and spatial perception also play a role.

Implications of dysfunction:

20
 Letter formation may be poor as the child has difficulty closing letters (an “a” may be written
like a “u”). The motor planning of completing letters is affected as the child has difficulty
visually closing the letter once part of the letter is drawn.
 Determining the characteristics of partially hidden objects in the environment.

Principles of treatment: Improve visual closure

 Ensure that the child has good form concepts.
 Provide opportunities to recognise an incomplete object as incomplete.
 Grade the portion of the object that is omitted.
 Provide opportunity for the child to complete an incomplete object.
 Grade from the child being given an example of the completed object to not being
given the example and having to use his own experience to complete the object.

VISUAL MOTOR INTEGRATION (VMI)

Definition: Visual motor integration is the ability to reproduce a posture or image that is seen
through the use of motor output. Playing “Simon Says” requires the child to look at the body
position of the leader, and place his own body in the same position. This spatial orientation and
position in space perceptions are required on a visual level, and control and motor planning are
required on a motor output level. This also applies when copying a picture (Visually = spatial
orientation and spatial relations, Motor = control, motor planing, postural stability, pencil control
etc). The child may have adequate visual perception and adequate motor output, and yet may not
be able to integrate these in order to reproduce what is seen.

Development: VMI develops from the appropriate development of visual perception and motor
output, as well as the integration of the other senses with each other and memory of past
experience. VMI develops through childhood and adolescence.

Implications of dysfunction:
 The most common implication is the difficulty in copying work accurately from the blackboard,
especially if diagrams are to be copied.
 Difficulty learning movement patterns or sequences, such as dancing routines where the
sequence changes regularly.

Principles of treatment: Improve visual motor integration

 Provide opportunities for the child to imitate (the therapist demonstrates and the child
copies). Grade from body movements to building objects (blocks - 3D) to pencil and
paper tasks (2D).
 Provide opportunities for the child to copy (the completed image is given, and the child
must determine for himself how to copy it).
 Grade from:
o 3D – 3D (copying a block gate)
o 2D – 3D (brainyblox / peg boards)
o 2D – 2D (Redrawing block designs)
o 3D – 2D (art)

COGNITIVE PROCESSES
MOTOR PLANNING (PRAXIS)
Definition: Motor planning is the cognitive component to movement. When faced with a situation
in which a motor response is required the child decides if a response is necessary and the nature
of possible responses. Ideation. The child must receive all the sensory information available
(visual, proprioceptive, vestibular etc). Sensory input. The brain then integrates this information
in order to determine the nature of the current situation. This information is processed by
comparing the data from the different sensory systems and to prior knowledge to determine the
nature of the required response. Prior knowledge and the ability to adapt this knowledge to a
slightly different situation are vital in planning the response so that previous errors are accounted
for. Integration & Processing. The brain then works out the sequence of motor outputs required
21
in the response and sends the output command from the precentral gyrus to the muscles.
Planning. The muscles perform the motor response. Motor output.

Prior knowledge also takes the form of motor engrams. Motor engrams are patterns of
movement that are learnt through practice, so that the motor act may be almost automatic.
Handwriting is a series of motor engrams for each letter where the brain sends out the message
of the sequence of engrams as opposed to the sequence of movements incorporated in each
engram. It is almost automatic, thus allowing a person to listen to a speaker or even look at the
next piece of text while writing. The engrams are laid down for the dominant hand in writing. This
explains why it is difficult to write with the non-dominant hand (there are no writing engrams for
that side – they have to be learnt). Engrams should be adaptable to a degree. You do not have to
relearn how to write every time you have a new size or shaped pencil.

Implications for dysfunction:

A child may have a praxis difficulty in any of the highlighted elements. S/he may not adequately
develop motor engrams, or be unable to adapt the engrams to similar situations. The child may
have difficulty with the ideational aspect, or the processing or the planning of the sequences.
Difficulty with the motor output is often considered to be poor co-ordination as the child is able to
ideate and plan the action accurately, but the quality of the motor execution is poor.
 Poor sports participation
 Untidy handwriting with many errors and poor letter formation
 Poor layout of written work
 Difficulty adapting to new situations
 Poor organisation of workspace, time and task independence.
 Difficulty learning new motor tasks.

