All posts by Guest Blogger

picture of a boy in a wheelchair completing an art project using the functionalhand to help hold his tools.

Executive Functioning – Making Strategies Inclusive

Assistive Technology, Executive Functioning, , , ,

Linda Merry, OTR/L, NDT/C

What is Executive Function?

The phrase “executive function” as described in the Harvard Journal, Developing Child, refers to a set of skills.  These skills underlie the capacity to plan ahead and meet goals, display self-control, follow multiple-step directions even when interrupted and stay focused despite distractions, among others.  

No one is born with executive function skills but nearly everyone can learn them.  Adults set up the framework for children to learn and practice these skills over time by establishing routines, breaking big tasks into smaller chunks, and encouraging activities involving rules, directions and planning skills.  

As our child becomes more competent and these areas of the brain develop, it enables them to plan for themselves.  It also allows them to focus and stay engaged with information to complete tasks.  Research has shown by 12 months of age, a child’s experiences are helping to lay the foundation for the ongoing development of executive function skills. 

Get Ready, Do, Done

Sara Ward and Kristen Jacobsen’s  framework, “get ready, do, done”, to support skill development provides a process to develop the executive functioning abilities.   This system is easily incorporated into all activities.  

Implementation

The first step is to help your child or student visualize what the project will look like when it is done i.e., what does the end look like.  Children need the opportunity to visualize the end before they plan their steps. This is especially true for a child who lacks the motor control to move their body or communication skills to verbalize their intent.  A child may have the ability to plan a task but lack the opportunity when others bring materials to them, place them on their surface and physically help with each step.

Next, you want the child to visualize the steps they need to take.  It may involve cutting a circle, drawing a picture, gluing, etc.  You want your child to think through the process. Let the child tell you what steps they want to take before beginning.

Last, to “get ready” the child should tell you what materials they need.  Is it markers, paper, ruler, glue stick, etc.?

Accessibility For The Child With Special Needs.

When a child can visualize what their completed project looks like, they can talk through the process and collect needed materials as independent as possible.  What if a child is unable to communicate verbally or walk over to get what they need?  Here are strategies that provide inclusive opportunities to use this framework.  It allows the child with neuromotor difficulties to participate in opportunities that lay the foundation for executive functioning.  The goal is to support their abilities and not allow their impairments to limit their learning.

Get Ready, Do, Done provides a visual or template to clearly demonstrate the thinking process.

Strategies To Support Inclusive Learning

  • Positioning Needs of the Child: When completing activities that require attention, concentration and upper extremity control, optimal positioning is important.  A child seated upright so they can view what their project looks like when completed.  Positioning  the child at 90:90:90 for the hips:knees:ankles  with feet supported is usually preferred.  
  • Tray Surface: Supporting the upper arm on a table surface provides a base of support for upper extremity control.  By increasing the contact surface of the forearm and hand, it provides stability and increased sensory awareness of movement in space. We have found a tray surface that supports the elbows, by curving around the body, makes a significant difference. The work surface should be large enough to fit materials and support the upper body.  Common errors are elbows falling off the table or not enough room for materials. 
  • Organization of Work Surface:  For the individual with motor coordination, it can be helpful to have a container where materials are placed avoiding knocking them off the tray.  This can be a small bowl or box that serves as a “waiting area” for items such as scissors and glue.
  • Vision Considerations: The size, colors and position of the project are important.  Placing the project that is “done” and showing what the end looks like should be of a size, position and contrast that supports vision needs.  Placing it on an easel, on the wall or at an angle that allows for easy viewing is helpful and allows the child to visually reference the project that they are completing.  Adjusting the size by enlarging pictures or having a black contrasting background may help the individual with vision impairments.
  • Activity Selection/Material Considerations:  Using templates and/or pre-made cut outs may help the individual with motor impairments.  If the end is a picture of a farm, using a template that supports coloring inside can be helpful.  Using stickers that allow the individual to place or glue them reduces the motor demands.  Forming Wikki Stix into shapes that allow the child to color inside simple shapes is another option.
  • Tool Use: Using adaptive crayons or adapted markers, glue sticks and other materials may allow the child to do the task without hand over hand assistance.  You want to reduce the motor demands when you increase the cognitive requirements.  There are many options to help children hold their own tools.  The Functionalhand allows children to hold objects in either the  horizontal or vertical orientation.  Any size crayon, marker, glue stick, dry erase markers or school tools can fit into the flexible cord system.  For children who are unable to sustain a grasp on the Functionalhand independently, the Eazyhold strap is the ideal complimentary product.  
Finished project displayed on a slant board as a visual reference for “Done”
Alistair references done while he uses the Functionalhand to paint his cow.  

