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Always remember to make your intervention fun and meaningful 😊

Also, play is the way the child learns what no one can teach him, so try to benefit from that.

Some tips:

  • Provide an environmental context and provide opportunities for play such as directing the child to the place where he can play.

  • Teach the child what is allowed, acceptable and the rules and expectations within the play setting.

  • NOTE: Caregivers attitudes and expectations are vitally important in setting the stage to enable the child to be an active participant.

Cerebral palsy (CP) is a long-life condition that is known as a group of non-progressive motor conditions often caused by brain damage. These disorders are characterized by a loss or impairment of body movement, reflexes, balance, muscle control, muscle coordination, muscle tone, and posture. This neurological disorder often develops as the result of a brain injury inflicted before, during, or after delivery. The child with CP may have some coexist problems such as intellectual disabilities, Seizure disorders, Hearing and visual impairments. Severity of CP is different from one child to another, can be either very mild that the child is completely independent or very severe that the child become totally dependent to others for daily activities

  • Note: the most prevalent type of CP is hypertonicity



  • Anatomic (Geographical) classification: based on the distribution of affected limbs

  • Physiological Classification: Based on the quality of muscle tone and motor disorders

  • Functional Classification: Based on the functional capabilities of the child (explained in the assessment part)

Click here for more information about classifications

The most common trisomy syndrome (excess chromosome) as there is one additional chromosome 21. Disease is characterized by physical and mental problems and they usually will have a short and stocky stature, small and flattened head with upward slanting eyes, low-set ears, flat nose, and mouth slightly open with tip of tongue protruding.

Some coexisting conditions might include:

  • Cardiovascular abnormalities, obesity, respiratory tract infections due to an altered immune system, thyroid deficiencies (mostly with an overactive (hyperthyroidism), poor visual acuity, atlanto-axial dislocation[1].

Note: those children require early intervention, Be careful about the neck joint in the intervention


[1] Dangerous condition that may cause spinal cord damage

Developmental delays can be in gross, fine motor or cognitive (including speech). When the child is delayed in the milestones. In other words, child is delayed in his chronological age in any of the developmental skills.

Most common neurobehavioral disorder where there is heterogeneous behavioral disorder of unknown cause. Onset is in childhood and may continue to adulthood and it is characterized by inattention, hyperactivity, and impulsivity. For diagnosis instance, behavior must be frequent and across different settings or situations for the last at least 6 months and that it interferes with occupational activities.

Three subtypes

  • ADHD combined

  • ADHD predominantly inattentive

  • ADHD predominantly hyperactive impulsive

 *is similar to ADHD but it is all about attention

Most common of developmental disabilities that is characterized by significantly impaired intellectual ability, an onset before 18 years of age and impaired ability to adapt for independent living.


  1. Mild (IQ 55-70): Learn academic skills up to 7 grade, 80% marriage, and 80% employment

  2. Moderate (IQ 40-55): Requires support to function in society, learns up to 2nd grade, handle some daily routine

  3. Severe (IQ 25-40): Requires extensive support and supervision, learns to communicate, trains on some health habits

  4. Profound (IQ < 25): Needs assistance for basic survival skills, minimal self-care skills, neuromuscular, orthopedic, and behavioral deficits.

Additional problems include:

  • Speech, Ambulation, Seizures, Visual problems and Chronic conditions like Heart disease, diabetes, anemia, obesity and dental problems

A group of problems affect the child ability to master school tasks, process information and communication that is not associated with a specific neurology problem but may include conditions such as ADHD, perceptual disabilities, dyslexia, and aphasia. It also does not include learning problems that stem from sensory deficits, MR, socioeconomic conditions or psychosocial impairment. Most of them have an average or above average intelligence, adequate sensory acuity, and an appropriate learning experience. Finally, some degree of the disability may continue to adulthood.

Categories based on behavior:

  • Disorders of Motor Functions

  • Educational Disorders

  • Disorders of attention and concentration

  • Disorders of thinking and memory

  • Speech and communication problems

  • Auditory difficulties

  • Sensory integration and perceptual disorders

  • Psychosocial problems

Most common and documented Pervasive Developmental Disorder (PDD) with an onset before 3 years of age that continue throughout life (chronic developmental disability). Characterized by severe and complex impairments in social interaction, communication, and behavior showed as inability to make relationship with others, and displays of repetitive behavior. More common in boys.