Principles of treatment:
Improve body scheme (see postural control)
Improve ideation
 Provide a variety of environmental objects, obstacles, materials and events.
 Stimulate brainstorming of methods of interacting with the environment
Improve ideomotor processing
 The child can describe step-by-step what they intend to do.
 Use a variety of methods of giving instructions (verbal, written, diagrammatic,
demonstration and passive enactment of movements)
 Break the activity into simple steps (grade presentation of steps – step-by step to
multiple steps)
 Allow for repetition and practice in order to lay motor engrams
 Provide opportunity for adaptation of motor engrams
 Provide opportunity for exploration and problem solving within the environment (don’t be
too hasty to intervene)
 Provide novel aspect to tasks that are unexpected and require adaptation to.
 Grade from heavy resisted movements to give maximal kinaesthetic feedback, to more
free movement.
 Provide appropriate, realistic verbal feedback on performance and encouragement
Improve motor output
 Therapist provides verbal, cognitive feedback where the child is oblivious to environmental
feedback. (Increase the child’s awareness of environmental feedback).
 Grade from gross motor to fine motor activities.

VISUAL MEMORY & VISUAL SEQUENTIAL MEMORY

Definition: Visual memory is the ability to recall a visual stimulus, including all the detail and
specific characteristics of the stimulus. When remembering a drawing of a house, it is important to
be able to recall the colours of each part of the house, the shapes used in making each part, and
any details like the presence of red curtains in the top left window. Visual sequential memory is
the ability to recall a specific sequence of objects or digits in the correct order.
The delay of recall for both visual and visual sequential memory may be immediate, short term or
long term. Immediate recall is temporary. The information is only held for long enough to be used,
and is then discarded. (Copying a sentence off the blackboard) Short term recall is held for longer
22
periods were the information can be recalled repeatedly. (Learning for an exam). Long term recall
is internalised information that is of significance to the person and thus can be recalled at any
time for many years. (Memories of winning the swimming trophy in grade 3).

Implications of dysfunction:
 Difficulty copying work accurately from the blackboard.
 Difficulty learning spelling and maths bonds/multiplication tables.
 Difficulty studying for exams, especially where rote learning is required, such as dates in
History.
 Inability to remember what has happened during the day (poor at telling of NEWS stories /
remembering what had for supper last night).

Principles of treatment:
Improve visual memory
 Provide opportunities to practice memorising the characteristics of objects. (look at a picture
and redraw it once it is covered)
 Grade the amount of time that the child has to look at the object before it is removed from
sight.
 Grade the amount of time from when the object was removed from sight to when it is need to
be recalled.

Improve visual sequential memory

 Provide opportunities to practice memorising the order / sequence of objects.
 Grade the number of objects within the sequence.
 Grade the time which one object is repeated within the sequence (red-blue-red-blue to red-
blue-green-blue)

BASIC CONCEPTS
Definition: Concept is the ability to name objects/drawings based on constancy characteristics,
and determine its uses. Constancy develops before concept. Concept is the cognitive component
of the form/ colour/ size/ number etc.

Treatment Principles for all basic concepts: Improve basic concepts of ____________
 Ensure that the child has developed the related constancy.
 Practice naming within a variety of contexts.
 Discuss the functions, and properties of different concepts

a) Body Concept
Definition: The ability to name and indicate parts of the body on oneself, others and then on
drawings or representations of a body (e.g. this is a foot, that is your eye). This includes
knowledge of the functions of the different body parts.

Development: Body concept relies on the development of body scheme, as well as on other
perceptual concepts and visual discrimination.

Implications of dysfunction:
 Poor following of instructions where use of a body part is required. (Put the gloves on your
hands. Put your hands on your head.)
 Difficulty drawing or making representations of the body or body parts.

b) Colour
Definition: Colour concept is the ability to name the colours, and later to attach symbolic
meaning to a colour (the dove is white, which symbolises peace).

