What is Motor planning?

Running, hopping, jumping requires a high level of Motor Planning 

Picture Credit: Google 

The ability to order, plan, sequence and execute a series of intentional motor actions. It is the ability to learn a new task, following all its sequential steps. It requires a person to be attentive.

Consider, when we try a new recipe for the first time, how much attention is needed to follow all steps. We are conscious about ingredients, water, salt, baking duration and all the other aspects to make the perfect dish. The way we react towards the above process is called as motor planning. Our brain is learning a new task, therefore, we need to pay more attention as compared to doing it for a second or third time.

We can frequently see infants doing motor planning process. A child perceives, hold, and explores spoon or rattle at 7 months, mouths it at 8 months and bangs it on different surfaces (table, floor) to hear different sounds. So here, the brain first learns to hold the spoon than to put it in the mouth and later banging. This process needs attention. More he learns to move his body in different directions, better is motor planning. Since planning involves conscious attention, therefore, it is connected to metal and logical functions.

A child initiates crawling at 7 -8 months and starts to enjoy it as soon as he masters it. He uses large joints which are essential for the development of higher brain centre’s functioning and motor planning abilities. Crawling, kneeling, standing, walking are all components of developmental milestones that require a child’s attention to developing postural balance and control. Initially, child plans and then executes actions slowly in sequential order, which is later called as developmental progression and locomotion.

Brain prepares messages and sends them to a different group of muscles in the upper and lower body. This causes muscles to contract and relax. Further to this, the joint movement takes place to perform the desired action. Different day to day chores which we perform without thinking much needed a lot of attention when we learned in childhood. Putting on clothes, holding knife or spoon, making a cup of coffee, doing laces or ties, time-telling are examples of tasks which a person learns in childhood with much attention and practice, however, once understood it becomes the neural memory for future times. On repeated practice, it is called as Motor Skill.

If the child has poor motor planning, he may be Dyspraxic.
He might not able to get an idea to perform, plan, and execute any task on his own. In such cases, teachers and parents need to provide cues for given tasks. Encouragement, supervision, and consistent practice are key to teach any tasks, such as handwriting and tooth brushing. Following all the steps in a sequential manner is important for a child to learn this task.

Handwriting skill requires a high level of motor planning, planning and execution of actions.

Let’s contemplate an example of poor motor planning, during one of my OT sessions, I asked a pupil to take off his shoes and sit on the mat. I got engaged in other tasks and observed him from another corner of the room. He untied the laces with hit and trial method and then stopped. I asked, “you okay?” He politely responded, “what do I need to do now?”

The poor little lad did not have any idea, how to take off his shoe from the foot. His brain couldn’t do the sequencing of actions, that after untying lace he needs to pull off the shoe from feet.

Climbing and descending stairs need complex motor planning and children with poor skill show anxiety to use staircase or escalators. Fear of falling or tripping makes them avoid stairway. Doing practice on climber frames is one of the ways to reduce anxiety. Making staircase of different size mattresses can be safe, appropriate and fun ways. 

Classroom Strategies for a child with poor body planning Intervention Strategies:

Star Jumps: These are good to involve whole-body coordination.

Animal Walks: Walking like bear, the elephant will improve body sense

Marching: This also involves coordination between both sides of the body, can be difficult. Initially start with feet marching, once mastered, then include arms.

Play Hopscotch: This will give distance and space judgement.

Commando Crawling: Involving both hands and feet.

Body Paint: Ask the child to paint his particular body parts such as a right-hand or left-hand index finger.

Body Image: Ask the child to draw around his partner’s body on the large sheet and label body parts.

Swimming: Will give tactile and proprioceptive input.

Obstacle courses: Make obstacle courses and ask the child to complete them in different positions (supine, prone, kneeling) while sitting on a scooter board.

Target Games: Activities involving trunk rotation and both sides of the body should be incorporated such as throwing bean bags while picking from the left and throwing them to the right side. Throwing them in hoops, buckets or bags can be done.

Hiding Objects Games: Hide different objects in the room and ask the child to find them. Two things can be hidden together such as lock and key.

Involve in-home chores: an Involving child in kitchen activities asking him to give you different items needed will help to develop under-over, left-right concept. You may ask him to put the cake for baking in a lower-most shelf of the oven.

Tunnel Games: Crawling in the tunnel is a

fun activity.

Climbing Activities: Climbing frames, monkey bars, ladders, ropes or slopes.