Categorized based on clusters of disturbances:

  • Disorders of Motor Functions

  • Disturbances in Communication

  • Disturbances in Behavior

  • Disturbances in Sensory and Perceptual Processing and Associated Impairments


Developmental milestones

Red flags:

Are the dysfunctions of developmental milestones (for example, W sitting is a physical dysfunction, wandering behavior, or unexplained stubborn))

Some links for extra info:

* Standardized,

** Non standardized

A classification system that describes how children with cerebral palsy (CP) use their hands to handle objects in daily activities. Ability is ranked on five levels based on the children’s self-initiated ability to handle objects and their need for assistance or adaptation to perform manual activities in everyday life.

Age range: (MACS) 4–18 years, and Mini-MACS is an adaptation of MACS for children aged 1–4 years.


A classification system for cerebral palsy that is based on self-initiated movement, with emphasis on sitting, transfers, and mobility. When defining a five-level classification system, the primary criterion has been that the distinctions between levels must be meaningful in daily life. Distinctions are based on functional limitations, the need for hand-held mobility devices (such as walkers, crutches, or canes) or wheeled mobility, and to a much lesser extent, quality of movement.

Age range: from birth to 18 years old.


A classification system that aims to classify the everyday communication performance of an individual with cerebral palsy into one of five levels. The CFCS focuses on activity and participation levels as described in the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health (ICF).


Measures fine and gross motor proficiency with subtests that focus on stability, mobility, strength, coordination, and object manipulation:

  • Subtests: Fine Motor Precision, Fine Motor Integration, Manual Dexterity, Upper-Limb Coordination, Bilateral Coordination, Balance, Running Speed and Agility

Individually administered test in 40 to 60 min.

Age range: 4 to 21 yrs. (school-aged children and young adults)

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Assesses fine (2 subtests) and gross (4 subtests) motor skills of children, can also be used to assess delays of milestones.

  • Subtests: Reflexes, Stationary, Locomotion, Object Manipulation, Grasping & Visual-Motor Integration.

Can be individually administered in 45 to 60 minutes, testing can be broken to shorter sessions.

Age range: from birth to six years old relative to their peers.

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Set of norm-referenced, standardized questionnaires designed to assess sensory processing patterns of children from birth- adolescent/adult. Judgment-based questionnaire. The caregiver who has daily contact with the child completes the questionnaire

  • Provides different forms selected based on age: Infant Sensory Profile, Toddler Sensory Profile, Child Sensory Profile, Short Sensory Profile, School Companion Sensory Profile, Adolescent/Adult Sensory Profile

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Sensory Integration and Praxis Test offers the most complete and flexible assessment of sensory integration available. It measures the sensory integration processes that underlie learning and behavior. By showing you how children organize and respond to sensory input, SIPT helps pinpoint specific organic problems associated with learning disabilities, emotional disorders, and minimal brain dysfunction. 

17 Tests Provide a Comprehensive Assessment the SIPT measures visual, tactile, and kinesthetic perception as well as motor performance. It is composed of the following 17 brief tests:

  • Space Visualization, Figure-Ground Perception, Standing/Walking Balance, Design Copying, Postural Praxis, Bilateral Motor Coordination, Praxis on Verbal Command, Constructional Praxis, Post rotary Nystagmus, Motor Accuracy, Sequencing Praxis, Oral Praxis, Manual Form Perception, Kinesthesia, Finger Identification, Graphesthesia, Localization of Tactile Stimuli

Administration: 10 minutes per test; 2 hours for the entire battery

Age Range: 4 years to 8 years, 11 months

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Standardized, norm referenced assessment for preschoolers. It investigates visual motor integration skills to identify and ascertain any visual motor integration deficits

Total 33 items administered in 20 to 30 min

Age range: 3 1⁄2 yr. to 5 1⁄2 yr.

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A reliable, Valid, economical and standardized visual motor screening test that helps to assess the extent to which individuals can integrate their visual and motor abilities.

Administration: Short Format and Full Format tests: 10–15 minutes each; supplemental Visual Perception and Motor Coordination tests: 5 minutes each, can be administered individually and in groups

Age range: preschool to adult

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The Shore Handwriting Screening (SHS)**:

A non-standardized diagnostic tool used to determine the causes of handwriting dysfunction in children. The SHS provides a simple, check-list style format to record findings.

Administration: 15-20 minutes

Age range: 3 to 7 years

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WeeFIM* (FIM for children):

A standardized measure of functional performance. It includes 18 domains of performance which are scored on a 7-point scale from 'total assistance' to 'complete independence'.

