SUPPORTING A DYSPRAXIC CHILD

                                                

Our body’s ability to conceptualise (think), plan and execute a movement in the correct sequence is called as praxis. Learning a new task and following all its sequential steps happens due to our motor planning ability. It requires person’s attention to highest level.In simple the terms, Praxis is "Doing".

We can frequently see infants doing motor planning to achieve developmental milestones. A child perceives, holds, and explores a rattle at 7 months, mouths it at 8 months and bangs it on different surfaces (table, floor) to hear various sounds after achieving successful grasping skills. 
Here brain first learns to hold the spoon then to put it in to the mouth and later banging. All these tasks need attention. More child learns to move his or her body in different directions, better is the motor planning which all happens during foundation years.

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 above process is called as praxis. 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.

Planning involves conscious attention, therefore, praxis is connected to analytical and logical functions.

Different daily chores that we perform without thinking much demand

a lot of attention during childhood learning phase. Putting on clothes, holding knife or spoon, making a cup of coffee, doing laces or ties, time-telling are some of the examples of tasks which a person learns in early years with much focus, concentration and practice, however, once understood and practiced it becomes a neural memory for future times. On repeated practice, this task becomes Motor Skill.

However, a child with poor praxis will have difficulties in processing information, formulating ideas to planning, and execute any task on his own. A child with consistent poor praxis may be diagnosed as be Dyspraxic.
Features like clumsiness, avoidance of motor activities, lethargic behaviour, difficulties in learning new tasks, poor balance and postural control are prominent in children with Dyspraxia. 

An occupational therapist plays a vital role in completing the full assessment and planning direct intervention strategies for the child to overcome functional difficulties in day to day activities such as self-care, handwriting, dressing, PE). Encouragement, supervision, and consistent practice are key to teach any tasks, such as tooth brushing. Following all the steps in a sequential manner is important for the child to learn this task.

Children with dyspraxia often display difficulties in figuring out and remembering how to carry out a task physically. They may face challenges while performing an activity having a number of steps. Putting together steps is tough for them. Often children with sensory issues involving proprioception, vestibular, tactile and visual sense display praxis inabilities. Proprioception sense contributes in balancing, postural control, motor planning, motor skills. Children with sensory modulation issues face challenges in performing simple and complex tasks.

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 a room. He untied the laces with hit and trial method and then stopped. 

I asked, “you okay Andrew?”

He politely responded, “what do I need to do now?”

The poor little lad did not have had the idea, to how to take off his shoe from the foot. His brain couldn’t do the planning, sequencing and execution of actions at all. The "doing part" needed for untying laces, pulling off the shoe from feet, and standing was missing.

Climbing and descending stairs needs 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.

RELATIONSHIP BETWEEN MOTOR PLANNING AND BRAIN'S FUNCTIONING

Our brain has body “maps” which carry information about every body part

and its relationship to each other.

These maps help’s person to feel how his own body feels like when vision is blocked. It also tells what it is doing without looking at different body parts. For example, scratching our back when it itches or wiping face when it has dirt on it. Our proprioception receptors update these body “maps” (precepts) which helps the brain in sending messages to needed body part for further actions.
In above, face wiping example, the brain sends messages to elbow so that specific muscles can contract and relax to bend elbow joint and hand can go up to face to clean the dirt. Related hand muscles also contract and relax.

In children with poor motor planning skills the relationship between body actions and these “maps” do not work well. Due to poor functioning of body percept, a brain is not able to plan actions leading to poor motor planning.

This is the reason children with Dyspraxia are disorganised, forgetful and clumsy. Their brain is not able to do motor planning causing them not being able to judge speed, weight rate, the direction of any object or task. 

Moreover, these maps also contain memories related to environment such as gravity. For example, while sitting on swing we know our upper body is on swing however legs are swinging. Another common example is while swimming whether our body is in deep or shallow water. In both the situations, body maps help the brain to plan the movements according to the state of the body.

In conclusion, it is essential to understand child's difficulty zone, create child-friendly strategies and provide sensory, playful opportunities which involve her imagination abilities, creativity and motor planning skills.

INTERVENTION STRATEGIES FOR DYSPRAXIA:

A. HANDWRITING STRATEGIES: -

Handwriting is an important functional task for school-aged children and the primary way to express thoughts, ideas and knowledge, and emotions.

Here are some significant handwriting strategies with proprioceptive input.

Hand strengthening activities:

·        Use hole punch

·        Make orange juice using a hand juicer

·        Playdoh activities such as pinching pulling, hiding items in playdoh, kneading

·        Finger extension and finger spread exercises.

·        Hand Exerciser

·        Ask the child to write on a vertical surface followed with a horizontal surface.

·        Wax pencil

·        Games like bed bug,operation can be useful for young children

·        Use clipboard while writing for stability or clip the paper to a desk.

·        If the child moves the whole arm, shoulder, and elbows while writing than practice while lying on the stomach.

·        Propelling pencil can be used if children apply too much of force while writing. This may break the lead but wouldn’t create holes in paper.

·        Vibrating Pen

·        Use non-slip mat under the book to prevent slipping of paper.