Sensory Strategies for Handwriting Skills

                                                 
                                                          

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Lewis is a 5-year old child who has recently joined pre-school. According to his parents he is very active, energetic and friendly boy who likes running in ground, spinning, jumping, watching Doctor Who and talking to everyone. After working with Lewis for a week, his class teacher discovered some unique habits, characteristics and behaviours of him which were as follows:

• While sitting in his chair or writing he slouches without him knowing about it. Likes wandering in the classroom and “always on a go”. He cannot sit for more than 10-12 minutes in his place.
• Doesn’t like playing with Lego or construction toys.
• Easily distracted by background sounds or outside noise (e.g., bird chirping or vehicle passing by)
• Gets confused with letters and numbers while reading and writing
• He is right handed but often uses left hand to write.
• While writing he goes out of space without realising it.

When these observations were discussed with school OT, she strongly recommended him for Sensory Integration assessment as all above stated features were part of sensory difficulties which were interfering in his handwriting, self-care, fine motor skills and day to day activities.

Handwriting is an important functional task for school aged children and primary way to express thoughts, ideas and knowledge, and emotions. Composing stories, expressing own emotions, copying numbers, from the blackboard, completing school assignments, writing formal letters, or applications all needs precise handwriting skill. 

According to Case-smith (1992), children began to draw and scribble on paper as soon as they are able to grasp a writing tool. The development of writing process in early years includes scribbling, drawing lines and circles.

During 7-8 years they learn to use the different functional tool such as

knife and fork, scissors, pencils, zippers, buttons, brooms. They learn to plan and sequence actions which are the important part of motor planning. 

Developing ideas, for building blocks, construction toys, Legos, sand castles, are taken enthusiastically. All these experiences of childhood enable a developing brain to work efficiently and organise incoming sensory information received from different sense organs.

However, for an atypically growing child these opportunities and playful scenarios are sensory challenges. They may experience stress in the case in the course of the day to day tasks related to fine motor, gross motor and handwriting skills.

These children are reluctant to write, easily tired, seen slouching in their chair, their desk is often disorganised, may drop things in hand and may display behavioural issues due to frustration, the anger of not being able to accomplish tasks in hand and other sensory difficulties.

Why do ASD kids get Anxious ? 6 Core Strategies

                                                      

14-year old Jack diagnosed with Asperger’s Syndrome came to attend Occupational Therapy (OT)  session in school's OT room. Jack loves OT as he feels that he doesn’t have to study in this lesson and he can learn and do fun activities. However, this time, when he came to attend a lesson, he was seen worried and unfocused while carrying out tasks. On being asked,the reason of consistent worry, it was found that he has to come to school by public transport (bus) whole next week along with his class friend, as his father has gone on an official tour and mother doesn't know driving.

A thought of travelling in the bus made Jack extremely anxious because of which he couldn’t focus even on tasks he like. Waiting for the bus, getting on it, asking for a ticket from bus driver (new person), standing along with new unknown people, being touched by people which creates defensiveness while bus is moving, hearing different sounds (people talking, vehicles on road, baby crying, music), smell of various deodorants, are some of challenges which made Jack so nervous! 

Above mentioned experiences are just so normal for anyone of us and do not affect any typically growing adolescent, however, for a child like Jack they are big reasons of worry!

Children with or without autism display anxiety during the day to day situations. Getting separated from the parents (separation anxiety) is most common cause of nervousness among typically and atypically developing children. Recent research at the University of Amsterdam suggests that 40% of children and adolescents with ASD have anxiety issues.

Every day most of us face situations that can cause anxiety or nervousness such as getting late for school or office, getting stuck in traffic jam, before examination or interview or even not being able to understand a simple joke that others find funny. 
We simply know how to cope with such situations, either by informing office staff that we are running late or ignoring joke that we do not understand. However, for autistic or learning disabled adult and child coping with stress, anxiety or frustration can be a great challenge.

“My 5-year old son with Autism gets nervous easily in school and public places. He often starts crying in malls and I feel embarrassed. Is there anything I can do to help him?"

This is a common question heard from parents of children diagnosed with Autism Spectrum Disorder (ASD), Sensory Processing Disorder (SPD), Learning Disabled (LD) and ADHD. Anxiety is not uncommon to anyone of us, however, atypically developing children display extreme nervousness in ordinary situations too.
As per anecdote reports, many children with autism will receive the another diagnosis at some point of development. The additional diagnosis is mostly related to (Simonoff, et al). 