Age range: developed for use in children 6-months to 8-years of age but with application through adolescence


The COPM is a client-centered outcome measure for individuals to identify and prioritize everyday issues that restrict their participation in everyday living. This measure focuses on occupational performance in all areas of life, including self-care, leisure and productivity.


This outcome measure is used with persons of all ages.

Check dysphagia's page for more information.

Screening sheets can help the therapist identify the deficiencies by observing the child.

  1. Child OT referral checklist

  2. Sensory screening

  3. Self-help skills attainment (Toileting, Feeding, Dressing, Grooming): screening

Play is very important to the child, as it is his primary occupation!

That is why we use play as an intervention to improve other skills of the child.


Note: Mainly you have to come up with an activity that requires movement in the opposite direction of the reflex to break it.

Prone for fine motor activities & games: The elbows provide a point of stability for freeing the hands for manipulating.


  • Hold a large dowel with both hands, use this to push a ball back and forth or a ball

  • Color, print, draw, read, or complete puzzles in prone

  • Pivot in both directions

  • Prone on therapy ball, platform swing, or over bolster

  • Prone on scooter board

    • Push off with arms from wall to glide backward

    • Being pulled by a rope while grasping onto it with both hands

  • Superman/Super Woman

    • Prone extension with arms and legs fully extended activates muscles antagonistic to the tonic labyrinthine prone reflex

  1. Meatball Position- activates muscles antagonistic to the tonic labyrinthine supine reflex

    • Child uses their own hands to place/remove stickers on knees or feet or rings from their feet

  2. Supine

    • Bounce ball off hands while child’s shoulders flexed to 90 degrees with elbows straight; therapist drops ball from above for child to volley back

    • Use legs to kick suspended ball

    • Supine on therapy ball; transition into sitting

  3. Bridge Position

  4. Rolling

    • Outside-down or up hills

    • With arms overhead or at side

  • Note: Be sure to encourage chin tuck

The Side lying Position offers the opportunity to increase strength and endurance while moving in 3 planes.

  • The child will learn to balance by keeping their head and body oriented in midline; remember to not only focus on maintaining this static position, but transition into and out of side lying.

  • The child should remain static for brief periods; even minimal weight shifting from the child’s center of gravity may activate head and torso righting.

  • Be sure to encourage the use of this position on their right and left sides. This will lengthen muscles needed for full rotation of the trunk.

  •  Remember…full expression of equilibrium reactions requires torso rotation and freedom of movement in the upper and lower extremities

Reach- Use free arm to encourage reaching and other movement /manipulation

  • Play games such as Connect Four in high side lying

  • Swat at suspended ball with free arm while in high side lying

  • Work puzzles with free hand while in high side lying

While Side Sitting strive to have child free both hands free to manipulate object at midline; this may require considerable time and practice.

  • To work toward this, encourage the child to adjust to small weight shifts away from their midline.

  • Remember…diagonal control sets the stage for isolation of movement for each limb, important for minimizing the effects of primitive reflexes on functional movement.

  • Side Sit

  • String beads in side sit

  • Lace in side sit

  • Toss a ball while side sitting

  • Catch a balloon while in side sitting

Offers the opportunity to stretch muscles that are often tight in children that need to “fix” due to immature balance and ongoing influence from primitive reflexes.

  • This position can help lengthen the hamstrings[1]

  • Strive to have child free both hands to manipulate an object at midline.

  • This position also provides a chance to develop balance by narrowing the child’s base of support.


[1] a muscle that often tightens as children over-use to stabilize.

  • On tilt board

  • Turn head side to side, raise head up & down, or “roll” neck without moving knees or hands

  • Rock body back & forth or side to side while knees and hands planted

  • Creep though tunnel forward and backward

  • Creep over obstacles such as cushions, pillows, bolsters, etc.

  • Creep sideways

  • Donkey Kicks- raise one leg into extension, then flex/extend knee so as to kick

  • Two Point- Maintain one arm & one leg in full extension  

  • Transitioning between Tall and One-Half Kneel provides an excellent opportunity to develop the strength and balance to not only minimize the influence of primitive reflexes, but to develop the motor planning for energy efficient and functional movements.

  • Slowly transition between tall and one-half kneel

  • Use hands to complete tasks placed on vertical surface

  • When encouraging transitional movements, such as Standing to Squat, be sure to focus not only on the end position, but accomplishing the movement in a smooth and efficient manner.

  • This will set the stage for the child to adopt this pattern in to their functional movements.