Development: Colour concept develops from colour constancy and elements of cognition such as
memory and concentration. By three years old the child is able name at least three colours.

Implications of dysfunction:

23
 Poor following of instructions where use of a colour is required. (Use your red crayon to colour
in the flower.)

c) Form
Definition: Form concept is the ability to name the forms or shapes, and to discuss uses or any
significant details regarding the it (that is a pen and it is used to writing. The child drew a circle for
the sun).

Development: Form concept develops from form constancy, with the concept aspect requiring
elements of cognition. By three years old the child is able to name a circle and/or square. By
seven years old form concepts are usually refined.

Implications of dysfunction:
 Poor following of instructions where use of form/shape is required. (Put the jug on the table)
 This may influence the learning of phonics as the child needs to attribute a specific sound to a
symbol.

d) Size
Definition: Size concept is the ability to indicate and name whether an object is big, large, huge,
middle size, small or tiny relative to other objects.

Development: Size concept develops from size constancy and cognitive abilities.

Implications of dysfunction:
 Sequencing and form constancy may be affected.
 Poor following of instructions where use of size is required. (Put the water in the big jug)

e) Number
Definition: Number concept is the ability to rote count, count objects, name the number symbols
(2 is two) and write each number symbol. Basic addition and subtraction are part of number
concept.

Development: Low level space perception, body scheme and concept, form and size constancy
contribute to the development of number concept. Usually by two years old a child is able to rote
count to 4/5 and object count to three. Number concept is usually integrated by nine years old.

Implications of dysfunction:
 The primary implication is on basic arithmetic, which in turn impacts on the learning of
mathematics
 Sequencing, form constancy and space perception at higher levels may in turn be affected.
 Poor following of instructions where use of number is required. (Take three sweets out of the
jar.)

f) Part - Whole
Definition: Part – Whole concept is the ability to identify the parts/segments/pieces of an object,
and determine how the parts fit together to make the whole object. (Two semi-circles make a
circle.)

Development: Part – Whole concept develops from size and form constancy. It may involve
aspects of space visualisation. A three-year-old child usually has basic part - whole concepts, and
this becomes refined by nine years.

Implications of dysfunction:
 Visual closure perception may be influenced, as it requires part – whole understanding.
 A child may present with poor mathematics skills.

g) Sequencing
Definition: Sequencing is the ability to place objects in a meaningful order or to perform a series
of movements in a specific order.
24
Development: Object sequencing develops through maturity of the basic concepts as basic
concepts are often used as the sequencing criteria. (Order the blocks from biggest to smallest –
size constancy). Midline crossing plays a role in the development of sequencing as objects on the
contralateral side may be omitted, or inappropriately sequenced.
Movement sequencing relies on the development of motor planning skills, bilateral integration
and midline crossing. Sequencing is usually consolidated by nine years old.

Implications of dysfunction:
Poor object sequencing
 This will impact on mathematics skills and the child may confuse the number sequence, or
have difficulty understanding relationships between number groups.
 Poor spelling often influences writing and reading skills, as the child confuses the ordering of
the letters.
Poor movement sequencing
 Poor anticipation of actions requiring adaptation to the environment (catching a ball while
swinging in a swing).
 Difficulty with sports and games that require specific sequences (hopscotch, ballet, swimming)

h) Left - Right Concept

Definition: Left - right concept is the ability to name and indicate the left and right sides of the
body on oneself, others and projected to objects and directions in the environment. The following
indicate left – right concept: “This is my right hand.” “That is your left foot.” “Put it to the right of
the book.” “Turn left at the stop street.”

Development: Development of left – right concept is largely dependent on the development of

laterality and hand preference. A child becomes aware of left – right concept as early as three
years old through dressing activities, but only productively uses it from about seven years old. A
child first learns to identify left and right on themselves, then others, then on objects and lastly
projected into environmental space.

Implications of dysfunction:
 Following of instructions is often dependent on left – right concept, and thus may be poor.
 Directing and describing three-dimensional space is difficult if there is left – right confusion.

