Oftentimes parents ask me, “Why would my child need OT in a clinic setting, if they receive OT as part of their IEP?”. This is such a great question! Occupational therapy is such a wide-reaching profession, that it sometimes seems like all settings are the same. In actuality, there is a big difference in the scope of practice depending on the setting. Let’s break down the difference below!
Sessions typically occur in a specialized clinic setting with swings, slides, climbing equipment, and games. Parents are invited into the sessions to learn ways to work on skills outside of the session. The frequency and duration of sessions are based on recommendations from the therapist at the start of intervention, but can be adjusted to a child’s schedule as needed. Therapists can also perform occasional classroom observations to support the child if needed. Typical frequency/duration is 30-60 minutes per week of direct services (i.e. one therapist working with one child for that length of time).
Skills Addressed:
Dressing: putting on and taking off clothes, tolerating clothing textures, fastening buttons and zippers, tying shoelaces
Hygiene Routines: Toileting, teeth brushing, showering and bathing, hand washing, flossing, hair washing, etc.
Feeding: using a spoon, using a fork, using a knife, tolerating food textures, trying new foods
Play Skills: Cooperative playing with others, frustration tolerance, following group instructions, playing in a variety of settings (i.e. sand, grass, play structures, etc.)
Fine Motor Skills: Handwriting, pre-writing shapes, scissor skills, coloring, opening food packages, pencil grasp, etc.
Sensory Processing: Being able to handle all aspects of a child’s daily routine (all the tasks- and more- listed above) without becoming overwhelmed or upset. Being able to sit and attend to daily tasks without needing to get up and move, and being able to tolerate change in routines.
What a Session Looks Like?
At Valued Voices, our sessions are designed to meet the needs of the child and their family. Parents are invited to participate in the sessions, but if this is not possible, a detailed report is provided after each session. The activities are all child-friendly, encourage movement, and are adaptable to your child. They take place in both the clinic gym, and the fine motor room, and can include obstacle courses, fort building, swings, board games, crafts, and more!
Funding:
Typically outpatient services are funded by medical insurance or private pay.
School-based occupational therapy:
Place:
Sessions can occur in your child’s classroom or in an occupational therapy office. Sessions can also take place in a group format or individual format (one therapist to one child). Therapists are a part of the IEP or 504 team, and are mandated to fulfill the service requirements outlined in the IEP/504 plan. The frequency and duration of services remains the same until the next meeting with the team. The duration/frequency typically ranges from consultation (i.e. the therapist meets only with your child’s academic team and no direct service is provided), to 15-60 minutes per week. This can vary, though, depending on the child’s needs.
Skills Addressed:
Fine Motor Skills: Handwriting, pre-writing shapes, scissor skills, coloring, opening food packages, pencil grasp, etc.
Access to the academic curriculum: This basically means making sure your child can participate in the school day to a functional degree. This may include adapted seating, accommodations for breaks and regulation strategies, or extra time for test taking. School based occupational therapists can suggest tailored accommodations to make the school day functional for your child.
What a Session Looks Like?
The therapist arrives at your child’s classroom and will conduct the session during the school day. The sessions focus mainly on the goals included in the IEP/504 plan. Activities include specific games, movement activities, writing tasks, typing, and crafts geared towards boosting skills in a fun way.
Funding:
School based occupational therapy services are financed through the state, and are free for students in public schools if they qualify.
Ultimately, both school based and clinic based occupational therapists are dedicated to adapting your child’s environment to their skills, while fostering growth and independence. Oftentimes, children receive both types of services to make progress in both the school setting and the home/community settings. If your child is in need of support, it’s important to determine where they are having trouble (i.e. school only, or school, home, community) and where the challenges arise (i.e. daily routines, during the school day, outings with family, etc.) to best determine which type of occupational therapy to pursue. If clinic based occupational therapy seems to meet the needs of your child, reach out to us for a complimentary consultation!
Sholeh Shahinfar is the Founder of Valued Voices, a licensed Speech Language Pathologist, Child Communication Specialist and Certified Oral Motor Therapist. She is passionate about uplifting children’s voices in the world and inspiring self-expression. In her free time, Sholeh embraces a vegan lifestyle, loves going to the ocean, exploring nature with her pup Kobe, practicing yoga, traveling, and spending time with her loved ones.
KAELYN GREEN
Kaelyn Green is a licensed occupational therapist at Valued Voices. She is certified by the University of Southern California in Sensory Integration and is an advocate for addressing underlying sensory functioning in order to improve occupational performance. She is passionate about meeting children and families where they are at and seeks to tailor interventions to the unique needs of her clients. When she is not working, you will find Kaelyn taking care of her two goldendoodles, working in her garden, or taking trips to the Central Coast.