  • Squatting provides opportunity for developing hip stability and balance.

When Standing & Walking:

  • Stand and roll a ball up & down the wall with head sideways and arms perpendicular to torso

  • Stand and balance on one foot for several seconds

  • Hop from one foot to another

  • Stand with feet planted while catching a ball thrown slightly out of reach toward his/her side

  • Stand facing wall with straight elbows and palms against wall, rotate head left to right without bending elbows

  • Stand with back to wall and legs apart; touch right foot to left hand, then left foot to right hand

  • Stand while using hands to complete tasks placed on vertical surface

  • Walk while holding a tray full of objects; pause and turn head side to side and up/down

  • Walk & catch objects with a play fishing pole; use one hand to hold the pole and other to remove “caught” object

Primitive Reflexes Inhibition/Transition: Explained above

Development of Equilibrium & Postural Reactions

  • Make the child set on a swing or unstable surface like therapy ball and push the child or tilt the board to make him give the reaction.

Head Control

  • Prone or supine over a bolster, wedge, or half roll

  • Traditional and Modified Pull-to-Sit Maneuver 

  • Tummy Time (prone on floor)


  1. Start with propping on elbows

  2. Turn head to look to the side and side-bending of trunk

  3. Weight shifting by moving the elbows sideways, first by pulling with leading elbow to pull the trunk sideways, and then moving the other elbow closer to the pulling elbow

  4. Start with one pivot at a time & move gradually to pivot in full circle 


Rolling from Supine to Prone Using LE

  1. Using your right hand, grasp child’s right lower leg above ankle & gently brings child’s knee toward chest

  2. Continue to move child’s leg over body to initiate a rolling motion until child is side lying or prone

  3. Alternate the side toward which you turn child

  4. If the lower extremity is used as the initiation point of movement, the pelvis and lower trunk will rotate before upper trunk and shoulders (Segmentally)

  5. As child does more of the movement, you will need to do less and less until, eventually, the child can be enticed to roll using a sound or visual cue or by reaching with an arm

Trunk Control/ Sitting

Progression of Sitting Postures Based on Degree of Difficulty

  • Supported Sitting

    • Gradually decrease level of support (Move from proximal to distal)

    • Progress to high sitting position

  • Sitting Propped Forward on Both Arms

  • Sitting Propped Forward on One Arm

  • Sitting Propped Laterally on One Arm

  • Sitting Without Hand Support

  • Side Sitting Propped on One Arm

  • Side Sitting with No Hand Support

  • Kneeling

Movement Transitions

Once child is relatively stable within a posture, he needs to begin work on developing dynamic control

One of the first things to work on is shifting weight within postures in all directions, especially those directions used in making transition or moving from one posture to another

  • Coming to Sit from Side Lying

  • Coming to Sit from Supine or Prone

  • Sitting to Prone

  • Prone to Four-Point

  • Four-Point to Side Sitting

  • Four-Point to Kneeling


Creeping & Crawling

Put child in a quadruped position to enhance segmental movement

Balance & Post walking skills

  • Balance board activities

  • Jumping rope

  • Obstacle courses

Core strengthening activities

  •  Therapy ball activities

  •  Scooter board activities

  •  Animal walks

Bilateral Motor Coordination

  • Animal walks

  • Jumping, skipping, ball play


  • Brain gym

  • Playing or watching TV in prone on elbow position

  • Animal walks, Wheelbarrow walk

  • Monkey bars

  • Push-ups, Chair push ups

  • Therapy ball exercises

  • Drawing or coloring on vertical surface

  • Set up table top activities that force the child to pick up an object with right hand and place it on left side of table and vice versa

  • Ask child to use one hand to reach across body to pick up items on the table or on the floor (blocks, Legos etc.)

  • Have child draw large sideways figure eights on a vertical surface (i.e. on a whiteboard, chalkboard, or piece of paper taped to wall)

  • Have child imitate large movements that require crossing midline and diagonal patterns (i.e. left hand to right foot)

  • Maximize chances to use both hands (bilateral tasks)

  • Present items at midline & let child select the item with either hand, but have the child use that hand for the entire task without switching

  • Observe child carefully & note what hand they use most often

  • After identifying which hand is more skilled (dominant hand) have the child wear a bracelet or ring on that hand as a reminder

  • Therapeutic putty is available in different strengths, identified by color

  • Note: Give the correct strength to child, especially if he has hyper-mobile joints