Do 

Keeping the activity initially simple and building on the concept once the child is familiar is important. Initial activities may be to color pictures and glue them in position.   Having two sets of icons, one showing the action and the other showing the tool helps them to understand the difference.

Use a picture of the action for “Do”
Use a picture of the item for “Get Ready”

You may start by showing  the pictures and asking, “do we cut first or color first”.  Using “first” and “then” concepts allows your child to know there is a progression to activities and reflect on the order.  The child can point, answer or place the icons in order. 

Get Ready

Several strategies will assist the individual to be actively engaged in the “ Do” and “Get Ready” process.

  • Use picture icons that allow the child to point to or grasp to put in the “Get Ready” column. Using Velcro to keep the pictures in position may be helpful.
  • Use an augmentative communication device with a page that lists options and allowing the child to point to or use a stylus to access their selections individually. The child can then grasp the item to put into their “waiting area” bowl or box or you place them upon making their selection.

Summary

How does a child with neuromotor impairment that may lack the postural control to move, reach and communicate get the same opportunities to develop executive functioning skills as other children?  Structuring the learning opportunity and providing activities in a manner that supports their thought processes to plan and participate in the execution of tasks is important. Incorporating alternative strategies to minimize hand over hand assistance is the start.  The key is to  let the child do as much for themselves as possible both in terms of thought process and motor participation.  Learn more about Executive Functioning by listening to Therapro’s Lecture series on this and other topics.

References

Ward, S., & Jacobsen, K. (2014). A clinical model for developing executive function skills. Perspectives on Language Learning and Education, 21(2), 72-84.

What Is Executive Function? And How Does It Relate to Child Development? (N.D.) Center for the Developing Child Harvard University. https://developingchild.harvard.edu/resources/what-is-executive-function-and-how-does-it-relate-to-child-development/

Trunks

Trunks! Adapted For Use Across All Ages & Abilities!

Executive Functioning, Occupational Therapy, Uncategorized, , , , , , , ,

Sarah Glovasky, M.S., OTR/L

Trunks® is an engaging, interactive game developed by Diane Long, EdD, MOTR/L  and published by Therapro. Trunks® has gameplay challenges for all abilities!

How Do You Play?

In this game players move their bodies, make sounds and perform actions from memory! Gameplay involves picking an Action Memory Card and performing the action depicted. Six categories of actions are involved:

  • Musical You: Encourages creativity with motor actions that produce sounds.
  • Animal Sounds: Players mimic animal sounds.
  • Animal Motions: Players move their bodies and demonstrate how animals move.
  • Sound Like: Players recall and reproduce commonly heard sounds.
  • Pretend To: Encourages imagination as players pretend to be like someone else.
  • Show How: Involves a step-by-step demonstration of an action requiring the player to create an original sequence.

Trunks involves remembering and performing motor sequences. Players draw a card, look at the given action from the six categories previously mentioned, turn the card over and perform the action from memory. There are visual pictures as well as words on each card. On their next turn they would draw an additional card and perform both actions in their memory sequence, without looking at the cards. When an action is performed correctly, the player gets to keep their card and continue to work toward building a “trunk” (a series of 4 cards that, when combined, create an elephant’s trunk). 