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Handwriting is one of the most common areas parents ask me about in my practice. It is such a necessary occupation for classroom tasks, general fine motor development, and visual perception/motor tasks. Pencil grasp development is central to legibly completing handwriting tasks and there are so many factors impacting pencil grip development and fine motor control that it can be tricky to determine when grasp patterns are ineffective and when/how to intervene.
What is a Pencil Grasp and Why is it Important?
Simply put, a pencil grasp is the way in which one holds onto a writing utensil. While I could go on and explain the technicalities of finger placement in relation to the writing tool, and how the hyperextension of different joints impacts the success of the grasp, it really is not relevant in this context. In general, an effective grasp pattern is one that does not cause fatigue quickly when writing or drawing, and that does not impact the legibility or accuracy of the work. Pencil grasp can have a large impact on the legibility of handwriting, which is a relatively large occupation for kids. Therefore, remediation of dysfunctional grasp patterns is important to academic success.
Pencil Grasp Development and Dysfunctional Pencil Grasps
As a child grows, they gain more control over coloring and writing tools, which lead to development of a mature grasp. Typically a child’s pencil grip moves from fisted (or using the entire hand to retain grasp of the tool) to digital pronate (or holding on to the top of the pencil and pointing the index finger down towards the writing tip) to a four finger or quadrupod grasp. A quadrupod grasp is where the thumb and index finger are in opposition around the pencil tip, the middle finger supports the index, and the pencil rests on the ring finger. A three finger or dynamic tripod grasp is where the thumb and index fingers are controlling the pencil movement, with the back of the pencil rest on the middle finger. Basically, it’s expected that the child holds the pencil with an “adult grasp” around age 5. There is a lot of variation in pencil grasps, and really pencil grips are dysfunctional when the child is using an immature grasp pattern or when they are using too much force or pressure when completing work.
Factors Impacting a Child’s Pencil Grip
Surprisingly, many different body systems need to work appropriately and efficiently to support a functional pencil grasp. The common areas impacting pencil grip are detailed below, however it’s by no means comprehensive. Occupational therapists work to determine if the pencil grip is dysfunctional, if intervention is warranted, and what specific areas are impacting functional grip development. Occupational therapists in both the school system and in outpatient clinics can work on fine motor skills and help your child develop an appropriate grasp.
Core Strength and Postural Control:
As an OT, they teach you “proximal stability leads to distal mobility”. In other words, you need to have strength and control in your core, shoulder and arm muscles to allow for your finger and wrist muscles to do their jobs. If you think about it, you won’t be able to write or draw anything well if you can’t sit upright in your desk, or are having to use whole arm movements to complete that drawing. If you don’t believe me, I highly encourage you to try signing your name or completing a more precise drawing activity while keeping your wrist and elbow stable, and only moving your shoulder and arm. It’s tricky, I promise. Core strength and functional strength in your shoulder and arm muscles allow for development of tool use and fine motor coordination. When remediating pencil grip, this is usually where I start.
Proprioceptive and Tactile Processing:
Proprioceptive processing and tactile processing are exceedingly important to efficient pencil grasp development. Proprioception is our body’s way of determining body awareness and body position. The receptors are located in all of our muscles and joints and are activated by stretching and contracting our muscles or applying force or resistance to our joints. This system helps other types of input integrate in the central nervous system due to the anatomical orientation of the nervous system tract. It is responsible for safety awareness, gradation of force and pressure, tool use, gross motor and fine motor coordination, and self-regulation. The tactile system is our body’s way of receiving, decoding, and reacting to touch. This system can process light touch, deep pressure (tight hugs, weighted blankets) vibration, and temperature. The main receptors are in our skin, with the highest concentration of receptors located around our mouths and fingers. Now you may be thinking that these don’t sound relevant to handwriting and hand muscles, but trust me on this. Hand muscles require the same communication from our nervous system as all other body systems do. When proprioception or tactile processing is not efficient or is unreliable, maintaining an effective grasp pattern is challenging to say the least. It can be hard to “feel” the writing tool in your hand, resulting in needing more surface contact in order to feel in control of that writing utensil. This may look like a closed web space (or the area between the thumb and index fingers is small) rather than the ideal open web space. Therefore, you may often see a fisted grasp or a variation of a four finger grasp when children who present with sensory processing differences are writing. It is not always a matter of strength, it’s maybe a matter of subcortical processing and sensory integration.
Fine Motor Strength:
Oftentimes children have limited strength, low muscle tone or limited dexterity in the small muscles of the hands, impacting their ability to maintain an appropriate grasp on a coloring tool. This is typical of children who can write one or two sentences with a dynamic tripod grip, then fatigue and switch to a less functional grasp pattern. Generally speaking, a closed fist grasp or digital pronate grasp require less strength and coordination than a tripod grasp does.