  • Clothespin activities

  • Finger tug of war

  • Squirt guns or spray bottles

  • Pop bubble wrap with thumb and index finger

  • Squeeze ball/ stress ball

  • Hammering game

  • Sopping Sponge: use a sponge to sop up water & then squeeze into another container

  •  Use raw beans, popcorn, coins, buttons, marbles etc., hold them in the palm & manipulate up to finger tips using one hand at a time

  • Place a small object between the tips of child’s finger & thumb and ask her to hide the object in his hand

  • Ask child to pick up small object w/ his fingers & thumb & hide it in hand

  • Ask child to hide a coin in her hand and then put it in a moneybox

  • Use a dice or place a sticker on one side of a wooden cube & Encourage child to hold the dice or cube between the tips of fingers and thumb and turn it around and over to find “the number 6” or the sticker

  • Rolling Dice

  • Flipping Coin

  • Spinning game

  • Finger Twister, Finger soccer

  • Shuffling cards

  • Imitation of finger movement

  • Playing on piano

  • Dancing Finger songs (i.e. itsy bitsy)

  • Use eye droppers to pick up colored water and make designs on paper

  • Play dough-roll into small balls

  • Stickers

  • Opening/closing jars

  • Nuts & bolts activities

  • Using a toy hammer and nails

  • Using screw driver

  • Lacing cards

  • Stringing beads

  • Legos

  • Placing stickers

  • Using rulers or stencils

  • Spooning into a container

  • Throwing/ catching a ball or beanbags

Does not develop until at least 4 years of age & do not mature until 6 years, Much later in children w/ developmental motor delays.

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Pre-requisites for learning to use scissors

  • Ability to pay attention

  • Ability to open & close hand w/out spreading the fingers

  • Ability of one hand to move in a different way to other hand (holding/ cutting)

  • Eye-hand coordination

  • Adequate tone & strength to stabilize trunk, shoulder, elbow, forearm wrist

  • Adequate sensory feedback to calibrate motion (right amount of force)

Correct way to hold scissors

  • Thumb in small loop & facing upwards

  • Middle & ring fingers through large loop

  • Index finger curled over large loop to provide stability

  • Ring & little fingers curled into the palm for strength

Common grasp used by children w/ delays is pronated scissor grasp

  • Thumb pointing down toward the table & other fingers extended

  • Very inefficient & must be discouraged 

Progression of cutting skills

  • Snipping: child cuts short, random snips

  • Cut between lines of glued straws, lollipop sticks or sandpaper

  • Cutting along thick straight lines in a forward motion, gradually moving to thinner lines as level of skill increases

  • Cutting and stopping: child is able to control cutting to stop at a point. It is important that children can do this before trying to change direction

  • Cutting with direction changes: child is learning to stop and turn the paper when they reach a corner

  • Cutting shapes w/ rounded edges: child has to continuously turn the paper as they are cutting


Progression of cutting shapes

  • Cut out large squares, rectangles, triangles before attempting smaller shapes

  • Cutting more complex shapes and figures (i.e star, cloud)

  • Cut along a spiral to make a snake

  • Cut out large pre-drawn letters or numbers

  • Cut out pictures from a magazine to make a scrapbook


Activities to promote pre-cutting skills

  • Use kitchen or salad tongs to move items from one place to another

  • Punch holes w/ a handheld paper punch

  • Squirt water from one container to another using small ear drop bottle

  • Pick up & release objects between thumb & first two fingertips whilst holding the ring & little fingers against the palm

  • Open & close tools while holding a small object (e.g. cotton ball) in the palm w/ the ring & little fingers

  • Press the trigger on a squirt gun or spray bottles


Types of scissors for children:

Easy Grip Loop Scissors, Dual-Control Scissors, Self-Opening Scissors, Long Loop-Self-Opening Scissors

  • Easy grip loop scissors: self-opening lightweight scissors that allow the child to hold the loop without having to place fingers/thumb in smaller holes

  • Dual control training scissors: allow the child to experience the motor movements involved in cutting, as an adult and child can cut simultaneously

  • Self-opening scissors: Has a spring that automatically open the scissors after closing it, it makes cutting less effortful, so that more concentration can be applied to accurate cutting

  • Left-handed scissors: essential if left-handed children are to achieve success with cutting skills

  • Low-tech solution: put a colored dot on the scissors to remind the child where her thumb needs to go so she can hold it upwards


Ayres Sensory Integration:

  • Individual therapy to strengthen the weak sensory integration and praxis abilities

