June Smith, OTR/L’s May 4th seminar entitled: Integrated Learning Concepts: Practical Strategies to Promote Reflex Integration with Postural/Ocular-Motor Based Learning clearly demonstrated how integration of primitive reflexes provides a foundation for the development of postural and ocular motor skills that affect learning.
June has broad experience as an occupational therapist and has an insatiable appetite for learning. As evidenced in her presentation, she is able to skillfully apply what she has learned to her practice. Many attendees noted how beautifully June weaves her knowledge and experience into her practice to develop innovative, effective treatment strategies. She is a collaborative therapist who enjoys sharing her passion with others. Currently, she is a clinician and mentor at South Shore Therapies, a private sensory integration clinic in Massachusetts. She has developed a Vision Clinic with Developmental Optometrists to promote visual efficiency in those with learning challenges. June has lectured nationally on Brain Gym ® and Integrated Learning concepts.
Four primitive reflexes were discussed in
depth today: Moro Reflex, Tonic Labyrinthine Reflex (TLR), Symmetrical
Tonic Neck Reflex (STNR), and the Asymmetrical Tonic Neck Reflex (ATNR).
June provided general guidelines to determine when a primitive reflex
is adaptive and when it is maladaptive. She discussed treatment
considerations relevant to each primitive reflex. It was helpful that
June had many clinical examples through videos/photos showing how
primitive reflexes that are not fully integrated manifest themselves in
children and videos/photos of treatment strategies that help integrate
the reflexes. Throughout her talk, she drew from her Brain Gym®
training, Svetlana Masgutova (Reflex Integration-MNRI), Sheila Frick,
and others.
For a child who displays the TLR reflex long after it is typically integrated, June said we may see a host of associated behaviors such as the Moro Reflex where the child is toe walking due to an excessive extensor pattern; saccadic eye movements with reading difficulties; a poor sense of direction, developmental coordination disorder (DCD), Postural Ocular Disorders; hypersensitivity to vestibular activity where the child has motion sickness, dislikes gym class, and/or may have gastrointestinal issues; and has difficulty with extension prone or with neck flexion in supine. In general the child has poor balance of extension and flexion when the reflex is not integrated. Her treatment strategies include “going with the reflex” with fluid movement and gradually adding demands as tolerated, and finally working “against” the reflex. June’s treatment suggestions included activities involving facilitating head movement in all planes, linear vestibular input, using an 18″ Gymnic ball in 90/90 hip and knee flexion, and activation of the vestibular system.
June’s suggestions for therapeutic and reading materials include Rappin’ on the Reflexes: A Practical Guide to Infant Reflexes; See It. Say It. Do It!, whose author is a Developmental Optometrist; Developing Ocular Motor and Visual Perceptual Skills; and Understanding and Managing Vision Deficits: A Guide for Occupational Therapists, 3rd Ed.
June
is a vibrant, generous, and gifted speaker whose knowledge and clinical
expertise is extensive. She makes the application of what she has
learned to the clinical setting seamless. Encouraged by June, attendees
eagerly shared treatment strategies from their own clinical experiences.
June’s audience was energized by her discussion and walked away with
new treatment tools for immediate use!
Comments from attendees were very positive:
“Video and picture examples, interactive, and great descriptions of treatment activities/considerations.” – Kristina C., Occupational Therapist
“Great
crash course in identifying and integrating reflexes. It is easily
integrated into my own practice. For a complicated topic, very
effortlessly presented.” – Hannah D., Occupational Therapist
“As an OT student this seminar was a great learning opportunity.” – Paige H., OTS
“Great introduction to topic – makes me feel like I want more!” – Anonymous, Occupational Therapist
Hippotherapy is a specialized treatment area used by occupational therapists, physical therapists, and speech and language pathologists. It involves utilizing the sensory-motor aspects of horses to achieve therapeutic goals such as improving sensory processing to tolerate touch and motor plan sequential movements. Although the horse functions as a therapy tool, it is obviously much more exciting than a swing or therapy ball, offering opportunities to develop an emotional bond, communication and social skills.
Let’s look at the basics of hippotherapy
Although the healing power of horses has been recognized for thousands of years (Hippocrates mentions it in ancient Greek writings), hippotherapy only developed in Europe in the 1960s and soon after in the United states as an adjunct to physical therapy. Therapeutic goals might have included improving the rider’s strength, postural control, balance and coordination. Hippotherapy’s versatility as a treatment tool gradually expanded as SLPs used it to improve communication skills. Occupational therapists recognized the power of sensory stimulation in promoting engagement and functional hand skills, such as manipulating fasteners. For example, this rider enjoys opening the zipper on my glasses case and then handing me the sun glasses. She loves to help out and make both the horse and me happy!