CONCENTRATION
Definition: Concentration is the ability to focus attention on the task being performed. The child
should be able to maintain focus in the presence of environmental stimuli that are irrelevant to
the task (background noise, movements of others in the area, changes in lighting as a cloud
passes in front of the sun). Internally generated thoughts that are irrelevant to the task (thoughts
of an up coming birthday, or winning the race the previous day) should also be controlled. Active
concentration is focus maintained during active participation in a task. It is a deep level of
concentration where strong environmental stimuli are required to defer the child’s concentration
from the task. Passive concentration is focus maintained during non-active participation in a
task such as observing. It is a shallow level of concentration where mild environmental stimuli
easily defer the child’s concentration from the task.

The child’s level of concentration is influenced by the child’s level of arousal as determined by the
reticular activating system (sleep – wake fluctuations). A child with a low arousal level (near sleep)
will be more prone to passive concentration; where as a child with a high level of arousal will be
able to focus well in active concentration.

Active concentration span develops at approximately 2 minutes per year, thus a 5 year old can
usually concentrate actively on a 10 minute task, whereas a 10 year old copes with a 20 minute
task.

25
Implications of dysfunction:
 Impulsive behaviour with poor decision making is a common manifestation of poor
concentration.
 Many children have superior passive concentration with very limited active concentration. He
watches television for hours but is unable to sit still at the dinner table long enough to finish
his plate of food.
 Learning becomes problematic as crucial elements are missed during the child’s period of poor
concentration. He is unable to apply the “fairy e” rule, as he was not focussed while the
teacher taught the rule.
 Poor completion of tasks is common as the child looses focus on the task and slips into passive
concentration (observing a classmate sharpen a pencil).

Principles of Treatment: Improve active concentration span

 Initially limit distractions in the environment and gradually grade these in.
 Ensure that tasks are of interest to the child initially and grade towards more mundane
repetitive tasks.
 Monitor duration and depth of concentration, as well as the influence of the demands of the
task on concentration.
 Grade the amount of refocusing the child’s attention to the task with verbal and tactile cues.
 Ensure that the child is actively attending while giving task instructions.
 Grade the duration of the activity (a 5 minute activity does not improve concentration if the
child already is capable of 7 minutes of active concentration).

PERFORMANCE PROCESSES

GROSS MOTOR SKILLS

Definition: The ability to use the whole body in active participation in the environment. Co-
ordination of the large limb muscles and the use of postural reactions control the movements.
Through practice these skills are refined and become more specialised and more automatic
allowing higher level skills to develop. Crawling, walking and running are basic motor skills, while
climbing, balancing and ball skills are higher level skills.

Development: The gross motor skill developmental milestones of a child are well documented. A
baby gains postural stability in prone (puppy) and supine, with head control before learning to roll.
He then progresses from roll  sit  pivot sitting  leopard crawl  four-foot rocking  four-foot
crawling  crawl on one knee and one foot  bear walking  pull to stand  stand holding onto
support  cruising  standing unsupported  walking etc. Within each of these developmental
stages a baby / toddler needs to develop the postural tone to support the position, the righting
and equilibrium reactions for displacement within the position and integration of the brainstem
reflexes which may have assisted in the initiation of the stage.

Optical &
Labyrinthine Postura Body-on-body
Neck Righting l Tone Righting
Postura Righting
l Tone

Rolling Sitting Pivot Sit

Integrate
TLR

Prone / Supine Trunk

Equilibrium Stability Integrate Sitting
ATNR Equilibrium

Schematic diagram of motor skill development

26
FINE MOTOR SKILLS
Definition: Fine motor skill is the use of the hands to perform intricate tasks. It develops through
practice and learning, thus refining the movements to achieve a degree of automation. The child
is able to eat with a spoon while listening to the conversation at the table. Proximal stability, fine
motor co-ordination, bilateral integration, in-hand manipulation and hand preference are the
processes required for appropriate fine motor skills. Examples of fine motor skills are drawing,
handwriting, cutting with scissors, eating with a knife and fork, and hand sewing.