The ability to perform individual actions may differ from child to child. Furthermore, the ability to memorize subsequent actions or sequences may vary as well. For this reason the game was created with many variations that afford enjoyable game play for all ability levels.

What Skill Area Does Trunks! Target?

Working Memory! Working Memory is a necessity for engaging in a variety of everyday occupations including learning, socializing and task completion. Sequencing naturally falls under the broader category of working memory.  Inherent to the game is the pairing of multi-modal forms of input (visual cues, reading cues, motor engagement, etc.). Read on to learn how to adapt and modify this game to target other skill areas! 

How Can Trunks Be Adapted?

Preschool. This game can be used to target motor planning development for kids in preschool. Choose a card from the deck and ask the kids to complete the action. Things like pretend to lift weights, leap like a frog, and pretend to lick a drippy ice cream cone are good activities to choose. You can also use the Sounds Like cards for the kids to use their voices to participate. This is also a great option when working on oral motor and language skill. What does a train sound like?, snort like a pig, and hoot like an owl are sounds that preschool kids should be able to perform. Having their peers guess the sounds and or actions turns it into a whole group game everyone can participate in. Pro Tip: Pre-picking cards targeting the specific skill or development level of the group is always a good idea! 

Early Elementary Age. Working memory develops as kids age. Building a trunk of 2-3 trunk cards can make the game achievable for the younger crowd. The pictures on the trunk cards are helpful for the non-readers at this age (which many of them are)! Again preselecting cards can be key. If you are working with students who are nonverbal, take the sound cards out. If you are working with children who have limits in mobility, take the jumping and balance cards out. Pro Tip: For students struggling with motor planning, pre-teach and practice the actions on the cards prior to the whole group activity to help bolster confidence!

Later Elementary and Beyond. Target teamwork, this can be a difficult skill for some! Have the kids build the entire trunk, working in teams or as a whole group. Pro Tip: If you need an additional challenge, have the players remember the sequence both forwards and then backwards!

Other Helpful Tips

  • Use as many trunk pieces or make as many trunks as you have time for! For a 10 min group use 2-3 pieces or just complete one trunk. If you have a longer amount of  time, make multiple trunks!
  • Use the extra action cards or don’t! You know the players best. Is the extra challenge needed or will it be too much?
  • Playing the game Trunks is a great opportunity for co-treatments! Physical therapists, speech language pathologists, occupational therapists, and teachers all have skills that can be worked on during this game!

Trunks is a great option for targeting many key skill areas. It’s versatility makes it a great choice for a wide range of ages and ability levels. Check out Therapro’s handy guide, Gear Up for Games, for more great game adaptations and modifications. 

Making April Autism ACCEPTANCE Month

Autism

Claire McCarthy

April brings the beginnings of warm weather. It brings more time spent outside and the return of the birds who went south for winter. It also brings Autism Awareness Month. Fundraisers are held for local and nationwide autism related organizations. Facebook and Instagram are full of memes, posts, stories, and quotes about autism. This is all great, but what happens on May 1st? What happens when the posts get buried under cute animal videos and the fundraising moves onto the next mission?

Now, don’t get me wrong. I think awareness is wonderful. However, most of the world is very aware of autism now. They know organizations exist for it. There are plenty of tv shows and movies that portray autistic characters. We see autism in the news. What we need to be striving for is Autism Acceptance. We need to be striving for a world where autistic individuals are valued as community members, coworkers, and friends. A world that values and honors autism 365 days a year instead of 30.

To begin the move towards Autism Acceptance, there are some key terms we should know.