So what triggers anxiety in children?             Dr Chuck Edington (2010) suggested common triggers of anxiety at home and school setting are, Unstructured Timing, Academic situations, sensory issues, social situations and Routines. Other factors of anxiety can be homework, examination, meeting a new person, fear of rejection from peers, or health concerns. 

Children with autism commonly display self-stimulatory behaviours (stemming) such as hand flapping, finger flicking (hand mannerisms), chewing and mouthing things, watching spinning objects, rocking body back and forth while sitting, nail biting or hand biting which, if not stopped can be self-injurious in nature.
Stemming helps them to calm down and reduce anxiety. Children having under-responsiveness (hypo-sensitivity) towards touch or hearing lack danger awareness which can lead to self-harming behaviour. 

For highly anxious children sensory stimulation (stimming) as a way of shutting down their thoughts, anxiety and related stress. It works as a medium of shifting one's own attention to physical stimulatory behaviour that is more engaging.

There is no causal relationship between anxiety and over-responsiveness (hyper-sensitivity) established through researchers, however, it is commonly observed, that children with over-sensitivity often react negatively to noisy and visually complex environments. 

Shutting their ears in public places, displaying temper tantrums, meltdowns during recess, trying to avoid hair cutting or dental check-ups by any means, being avoidant to bathing or tooth-brushing are some of the behavioural patterns of ASD child with anxiety.

To resolve the problem, parents need to be carried out some ‘detective’ work to find out possible reasons for anxiety.

Strategies for Tactile Defensiveness!

                                                     

Touch is the first sensation that starts developing in the womb at five weeks. Some children react adversely, negatively or display  escape-like behaviour on being touched, hugged or kissed since they have difficulties in processing sensory information due to the poor tactile system. This behaviour is referred as Tactile Defensiveness.

Due to the inaccurate functioning of touch mechanism and neural system, these children are often in the state of 'red alert'. They may react by clinging or complaining (fright) to someone, or lashing out (fight) and running away (flight).

Often children displaying tactile defensiveness may also have self-stimulating behaviour. Repeated movements such as hand flapping, body rocking, hand gazing, spinning have been found prevalent in children with developmental disabilities and Autism.

Research done by Feig et al (2012), concludes that there is a significant relationship between Tactile defensiveness and Self-stimulatory behaviours.They both are problematic as they appear and interfere in child's day-to-day activities. For example, a child who engages in hand flapping may not be able to do any other activity such as washing herself or eating on her own. Likewise, due to tactile defensiveness doing teeth-brushing or other self-care activities will be difficult.


Here are some of the suggestions for tactile defensiveness which may or may not be helpful, as each child is different, however making appropriate changes within child’s environment or strategies according to his needs and priorities can support him to live better and stay calmer.

A) Understand your child: (Address child's issues seriously= Trustworthy relationship + better behaved child)

Most importantly, it is parent’s responsibility to understand their child and her problems. Giving labels such as she has "bad behaviour" or "poor "attitude will not solve the issue. 

If she says “something always hurts me” or gets irritated due to scratching herself all the time, do not think she is pretending to gain empathy or purposefully trying to seek attention. 

There must be something unusual happening causing her to behave in this manner. 

Developing trust and developing an understanding of child's difficulties are essential parts of combating any problem. 

It will be great if parent and child both stay on the same team as good team players to resolve the issue rather than opponents where parents label the child for being anti-social frequently, and child reacts impulsively and aggressively on hearing those words over and again. 

B) Deep Pressure: (Leads to release of Dopamine or "happy neurotransmitter"= Calm brain & relaxed body)

Firm massage or deep pressure with pillows, cushions or rolling in a weighted blanket is very calming. Parents should understand signals when these strategies are needed. Children having sensitivities are overloaded with touch or noise in crowded places or parties. Parents should be aware of these situations and intervention should be provided before emotional or anger outbursts happens.Children get sleep disturbances caused due to sensory issues.Using techniques like Wilbarger Brushing Protocol  has been found to be an effective way of calming child for better sleep.
This should be under the supervision of Occupational Therapist or consult child's OT before trying Brushing Technique.