Hippotherapy is a type of Animal Assisted Therapy
Please note that “therapeutic riding” (TR) is a different type of animal assisted therapy (AAT) that is offered by certified therapeutic riding instructors who teach riding skills to people with disabilities. A TR instructor may or may not be an OT, PT or SLP. However, hippotherapy is ONLY performed by a licensed OT, PT or SLP practitioner. Training and certification requirements vary at facilities and many require that the therapist have certification in both TR and hippotherapy. As an OT, my goal is not to teach my client how to ride a horse, although frequently that is the result and many children transition from hippotherapy to do TR and eventually earn medals at the Special Olympics.
Why are horses special therapeutic friends?
Well, many animals are special in their ability to connect with people nonverbally and provide unconditional love. Cats and dogs also provide great heavy pressure and tactile sensory stimulation as they lie on laps and cuddle. However, a child with cerebral palsy may improve range of motion by straddling a horse and the repetitive, smooth vestibular movement can gradually reduce muscle tone. A horse’s gait is similar to the human gait in terms of timing. Clients who have never walked or have an abnormal gait can kinesthetically experience what normal pelvic movement feels like.
I have primarily worked with very young children who received services through their early intervention programs. Many had developmental disabilities, including Down syndrome and autism spectrum disorders. My goals often focused on decreasing sensory defensiveness while increasing engagement, postural control and hand skills. Of course, this involves using a variety of reaching, grasping and manipulation hand activities.
Hippotherapy Provides controlled and graded Sensory Simulation
Simply being on a horse provides sensory stimulation. Actually, as soon as a client enters the hippotherapy facility, they are impacted by happy sounds, smells and scenery. Bouncing on the horse while walking and bouncing even more when trotting provides heavy duty proprioceptive and vestibular sensory input. I control and grade the sensory input with choices such as whether to:
walk slow, fast and for how long before stopping
walk in straight, curved lines or in circles
walk uphill, downhill or only on flat surfaces
the child faces forward, sideways, and backwards or rides in a different position such as in quadruped or kneeling.
Using Sensory-Based Materials
Hipppotherapy horses are selected for many specific attributes including tolerance for riders who may hit, kick or scream. I also use a variety of sensory materials that must first be introduced when there is no rider so that the horse becomes desensitized to materials such as:
clothespins clipped onto or removed from the mane (this does not hurt the horse)
ball play, playing catch with toys like Gertie Balls
The little girl in the photo is facing backwards while her hands bear weight on top of a vibrating cushion like a Senseez Vibrating Pillow. This helps to decrease her tactile defensiveness before asking her to engage in more complex fine motor tasks.
This vibrating ring stack is made by inserting a motorized pen, like a Squiggle Wiggle Writer Pen inside a swimming noodle.
Adapting activities to vibrate is one of the many sensory strategies described in my book From Flapping to Function: A Parent’s Guide to Autism and Hand Skills.
Hand Activities to Develop Postural Control
Clients may work on postural control while reach to touch body parts on the horse or therapist. I like to offer sensory materials to pull or squeeze such as Panic Pete (AKA Martian Popping Thing) while the client maintains a quadruped or kneeling position. The child in the photo squats to take rings out of the bag and stands up while stringing them. He typically has difficulty visually attending but it is difficult NOT to focus and be in the moment when standing on top of a large animal!
The girl in the photo reaches for rings positioned in front of her before rotating her body to place them over a ring stack. This “ring stack” is actually a cat toy and the mouse on top of a spring squeaks when moved. The sensory aspects of this activity help her to visually attend while developing postural control.
Hand Activities that Develop Cognitive and Manipulation Skills
In my book – From Rattles to Writing: A Parent’s Guide to Hand Skills I describe many simple adaptations that make it easier for children with and without disabilities to develop manipulation skills. For example, lacing boards can be cut out of cardboard and made to have just a few, big holes and thick cord that are easier than string to control.
During a typical Hippotherapy session, I spend time walking and trotting, followed by stopping to complete a simple hand activity such as this lacing board. When finished I encourage the child to say or sign “go” to continue movement. Most children are eager to resume movement.
A horse’s rear end is wide and functions as a convenient work surface. I adapted this puzzle by attaching the pieces with Velcro to the box cover. I encourage the child to use one hand to stabilize the box lid while pulling them off. Of course, this activity also teaches children to identify animals and imitate sounds. The Pizza Party is another activity that would be fun to use in this position.
Creating Functional Hand Skills Objectives
It’s a good idea to create OT objectives to improve functional skills such as opening and closing buttons because:
occupational therapy is all about increasing independence
this skill is measurable
insurance companies prefer work on functional, achievable daily living skills rather than abstract goals such as improving coordination
Therefore, I provide activities such as:
opening and closing extra large fasteners
opening bags and other containers (like my sunglasses case)
putting the helmet and gait belt on and off
unbuckling and putting away the reins, neck strap or other equipment
The first video shows how I made and use the “Sensory Pull Toy” (that I designed) during Hippotherapy to develop:
reaching, balance and postural control
hand strength
visual attention
eye-hand coordination
color identification
This toy is made out of detergent bottles and a strip of fabric. It’s simple to use – the child pulls the handle while in various positions. It can also be used during non horse activities to work on many skills. Please check out my book The Recycling Occupational Therapist for many other easy to make therapeutic activities. You can also try Stretchy String as another sensory toy.