  • Neuro diversity: a viewpoint that brain differences are normal, rather than deficits
  • Neurodivergent: people who have diagnoses such as ADHD, autism, OCD, dyslexia, etc.
  • Neurotypical: individuals of typical developmental, intellectual, and cognitive abilities
  • Ableism: discrimination in favor of able-bodied or neurotypical people

Most of us on this blog are familiar with autism. For those who may not be, it is defined as “a developmental disorder of variable severity that is characterized by difficulty in social interaction and communication and by restricted or repetitive patterns of thought and behavior”. It is deficit based. There is nothing wrong with acknowledging the challenges seen in an autistic individual. However, let’s flip that around with a quote from NeuroTribes and define neurotypical: “Neurotypical syndrome is a neurobiological disorder characterized by preoccupation with social concerns, delusions of superiority, and obsession with conformity. There is no known cure.” Makes one think a little, doesn’t it?

To continue on a path of autism acceptance, we also need to target the myths around autism. One I hear all the time is, “S/he can’t be autistic. S/he speaks so well.” The DSM-5 and DSM-5-TR say nothing about verbal communication deficits in regards to autism. “Accompanying language impairment” can be added to an autism diagnosis, but having typical spoken language skills does NOT mean an individual is not autistic.

Another common misconception is that every child who receives an autism diagnosis must receive Applied Behavior Analysis (ABA) services and must be eligible for an Individualized Education Plan (IEP) when they reach 3 years of age. Yes, ABA is one of the few evidence based autism specific teaching methods. This research dates back to the 1960s when autism rates were 1 in 2,500 people. This research was done on individuals that would be considered “low functioning” and often had accompanying Intellectual Disability. Autistic learners needs to be seen as individuals the same way that neurotypical learners are seen.

That last paragraph brings me to another issue that gets in the way of autism acceptance- functioning levels. Parents and therapists are so quick to get caught up in levels. Many people think that a functioning level can tell you all about the autistic individual. One of the problems with levels, though, is that it makes it harder to see past the diagnosis. When someone is diagnosed with “high functioning autism” people have a hard time understanding their challenges, honoring how hard that individual works day to day to appear high functioning, and sees less need for services. When someone is diagnosed with “low functioning autism” people don’t see their competence, assume lower intellectual capacity, and lower their expectations for the individual.

What can we do as therapists, parents, family members, and friends to change from Autism Awareness to Autism Acceptance? A simple place to start is to change our vocabulary. Try to ditch “red flags” or “symptoms” and replace them with “characteristics” or “learning profile.” Don’t be afraid to use “the A word” in your every day life. Talk about individuals being autistic the same way you would talk about someone wearing glasses or having black hair. Encourage children to ask questions about themselves or others. Using statements such as “don’t stare” or “mind your business” inadvertently tell children that what the autistic child or adult is doing is “wrong” or something to be ashamed of.

Along the lines of observing behaviors, remember that all behaviors serve a purpose. A tantrum or “noncompliance” is not the child being difficult or trying to upset an adult. They are letting us know they have had enough, do not understand what we are trying to do, or do not understand why we are trying to do something. Self-stimulating behaviors should not be a target in therapies. These are physical needs to self-regulate and make sense of a neurotypical world. The more an autistic individual suppresses the need to stim the more the individual will need to eventually “get it out” and it will likely be in a way that is not fun for them or others such as self-injurious behavior or a meltdown.

Some people may be reading this and thinking, “But what about all of the challenges? What about those who may never be able to live independently or have challenging behaviors day after day?” This blog is in no way saying that these challenges should be ignored. In fact, that would be just as ableist as saying the positive characteristics of autism should be ignored. What needs to be thought about is that we are not out there to “cure autism” or “teach a child to look typical.” We are out there to make an autistic person who has challenges become an autistic person with as little barriers in their life as possible.

One of the best things we can do is to listen to autistic voices. Autistic adults and children can teach us more about autism than any study or textbook can even begin to. Families who have loved ones with autism are also a wonderful resource. If it hasn’t been said clearly enough, the best thing to remember is that autistic individuals are just that- individual. They will all have different thoughts, feelings, and beliefs in regards to THEIR autism. Autism Acceptance begins with understanding that and valuing each individual for exactly who they are.