When is Pencil Grip a Problem?
Everyone uses a different type of grasp. Whether you use a thumb wrap, three fingers, four fingers, or some combination of grasp types. Pencil grasp development is important but its also important to recognize that different does not always mean wrong. Occupational therapy may be warranted when the grasp development is impacting function. If your child’s hand is getting tired quickly, or if their grasp is impacting the legibility of their handwriting, then remediation may be needed.
Tips for Adjusting Pencil Grasp at Home
While there are many different strategies for adjusting pencil grasp, here are a few of my favorites:
Pencil Grips
There are just about a million different pencil grips you can find which say they are the best for promoting a dynamic tripod grasp. I wish I could point you to a surefire brand or type that works for all kids regardless, but unfortunately that isn’t the case. Your child will likely need to try out quite a few different grips to determine which one fits their little fingers the best. Whether it’s a triangle grip, a “puppy dog” grip, or a crossover grip, see which is most comfortable for your child’s little hands and which is promoting appropriate thumb, index finger, and third finger placement.
Hiding “Treasure”
This may be one of my absolute favorite tricks. When a child is holding a crayon or pencil with a less than functional grasp, I ask them to “hide” pom poms or other small objects against their palm with their fourth finger and pinky. This will force the fingers to move into a. tripod grasp as only the thumb, index fingers and middle fingers are available to hold the pencil. Try keeping this small object in the hand for as long as tolerated, and work up to longer periods. If your child has smaller hands, use smaller objects. Remember, your child’s hands are working hard to maintain the grasp, and they may fatigue. It is okay to take breaks while the muscles build strength and develop.
Fine Motor Games
Just like other muscles in our bodies, our fine motor muscles need to develop with different stretches, exercises, and activities. In occupational therapy we often play different “warm up” games before moving to handwriting activities. This helps to wake up those muscles before we ask them to hold a pencil correctly. Your child can work on these muscles by using resistive putty to find treasures like beads or gems, placing coins into a piggy bank using their thumb and index finger to pick up the pieces, playing Mancala or opening and closing a tennis ball monster to feed him pom poms. Any activity that requires coordination of fingers and hands is likely helping develop those pencil-grasp muscles.
In summary…
Just like the rest of our body, our children develop hand strength and coordination over time. Exercising is key to developing an appropriate pencil grip. If you have concerns about the way your child is holding their pencil or crayon, it is always best to consult a trained occupational therapist. Whether or not occupational therapy is needed, the therapist can help develop specific activities your child can use to improve their pencil grip.
Kaelyn Green is a licensed occupational therapist at Valued Voices. She is certified by the University of Southern California in Sensory Integration and is an advocate for addressing underlying sensory functioning in order to improve occupational performance. She is passionate about meeting children and families where they are at and seeks to tailor interventions to the unique needs of her clients. When she is not working, you will find Kaelyn taking care of her two goldendoodles, working in her garden, or taking trips to the Central Coast.
As an occupational therapist, the number one question I get from parents, caregivers, and even other professionals is “What is occupational therapy?”. The name really doesn’t provide a lot of information on what OT intervention looks like, or how it benefits a pediatric population. Occupational therapists are trained healthcare professionals who help individuals who experience traumatic injuries, illness, or developmental delays increase independence and confidence in order to participate in everyday tasks. Occupational therapists have a master’s degree or a doctoral degree and can have additional certifications in sensory integration. While OT’s can work with adults too, pediatric occupational therapists work to develop fine motor skills, gross motor skills, school skills, and other types of skill sets in order to support participation.
What is a Childhood Occupation?
Occupational therapy addresses anything and all things you need to do during your everyday life. Consider how your morning went. You probably woke up, got dressed, brushed your teeth and hair, made breakfast, packed a lunch, etc, etc, etc. These activities are all considered occupations because they occupy your time during the day. In order to complete these tasks efficiently, you need accuratefine motor skills, gross motor skills, visual perceptual skills, sensory processing skills, balance, bilateral coordination, executive functioning, and more. Occupational therapists work on developing skills in order to improve independence with day to day tasks. For children, occupational therapists develop treatment plans which focus on improving sensory integration, developing gross motor skills, bilateral coordination, executive functioning, problem solving, and fine motor skills needed to meet developmental milestones, achieve independence with everyday activities, and improve their ability to play and develop peer relationships.
What are Fine and Gross Motor Skills?
Gross motor skills include any motor action that uses large muscles of our body. If you are. using your arms, legs, core, or any combination of those major muscle groups, you are likely completing a gross motor task. Examples of these skills include, skipping, jumping jacks, riding a bike.