C) Weighted Items: (Stimulates body joints & muscles = Improves self-regulation,modulation,stress and anxiety)

Wearing weighted blankets, vests, backpacks or hats can have the calming effect in the classroom as well as at home. Great range of weighted items is available on Amazon such as ankle weights, lap weights shoulder and neck weights. They help to calm down a child in the classroom as well as any other environment leading her to focus on the task and reduce distraction. Weighted blankets are very helpful in calming the child’s distractibility, emotional liability, and hyper activeness. Another very good resource is TFH, South Paw. 
T-Jackets have been found to be a good resource of calming down a child. They have been scientifically customised for providing deep pressure and calming effects. 

D) Safety: (Prevention is better than cure so TAKE-CARE of child!)

Children who are hypo-responsive or sensory seeking towards touch are unaware of bruises and injuries. They do not get pain sensation messages from brain centers due to which they are prone to injuries. They may display self-stimulating or self-injurious behaviours along with tactile defensiveness.The stereotyped behaviours are common among Autistic children. Most common form is motor patterns are hand flapping, body gazing or object manipulation. Temple (1992) in her study Calming Effects of Deep Touch Pressure in Patients with Autistic Disorder, College Students, and Animals has suggested that Tactile Defensiveness co-exists with Stereotypical behaviour in Autism .Sensory Modulation and regulation is an important function which does not work well in both hyper and hyposensitivity of touch.It is important to follow some hands-on strategies such as:

• Use of sensory experiences :Such as trampoline jumping,obstacle course, running
• Follow Routines and maintain structure: e.g., planning a week ahead
• Communication: Understanding child's behaviour in anticipation, environment, emotional liability.
• Visual Support: Emotion's chart, use of PECS.
• Talk to GP about Medication.
• Use Barriers such as using cushions or pillows if the child does head banging,or tie the cloth on his hand to reduce self-biting.
• Use soft furniture.
• Keep rooms safe, the child should not be able to lock himself in a room, windows should not be wide-open.
• Keep sharp objects like knife, fork, scissors, razors out of reach of the child.

F) Fabrics: (Removal of unpleasant sensory input = Relief & physical comfort)

Pay attention to the different fabrics. Following tips may be helpful related to fabrics:-

• Give preference to child's fabric or texture.Some children like to wear cotton and avoid woolens, synthetics or any other texture that might irritate them. 
• Wearing skin fit clothing is preferable than loose clothing. 
• Stick to seamless clothing. 
• Liners and tags are always irritable making child impulsive and distracted easily. Removing or cutting tags is the simple solution for this. 
• As far as footwear is concerned, it should be comfortable and slip on type. Fasteners are also the good option if he finds tying laces complicated.
• Long sleeves are preferable than short arm sleeves. 
• Do not force him to wear belts, waistbands if he doesn’t feel good about it.

H) Active Involvement: (Child knows himself better than anyone else)

Self-directed tactile experiences are more calming then done by anyone else. Therefore, encourage the child to perform activities himself rather than done passively, by anyone else for him, however, assistance or supervision may be needed for completing tasks. After bath let him rub himself or put lotion independently since he can judge well how much deep firm pressure will be calming for self. Make your own Play-Doh at home.

I) Classroom Strategies: (Favourable IEP = Better provisions = Better behaved child + raised self-esteem)

Let the child stand last in a row in school. Let him

sit alone if he gets distracted by other pupil’s touch. Talk to teachers and school management to create awareness about your child’s difficulties. Teachers should know what child is going through and why is he distracted multiple times or scratches himself during the lessons. They should allow the child to do wall pushes or chair pushes if he feels calming during break times. The child should also get movement breaks if the teacher allows.  This should be included in his IEP. http://www.additudemag.com/adhd/article/5894.html

J) Inform before touching: (Respect child's integrity)

Hugs, kisses or any other type of touch should be done with consent. Ask or inform him before touching the child. This reduces anxiety levels and arousal too.Touching without consent can create disruptive behaviour. To know more about cause and neuroscience of tactile defensiveness click here.

K) Heavy Work Activities (Proprioceptive Input): (Tactile + proprioceptive input = calming effects,reduced anxiety,disruptive behaviour)

Pushing and pulling heavy objects such as barrels, carts, large bean bags,
the pile of chairs or pushing another child on the swing. All this 
gives proprioceptive input!

These activities provide deep pressure to muscles, joints, ligaments and key points of the body (Shoulders, Pelvis, Hips) to a tactile defensive child. 
Moreover, giving movement breaks will support a child to concentrate better in studies, such as sending him to an office to handover papers or asking him to distribute assignments in the classroom. See Classroom strategies for more information.