The second video shows a few of the exciting ways therapists can use hippotherapy to develop hand skills. It is truly amazing how motivated children are to focus and engage in challenging hand activities because they love being cowboys and cowgirls!
Guest Blogger: Barbara A. Smith.
Barbara A. Smith has worked with children and adults with developmental disabilities for over 40 years! She is the author of the Recycling Occupational Therapist, From Rattles to Writing: A Parent’s Guide to Hand Skills and From Flapping to Function: A Parent’s Guide to Autism and Hand Skills. Learn more about her work at RecyclingOT.com.
Dyspraxia is one type of sensory processing disorder (SPD) that makes it difficult for children to plan and perform motor tasks such as stringing beads or riding a bicycle. Children with dyspraxia may
Appear clumsy
easily break things because they use too much force or
struggle to fit their arms into sleeves or sequence steps to shoe tying
Children with SPD often have more than one of the 6 subtypes that impact how their brains interpret and respond to what they see, hear, feel, smell, taste and how they move. They may seem extra active or lethargic, super sensitive or oblivious, have difficulty controlling their body while using their hands or can’t discriminate what part of their body was touched or is in pain. Let’s take a look at a few strategies that may help children with dyspraxia and other types of SPD as well as children who are typically developing.
Simplify for Success
Nobody likes failure; especially young children who have poor coordination to stack rings, string beads or lace boards. Consider purchasing, making or adapting these types of activities to make success easy and frequent. Try using
an extra large tube as a ring stack and rings to stack. The one shown in the photo is made by wedging a swimming noodle into a juice container and has a motorized pen inserted on top to make it vibrate. Vibration helps children to focus on what their hands are doing.
thick cord and shower curtain rings for stringing instead of offering string and beads. Many toddlers will find this an easier introduction to stringing.
lacing boards with a few extra big holes and thick cord. I attached the photo of a horse to this lacing board that I used with clients during Hippotherapy (therapy using a horse as a therapeutic tool).
Practice Makes Perfect
Design activities to require repetition. When a child closes a jacket there is usually only one zipper to connect or a few buttons. Many children benefit from the repetition of closing several button squares. As I describe in my book From Rattles to Writing: A Parent’s Guide to Hand Skills, these are made by sewing a large button or round plastic piece (see photo) to fabric. Then cut a slit into another piece. As your child develops skill, offer button squares with smaller buttons.
Many children are able to close a zipper once the slider is connected. But connecting the slider onto the zipper is very tricky. In the photograph you see me wearing an old jacket and attaching several zipper sliders. The sliders are sold in zipper repair kits or you can remove nice big ones from broken backpacks and suitcases. I have taught adults with developmental disabilities to zip their own jackets after practicing connecting and pulling up several slider every day.
Let’s Take Apart
Opening buttons, screw caps, zippers and knots seems to be a lot easier than closing them. One of the strategies I describe in my book From Flapping to Function: A Parent’s Guide to Autism and Hand Skills is to teach children to “ take- apart” before teaching them to “put-together”. In this way they will become familiar and successful with the materials before learning the more challenging motor skills of tying, buttoning, snapping, screwing lids etc. It is much easier to remove the fabric pieces from the “buttoning board” shown below and children will have many opportunities to practice. This board was made by drilling holes into a book stand and tying the “buttons” onto cord that is knotted through the holes.
In my book The Recycling Occupational Therapist I describe how to make activities that are perfect for opening and taking apart. The Manipulation Box shown in the photograph has screw covers, Velcro strips, pull lids, and magnets attached to a cookie sheet so that children can remove a variety of objects to drop inside.
Keeping It Fun
Yes, practice is important but we need variation and to add sensory stimulation to keep it fun. That’s why I love
form boards and ring stacks that make music
adding a motorized pen inside containers to make insertion tasks vibrate
using materials such as Velcro and elastic cord that feel good to pull
toy animals with clothing fasteners to manipulate
using pretend play toys such as “Feed the Bunny”
I covered an oatmeal container with fur, attached a face to the lid and photocopied some food items. Now “Feed the Bunny” is more than a plain old shape sorter. This great for working on choice making (i.e. shall we feed bunny a carrot or tomato?), identifying pictures, counting and of course promoting a healthy diet. I hope that you have fun implementing some of these strategies!
Here are some great Therapro products I recommend that you might use in addition to the activities I’ve discussed:
Squiggle Wiggle Writer Pen
Sound Puzzles
Giant Plastic Nuts and Bolts
Learn to Dress Monkey
Guest Blogger: Barbara A. Smith.
Barbara A. Smith has worked with children and adults with developmental disabilities for over 40 years! She is the author of the Recycling Occupational Therapist, From Rattles to Writing: A Parent’s Guide to Hand Skills and From Flapping to Function: A Parent’s Guide to Autism and Hand Skills. Learn more about her work at RecyclingOT.com.