Fine motor skills usually involve only the small muscles of the hands. Fine motor skills can include but are not limited to handwriting, scissor skills, using a spoon, fork, or knife, coloring, buttoning, fastening a zipper, shoe tying, stringing beads, etc.
What are Sensory Processing Disorders?
Sensory processing is the general term for how our body takes in information from the environment (sensory input) through our receptor organs (like our noses, eyes, mouth, skin, etc.), decodes that information, and then uses it to inform our motor reactions. We all process sensory information differently, and there is not a “correct” way to respond to different environmental input. That being said, when sensory processing issues impact function, well being, or independence with daily living, intervention may be warranted. Sensory processing disorders are the general description for difficulty tolerating, responding to, or registering certain types of sensory input from the environment, impacting day to day activities.
Emotional Regulation and Occupational Therapy
Oftentimes, when sensory processing or motor coordination are challenging, children can have difficulty regulating their emotions, tolerating frustration, filtering extraneous sensory input, and feeling confident and secure in their bodies. This can negatively impact social skills, school performance, and can cause strain for families. Seemingly minor disagreements or interactions can result in large emotional reactions, aggression, and big feelings. Occupational therapy works to help individuals develop a toolbox of coping strategies, communicate their feelings, and take steps to reduce the frequency of tantrums and frustration to promote positive interactions with daily activities.
Does my child need occupational therapy?
If your child is struggling to participate in everyday routines and activities (like brushing teeth, brushing hair, getting dressed, self-feeding, organizing materials, fastening zippers, fastening buttons, tying shoelaces, etc.) or is having difficulties focusing, completing multi-step tasks, or completing school activities, they may benefit from intervention.
Overall…
Occupational therapists work on developing skills in order to improve independence with day to day tasks. Childhood occupational therapy works to support those day to day skills for children ages 0-23. These areas usually involve dressing, self-care, self-feeding, fine motor, and gross motor skills. If you have concerns about your child’s development, behavioral problems, or suspect sensory processing problems, consult with your pediatrician or a pediatric occupational therapist to determine if services are needed. You know your child best, and if you have concerns, it is always best to reach out!
Kaelyn Green is a licensed occupational therapist at Valued Voices. She is certified by the University of Southern California in Sensory Integration and is an advocate for addressing underlying sensory functioning in order to improve occupational performance. She is passionate about meeting children and families where they are at and seeks to tailor interventions to the unique needs of her clients. When she is not working, you will find Kaelyn taking care of her two goldendoodles, working in her garden, or taking trips to the Central Coast.
Addressing the misconceptions and commonly asked questions.
As an occupational therapist, the number one question I get from parents, caregivers, and even other professionals is “What is pediatric OT?”. Occupational therapy encompasses so many areas of function, it can be hard to button down pages and pages of information into a succinct blurb in the moment. Below are some clarifications and answers to the most common questions surrounding occupational therapy.
Occupational therapists can work on many different areas including: dressing skills, grooming skills, feeding, sensory processing, handwriting, and pre-writing, attention and executive function, gross motor skills, fine motor skills, emotional regulation, etc.
Why do you find jobs for children?
Short answer is, “We don’t!”. The term “occupation” used to mean anything you do, and in more modern iterations has taken on meaning for “work or career”. Occupational therapy focuses on promoting independence with anything you need to do, want to do, or have to do as part of your daily life. Brushing your teeth, going to Target, getting dressed, swinging on a swing at the park can all be considered occupations. And those are the areas OT’s work on with children and adults!
So, you are basically a PT, right?
Nope! While we love our PT colleagues, and there can be a lot of overlap, we actually have very different jobs. Physical therapists work to “improve their [clients] ability to move, reduce or manage pain, restore function, and prevent disability” (APTA, 2021). Occupational therapists work to promote independence in daily occupations – whether that be improving strength, coordination, balance, fine motor skills, adapting the environment, etc. in many different performance areas.
Why do your sessions look like play?
If you have ever seen an occupational therapy clinic or an OT session, it probably looks like the clinician is just playing games with the child or being silly. In reality, we want the sessions to look like that. In order to develop rapport with your child, and to keep little ones engaged, we often disguise our exercises in games or movement activities. This way, your child has fun with their OT, while also working towards their goals. Rest assured, we are making progress towards the goals and improving function while being silly and fun.
Do you have any other questions about occupational therapy, or if your child would benefit from occupational therapy services?
Kaelyn Green is a licensed occupational therapist at Valued Voices. She is certified by the University of Southern California in Sensory Integration and is an advocate for addressing underlying sensory functioning in order to improve occupational performance. She is passionate about meeting children and families where they are at and seeks to tailor interventions to the unique needs of her clients. When she is not working, you will find Kaelyn taking care of her two goldendoodles, working in her garden, or taking trips to the Central Coast.