Development: Fine motor skill develops through the development of grasps and pinches. The child
first learns to reach  grasp  active release  in-hand manipulation  bilateral skills  unilateral
skill with non-dominant hand supporting. Tool and material handling becomes more refined as
hand preference becomes established.

PLAY

Definition: Although play is difficult to define, it is easy to recognise. Children are playful if they
are intrinsically motivated, internally controlled, free to suspend reality, and able to set and
maintain a play frame (Bundy, 1997). Play is a critical occupation of childhood. It is often
described as the "work of children", but is far more than a job to be completed. Play starts and
stops when the player wants it to. Its' self-initiated, self-directed quality offers a flexibility not
found in work. Unlike working, a player can do what he wants to do, including changing play at
any time, restructuring it, choosing a new play partner, or restarting the game.

Play has long been considered the “occupation” or “business” of children, which usually leads to
the inference that it is thus work. More recent literature appears to be shifting away from this
view, and distinguishing play as a leisure occupation rather than a work occupation (Kielhofner
2002). The characteristics of play, such as “pleasurable”, “free of externally imposed rules”,
“having fun” and “self directed”, seem to describe play as leisure. Aspects of play however seem
more work orientated, e.g. contributes to the academic success of children, is central to child
development, affords opportunity to practice skills required as an adult, serious business, not idle
or frivolous (Bundy et al 2002, Case-Smith 2001, & Frost 1997). There thus seems to be confusion
regarding whether play is indeed work or leisure when considering human occupation. Playfulness
thus may be considered the measure for how work or leisure orientated a play activity is. If a play
activity affords the player the perception of internal control, intrinsic motivation and the freedom
to suspend reality, then participation in the activity may be considered more leisure.

According to Bundy (1991):

Play is a transaction between the child and the environment, which is intrinsically motivated,
internally controlled, and not bound to objective reality.

Playfulness
Bundy found that there are three criteria for playfulness:

Intrinsic motivation is the internal drive to be involved in activity that is self-initiated / ideated.

Suspension of reality is the ability to pretend with the elimination of consequence. It enables
freedom to explore without structure and maintenance of preconceived concepts governing an
object or environment. (e.g. a box may be used to represent a car and a tent becomes a palace).

Internal locus of control is the child’s ability to perceive their control over their actions and
experiences. They are able to make choices regarding the progress of the play situation and be
active in determining the outcomes of play.

Development

27
Play as an occupation, develops through childhood play skills and extends into adulthood (Rodger
& Ziviani 1999, Case-Smith 2001 & Kielhofner 2002). Cooper 1997 (in Rodger & Ziviani 1999)
developed a model of the factors that influence the development of play in children. In this model
the criteria for play skills are individual style and experimentation, adaptive use of play materials,
and play competence. The model includes Bundy’s model of playfulness and acknowledges the
influence of developmental ability, social play choice and the play context on play.

Play in the first six months is characterized by the child being a passive interactor (passive play).
He will smile or coo in response to parent or caregiver. Play at this stage lacks initiation and
manipulation of objects. The child is the observer and receiver.

During the 2nd six months the child responds well to familiar people, and occupies himself by
mimicking the facial expressions, sounds and movements of those he is regularly in contact with
(imitative play). Their main play is the exploration of the properties of objects through mouthing,
banging and throwing objects. Play lacks symbolic meaning to objects and thus play is very
concrete.

From one to two years pretend play emerges. The child begins to imitate the behaviours of
familiar adults (sweep while Mommy sweeps). They have better understanding of the functions of
familiar objects especially those used in personal management tasks. Near two years old symbolic
play becomes evident, where the child will use a block as a train and push it along the carpet.

From two to four years old the focus of play is on role-play of familiar people. The child likes to
play “mommy” or “teacher”. The are involved in parallel play, spending much of their time
watching peers at play and developing their social awareness.
During the pre-school phase play becomes more active. The social setting is of most importance
as play becomes co-operative. The child may take on higher levels of role play such as being
Barbie or Spiderman. The child is more aware of social norms of taking turns during games and
has more control and contribution to the play process.