25 Tips for Sensory Smart Classrooms!

                                

                                   

    Classrooms need to be Multisensory for better learning!!

         

A.  Instructions should be simple, clear and short for the child to follow easily.

B.   Be precise and slow while giving instructions. One step at a time since brain’s information processing is slow.

Fidgets 

C.   Encourage the child to learn and practice the task. Practice! Practice! Practice makes a lot of difference.

D.  Keep Fidgets handy! They reduce anxiety levels in different environments and facilitate attention on a task in hand. Use of different magnetic balls, paper clips, blue tac, or mechanical pencils can work well too. Other common fidgets can be giant nut and bolt, key chains, fidgeting fleece bags, finger squeezers, tactile balls (koosh ball): Resource: 

E.   Let child do heavy work activities such as jumping, chair push-ups, wall push-ups, clearing cluttered desk,carrying the heavy bag.

F.   Give verbal instructions with visual demonstrations where ever possible. Showing child how to do activity is better than telling him about it. Demonstrate how to do the obstacle course and then let him perform.

Carrying heavy books has to calm effect

G.   Give extra time in the classroom to complete written work. Teachers need to have patience and calm!

H.  Remove visual distractions from the classroom. All wall decorations, notices should go on the back wall. Whiteboard should be clear (except when teaching!) with a date in the corner.

I.   Use colourful marker pens for teaching particular topic or concept.

J.   Child should sit near to teacher’s desk and in front of a classroom.

K.   Organise child’s desk, textbooks, supplies. Label different folders. This makes a lot of difference.

Supplies should be adequate

L.   Keep the supplies and textbooks in the good amount within a classroom.

M. Introduce and encourage calming music.

N.  Let child submit written assignments rather than hand written since handwriting can be illegible or messy.

O.  Labelling and Categorisation: Use sticky tags for labelling folders such as work done, work to be done, notices, to be read and other labels can be made according to requirements and relevance. It supports the child to distinguish and different folders and binders as well as subjects.

Sticky Notes for Organisation & Labelling

P.    Lighting: Use of Halogen lighting system is considered better than fluorescent lighting system in classrooms.

Q. Homework Print Outs: It is better to post homework on school website so it is easier for parents and kids to understand the given assignments.

R.   Visual Reminders: These can be in the form of picture posters, sticky notes, widgets or coloured writing on the board.

S.  Sensory Diet: A sensory diet is a carefully designed, personalised activity plan that provides sensory input to a person needs to stay focused and organised throughout the day (Occupational Therapist Patricia Wilbarger). It is developed by an Occupational Therapist specifically according to person’s sensory needs and abilities

Credit

T.   Movement Breaks: A child should be given a break for 2-3 minutes’ maximum. This for stress release and reassure that child can re-focus well on topic again. Doing deep Breathing or Stretching exercises can be beneficial. Going to an office to hand over paperwork is one example of movement break.

U.  Pencil Grips: Children respond well to pencil grips as it improves handwriting, legible and provides tactile-proprioceptive feedback. Resource: 

V.   Wobble Cushions: Good for ADHD kids especially. Keeps good posture and maintains focus.Resource:

W.                Ergonomics for Seating:

a.    While sitting on chair hips, knees, and ankle should be perpendicular to each other.

b.   Back should be straight and ninety-degree angle should form at an elbow.

c.    Wrists should be in resting position.

d.   Table and chair should have appropriate height.

e.   The seat back should be angled at 15 degrees.

f.    The child should lean forward with body weight supported by the floor with feet on the ground.

g.   Provide slanting desk or tilt table desktop for achieving ideal reading and writing angles for vision and spine.

h.   Elbow rests prevent straining of shoulders and neck muscles.

i.     Reading angle should be about 60 degrees from horizontal.

j.     Writing angle should be about 10-20 degrees.

X.  Introduce Theraband Stretching exercises or Deep Breathing as a part of Daily morning routine to concentrate well in a classroom.

Y.   Weighted Items: Use of appropriately weighted items should be done within the classroom on discussion with Occupational Therapist. Shoulder, Shoulder and neck weights, lap weights, wrist, ankle weights, snakey weights, weighted scarfs are weighted products for Calming down, reducing impulsivity, hyperactivity, and aggression. Resource