  • Therapist presents just-right modulation challenges, gradually expanding child’s ability to function in a wider range of activities & social situations

  • Usually provided in conjunction with other sensory intervention strategies

We also reframe behavior for parents & teachers’ insight

Sensory stimulation protocols (passive application)

  • Wilbarger brushing=>

  • Vestibular stimulation (Astronaut program)

  • Auditory programs (sound therapy)

For more info for both, you can check this link:

Sensory-based strategies

  • Weighted vests

  • Therapy ball chairs

  • Hug machine

  • Compression garments

Consultation on modification of environments or routines to optimize arousal state & performance

  • Changes in lighting

  • Use of headphones

  • Selected clothing

Design “sensory diet” =>

Routine that incorporates supportive sensory breaks experiences at strategic points throughout the day

Teach cognitive self-management strategies

  • Nonverbal: guide child to special calming place at home when distressed

  • Verbal: cue child to ask self “What can I do to help myself feel better?”

  • “Alert Program for Self-Regulation” is a curriculum to teach sensory strategies to children for self-regulation of arousal level

Other related interventions:

  • Water-based intervention:

The use of water and water-induced resistance to improve physical functioning is accepted by the medical community as a method in which to rehabilitate, or re-educate, the human body.,can%20be%20a%20healing%20force.


  • Hippotherapy

Hippotherapy literally means" treatment with help of the horse". It's a treatment strategy that utilizes equine movement in a therapeutic way for patients with movement dysfunction.


  • Aroma therapy 


For more information about sensory based intervention, check this link:

Sensory diet:

  • Personalized daily schedule (throughout the day) of specific sensory activities & environmental modifications designed to meet a child’s specific sensory needs.

  • Powerful behavioral tool

  • Provide just-right combination of sensory input to achieve & maintain optimal level of arousal & performance in the NS

  • Help a child stay calm, focused and organized throughout the day

  • Enhance the ability to orient & respond to sensation

  • Prevent sensory & emotional overload by satisfying the NS needs

  • Reduce self-stimulatory (stemming) behaviors & self-abusive behaviors

  • Improve postural function, enhance body schema, improve self-regulation & reduce sensory defensiveness

  • Applied regularly throughout the day/ part of daily routine

  • Consist of Main courses & Sensory snacks


D: Do an Informal Assessment

  • Assess the Environment and the Individual’s response to a variety of sensory experiences for all the sensory systems

 I: Individualize

  • What has worked for one person may not work at all for someone else!

E: Environmental Supports

  • Organized, Predictable, Structured, Consistent Environment, Visual Supports

T: The Power Senses

  • Tactile, vestibular & proprioceptive

Consideration for Sensory Diet:


  • Create stimulating environment

  • Give time to respond

  • Frequent encouragement to try new experiences


  • Provide sensory experiences frequently & proactively

  • Balance excitatory & inhibitory experiences

  • Provide proprioceptive inputs throughout the day


  • Use of visual supports & routines

  • Structure the environment

  • Limit stimulation

  • Limit change but prepare for changes when they need to occur

  • Use predictable stimulation (i.e. rhythmic)

  • Gentle introduction to new experiences

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Wilbarger brushing:

Specific professionally designed treatment to reduce sensory defensiveness. Lack documented research, but experienced therapists reported positive outcomes. Parents reported decreased sensory defensiveness & improved behavior &interaction


  • Deep massage using a surgical brush over arms, legs, back with a soft brush with consistent deep pressure

  • Followed by joint compressions to shoulder, elbows, wrists, hips, knees, ankles

  • Repeated every 90 minutes to 2 hours

Caution: Wilbarger protocol should only be implemented after an assessment & training by a qualified professional



  • Brushing start by arms, compressions start by lower body (hips)

  • Avoid spine and inner thighs

  • Avoid discontinuation

  • 3 lines on arm and leg

  • Not too fast not too slow!!

  • One-way direction, deep pressure

  • One stroke at one time

Joint compressions:

  • Joint compressions: neck and fingers are optional.

  • 7-10 joint compressions (all joints the same number of compressions)

Videos that explain how to do this technique:

Aromatherapy (related to smell):

Aromatherapy is a wonderfully therapeutic way to address children with sensory processing disorders (or even without) who are hypersensitive to smells (decrease olfactory sensitivity).

  • Through aromatherapy products, including aromatherapy machines, oils, candles, diffusers etc., child is helped to tolerate or drown out smells, or use them to relax and calm.