In the primary school phase the focus of play is on sharing, co-operation and peer relationships.
The child becomes concerned with the needs and desires of playmates. There is a decline in the
amount of “make-believe” play and an increase in sports, and games with rules. Creative tasks
may also be considered individual play.

During adolescents play becomes a preparation for taking on adult roles and responsibilities. Play
is abstract and creative in nature.

28
 Interests Skills

Roles Learning

Internal control External control

Intrinsic motivation Extrinsic motivation
Freedom to suspend reality
Playfulness No freedom to suspend reality

Play Sensory Development:

Personality, Interests
Skills Modulation Physical, Cognitive,
Language, Social and
Culture, Tradition, Emotional
Religion Parent – Child Bond

Environment: Physical (resources), Atmosphere, Internal (wellness, health)

SPECIFIC DYSFUNCTION

SENSORY MODULATION DYSFUNCTION

Definition: Sensory modulation is the process of filtering sensory information from the
environment in order to protect the brain from being bombarded by information, and only allowing
relevant and pertinent information to reach the cognitive processes. Children with sensory
modulation difficulties either filter out too much of the sensory information (sensory dormant) or
allow too much through to the brain (sensory defensive). This inappropriate filtering influences the
child’s activity levels, arousal, concentration and emotional range and expression.

Children presenting with sensory modulation difficulties should be referred to a sensory

integration trained occupational therapist.

GRAVITATIONAL INSECURITY
Definition: Gravitational insecurity is a disorder of sensory modulation. It presents as an
irrational fear of heights, unstable surfaces, and unknown environments, due to poor processing
of the vestibular sensory information received by the brain. The child experiences small changes
of height (or movements) as vast differences, and over responds to the stimulus. The child has
normal postural control abilities. The child has less fear when they perceive that they are in
control of the environment and their participation in it.

Development: Gravitational insecurity is a developmental problem and thus does not normally
develop.

Implications of dysfunction:

29
 The child will fear any unstable or raised surface irrespective of whether or not they are in
control of their own movement and stability (more so if they are not in control of their own
movement and stability).

POSTURAL INSECURITY
Definition: Postural insecurity is a rational fear of heights, unstable surfaces, and unknown
environments, which demand the use of postural control in order to maintain balance and upright
posture. This fear is due to the child’s knowledge that their postural control is insufficient (i.e. the
child has poor equilibrium reactions, low tone, poor protective extension or other postural control
difficulties) and is thus scared to challenge their bodies, as they are aware that they may fall. The
child has less fear when they perceive that someone else is in control of the environment and
their participation in it.

Development: Postural insecurity is a developmental problem and thus does not normally
develop.

Implications of dysfunction:
 The child will fear any unstable or raised surface where they are in control of their own
movement and stability

30
 REFERENCES

1. Banas, N & Wills, I.H, Prescriptive Teaching: Theory into Practice, Illinois: Charles C. Thomas
Publisher
2. Bundy, A. et al, Sensory Integration Theory and Practice, Philadelphia: F.A. Davis
Company, 1991
3. Bundy, A. et al, Sensory Integration Theory and Practice – 2nd edition, Philadelphia:
F.A. Davis Company 2002
4. Case-Smith, J et al, Occupational Therapy for Children: Fourth Edition, Missouri USA:
Mosby Publishers, 2001
5. Concha, M, The Sensory – Perceptual – Motor – Cognitive Model, Unpublished, 1998
6. Coville, B and 4th year OT students, Topics in Perception – A Resource, Unpublished,
1991
7. Craig, G.J, Human Development, 8th Edition, New Jersey: Prentice Hall, 1999
8. du Toit, V, Patient Volition and Action in Occupational Therapy, South Africa: Vona
and Marie du Toit Foundation, 1991
9. Kranowitz, C. S, The Out-of-Sync Child, New York: The Berkley Publishing Group,
1998
10. Faure M & Richardson A, Baby Sense, South Africa: Metz Press 2002
11. SAISI, Sensory Integration Theory Course Notes, 2001
12. SAISI, Sensory Integration Treatment Course Notes, 1999

31
32