  • They are a great relaxing OR stimulating tools,

    • depending how, where, and when they are used and which smells you choose (for example; while cinnamon might be stimulating, lavender may be soothing).

Basic cognitive skills:

  • Attention (focused, Sustained, Selective, Divided, Alternative)

  • Memory (immediate, Short Term, Long Term)

  • Alertness/ Arousal

  • Orientation (Time, Place, Person, Situation)

  • Initiation & termination of activity

  • New Learning

Higher cognitive skills:

  • Command Following

  • Sequencing

  • Planning/Organization

  • Abstract Thinking

  • Decision Making

  • Safety/ Judgment

  • Problem Solving

  • Mental Flexibility

  • Self-Awareness/ Insight

  • Generalization of Learning

  • Categorization

  • Self-Control/ Impulse Control

Visual perceptual skills:

  • Visual Discrimination

  • Visual Memory

  • Visual Sequential Memory

  • Visual Spatial Relationships

    • Depth Perception

    • Right-Left Discrimination

    • Figure-Ground Discrimination

    • Form Constancy Discrimination

    • Position in Space Discrimination

    • Topographical

  • Visual Form Constancy

  • Visual Closure

  • Visual Figure Ground

Motor Perception

  • Ideational Apraxia (understand the motor demands of a task involving sequential steps)

  • Ideomotor Apraxia (kinesthetic memory of motor patterns)

  • Constructional Apraxia

    • Copy or build two- & three-dimensional designs

    • Construct a house or a car using Legos (or similar toy construction pieces)

  • Identify object or picture shown briefly & shown again

  • Sorting by:

    • Primary colors, shapes, size, characteristics

  •  Matching:

    • Identical objects, identical pictures, objects to their pictures

    • Categories objects or pictures into common categories (like fruits, animals)

    • Match pictures based on functional relationships, such as shoes & socks (Logical association)

  • Identify body parts & Imitate simple motor actions

    • Clapping hands, hands up, hands on eyes, tapping left leg

  • Demonstrate use of everyday objects

    • Spoon, comb, toothbrush, socks, telephone, etc.

  • Complete several pieces of interconnected puzzles

  • Building blocks/ construction:

    • Imitate building tower, train, bridge, or from a picture

    • Build representationally with blocks

    • Reproduce simple block design from memory

  • Nest cups or stack rings of graduated sizes

  • Complete sequence of colors or shapes (Pattern)

    • AB pattern, ABB pattern, ABC pattern

  • Identifies missing parts in pictures

  • Sequence the steps of simple stories

  • Imagine & describe what happen next in unfamiliar story


For more information:


Development of Pencil Grasp:

  • 1–1.5 yrs: Palmar-supinate grasp: arm moves as a unit

  • 2–3 yrs: Digital-pronate grasp: forearm moves as a unit

  • 3.5–4 yrs: Static tripod posture: hand moves as a unit, wrist in neutral position, index & middle finger straight

  • 4.5–6 yrs: Dynamic tripod posture: thumb & index finger isolated


Pencil grip Intervention:

  • Tactile activities to improve tactile awareness

  • Pick up small beads/beans with thumb and index finger and drop in bottle

  • Draw w/ broken chalk or crayons

  • Draw in the sand with a stick, feathers, or straws

  • Clothespins, tweezers, tongs, chop sticks, spoons

Hand writing: (mainly fine motor and visual-motor integration[1])

  • Match

    • upper case letters

    • lowercase letters

    • numbers 0 to 9 (may confuse 6 & 9)

    • name & short words

  • Sequence of skills:

    • Scribble spontaneously

    • Vertical stroke, horizontal stroke, circle, cross, square

    • Connecting dots/ trace

    • Copy shapes

    • Coloring


[1] Involve coordinated use of vision & hand together

ADLs include:

  • Bathing & showering

  • Toileting and toilet hygiene

    • Bowel & bladder management

  • Dressing

  • Swallowing, Eating & feeding 

  • Functional mobility

  • Personal hygiene

    • Brushing teeth & grooming

  • Ability to listen and follow direction

  • Cooperation with others

  • Sharing with others

  • Respecting personal space

  • Waiting for turns

  • Using polite words and proper humor

  • Dealing with disappointments

  • Initiating, continuing, and terminating of conversations

  • Ability to guide and take care of others

Some recommended interventions:

here we can benefit from our role as a play partner.

  • Social skills training steps (for example wait for his turn):

  1. Identify the skill

  2. Discuss the steps of the skill

  3. Model the skill

  4. Practice the skill

  5. Provide positive reinforcement

  6. Provide corrective feedback

  7. Assign homework

  8. Review homework

  • Play with other kids and share things with others (maybe brothers, sisters, peers, friends)

  • May share the therapy session with another child


Family Routine: very important to consider when planning ADLs Intervention

Example: Work in the morning Vs. Practicing tying shoes

  • Repetition & development of habits &

routines are essential organizers,

especially for children who take long

time to learn new skills or have poor


  • Once self-care routines and patterns

are developed, it is essential to maintain

them and any of environmental supports that promote continued ADL success

Create a stable daily routine

  • Types of routine? (daily, weekly, weekend, summer time, etc.)

  • What can you use to create routine? Use visual schedules or written





  • Child should not depend on schedule, he should be flexible (ex, it is raining so we are not going to the mall)
  • Use schedule to prepare the child psychologically that we are traveling next week, or you are going to cut your nails after the shower

  • Routine will help the child to stop bad behaviors and replace bad habits with good ones

  • Rewards and charts can give the child sense of accomplishment

  • Routine should include activities the child likes

What to include in child routine? It is different for each child

  • Morning routine (ex: brushing teeth, dressing)

  • Afternoon routine (ex: lunch, HW)

  • Evening routine, (ex: dinner, sleep)

  • Indoor, outdoor activities (ex: draw, PlayStation, bicycle, swim)

  • Clubs (ex: football, swim)

  • Appointments

Quick and general tips for managing children:

  • Always give the child choices

  • Build on the child’s interest

  • Read the child’s cues

  • Use visuals

    • First-Then schedule

    • Token system

    • Reward Chart

  • Use rewards

  • Count Down

Behavioral therapy techniques:

We use the cognitive behavioral therapy techniques to reframe and restructure the thoughts and behaviors of the child and to enhance his coping skills

These techniques are specially used with stubborn children or those who have low self-esteem.

Techniques include:

  1. Practice and rehearsal

  2. Reinforcements

  3. Shaping

  4. Psychoeducation

  5. Relaxation and breathing exercises

  6. Physical exercises

  7. Interpersonal skills training

  8. Role playing

  9. Home assignments

  10. Scheduling activities

  11. Self monitoring

Five principles in handling children with CP

  • Principle 1:  Head position influences whole body position and should be in the midline

  • Principle 2:  For helping and supporting a child, you should always grab trunk and proximal joints

  • Principle 3: During working with a child, with joint compression you can increase stability in the body

  • Principle 4: Reduce your help to children gradually

  • Principle 5: Children and caregivers should get an appropriate and comfortable position during caring the children

Reference book: Bower, E (2009) Finnie's handling the young child with cerebral palsy at home, Elsevier, Edinburgh.

  • It helps to improve proprioceptive feedback by changing abnormal tone and facilitating more normal patterns of movement.

  • Position and movement activities that encourage mobile weight-bearing are particularly good.

  • The techniques of ‘tapping’ and ‘compression’ will also help to increase information to the joints.

Dysfunction in NDT is measured by:

  • level of muscle tone present

  • Synergistic movements

  • Automatic reactions

  • Developmental level of reflex present in the person

Techniques include:

  • Handling techniques

  • Facilitating techniques

  • Joint compression on affected side

  • Weight bearing on affected side

The occupational therapist might visit the house of the child to evaluate the accessibility, ensure the safety of the environment, make sure that the environment is helpful for the caregiver, and suggest home modifications.

  • Jelly balls: balls that come in sizes and has a soft touch. It can be used for tactile input, improve fine motor skills, color identification, etc.

  • Clip board: the board comes with pattern sheets so each clip has a specific place. It can be used to improve fine motor skills, sequencing skills and eye-hand coordination.

  • Grooved pegboard: a test that can be used for intervention also as it assess and works on: in hand manipulation, and eye-hand coordination.

  • Tack zap-farm: the game includes a hammer, board and wooden shapes. Child tacks the wooden figures on the board, which improves fine motor skills, concept formation, muscle strength, and expressive skills.

  • Swing: child can be swinged in many directions (spinning, spiral, vertical, horizontal) and the child can be positioned as prone, seated, supine, or standing. It gives the child sensory inputs especially vestibular, it can also be used to calm the child down

  • Cutting fruits and vegetables game: fruits in halves connected by Velcro, child has to cut them with a plastic or wooden knife. It improves: categorization, figure ground perception, concept formation, bilateral coordination, muscle strength, etc.

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