·        Use reading ruler if child is dyslexic to reduce visual stress and as reading tracker

·        Thick (fat) pencils can be used as they make holding and writing easier

·        Sitting Alterations: If child has poor posture which is difficult to improve, try following options: -

·        Allow child to sit on floor

·        Wobble cushion

·        Wobble wedge or Wedge Cushion

·        Bean bags

·        Workstations

·        T-stools: Should be prescribed by an OT as she knows how to make ergonomic changes and take measurements according to child's height and weight 

B. SELF-CARE STRATEGIES:

For the competent dressing skills at the age of 5-6 years onwards, a

reasonable sense of proprioception and body awareness are essential features along with an adequate sense of touch (tactile feedback).

It will be better to start with warm up exercises such as push- pull games, bouncing on the therapy ball, jumping on a trampoline, rolling on a mattress to increase sensory feedback.

Label child’s clothing drawer so that he can easily access clothes and garments.

Use large textured buttons for easier manipulations

Ask the child to see the mirror for visual feedback.

Place the clothes in a sequence night before school keeping garments on the top of other clothes.

Use bathroom checklists or visual checklists for ease.

Add a ring to zipper fastener so as to make it easier to grab hold of.

C. OT APPROVED GAMES FOR MOTOR PLANNING:

Go Fishing

The Twister Game

Fine MotorSkills Tricky Peg Tree Game

LearningMinds Mega Lacing Shapes Tub - 48 Pieces

Fine motor skills peg domino game

D. BALANCING ACTIVITES:

A child with Dyspraxia commonly display poor standing and walking balance as their sensory systems ae not supportive. Having inefficient proprioceptive, vestibular and visual systems can cause poor posture and balancing issues. Different activities such as walking, hopping, sidewalk, jumping, kicking a ball, running, dancing or riding a bike can be difficult tasks to carry out.

Activities:

• Obstacle Courses.
• Walking along a narrow beam or line marked on the ground – forwards, backward, sideways
• Walking on different surfaces such as grass, concrete, foam, mattress.
• Doing activities on balancing board or equilibrium board
• Walking in a straight line.
• Play hopscotch
• Walking on toes and on heel
• Follow a wriggly line – walk on the line or feet either side
• Tunnel Games: Crawling in the tunnel is a fun activity.
• Climbing Activities: Climbing frames, monkey bars, ladders, ropes or slopes.

                                                                   

Proprioception:The Position Sense

Apart from five basic senses (vision, auditory, touch, olfactory and gustatory), we have three more hidden senses called as Proprioception, Interoception (recently discovered) and Vestibular Sense. 
The following discussion is about our proprioceptive sense and how it works in typical and atypical children.Awareness about one’s own body position happens due to this sixth sense is known as proprioception.

Proprioception is also called as “position sense” since it tells us, where we are we sitting, standing, lying or walking in relation to any object or surrounding. The word Proprioception comes from Latin word, “proprius” meaning “one’s own”. This sense supports a child to regulate their responsiveness to sensations. 

This sensation occurs when our muscles move or work.Consequences of poor proprioceptive functioning are the poor academic achievement, lack of self-care skills, difficulties in self-regulating emotions, attention and stress.

To know more about proprioception, let’s consider a simple example.

Suppose, you are blindfolded and asked to ascend and descend stairs you have never seen. Now your eyes do not have any experience or measurement of these stairs.The depth of every stair is unknown that can actually help your body to go up and down without falling or tripping. It is obvious that your balance will lose while doing this activity.

So what role does body play to protect you?

To be careful and protect you from falling, your hands will try to search and hold railing or any other external support. 
Your dominant foot will step forward slowly and attempt to judge how much is the height of the first stair so that you can climb the second step easily, with a swift movement. 
As you will climb further, your body will be confident enough to take steps confidently and instantaneously with controlled balance. 
Moreover, descending stairs will be easier for you now since the body can easily judge and feet can measure the steepness of staircase.

So how does this all happen?

This all happens because of our Proprioceptive sense! It is a hidden sense, that carries sensory information telling us about our own body’s movements and positions. It allows the brain to understand body's position, posture and place in relation to surroundings and other individuals.
Whether we are standing under the tree, over the bed, in the sand or on the top of the cliff, this unconscious awareness happens due to this sense.

Being able to walk in the dark room without losing balance control, typing without looking at the keyboard, driving a car without looking at brakes and other components, or performing ballet will not be possible without this sense.

This sense is the foundation for our body postures and actions. It makes us feel where are we sitting standing or lying in relation to our surrounding.

Consider, while sitting on the chair, how does our body know, where it has to sit? How much our knees need to bend according to chair’s height? Is chair comfortable or not?This all work is done by Proprioceptive sense.

It informs body about direction, velocity and force needed by one’s body

for doing any task. Finely graded movements, body coordination and body scheme are some of the areas that are affected due to lack of proprioception.Heavy work activities are calming for these children.

The functions of proprioception are to increase body awareness and contribute to motor control and motor planning (praxis). Children with poor proprioceptive sense have poor body awareness which causes difficulties in carrying out a gross motor and fine motor activities such as playing football, get dressed, zipping a jacket, buttoning a shirt or doing handwriting tasks.

Characteristics of poor prop (short form used by OTs) sense can be easily observed within the classroom or home setting among SPD (Sensory Processing Disorder) children such as, they would slap feet on ground while walking, or hold pencils too tightly to make a clear impression, or that the points break, there can be erasure holes on sheet producing messy work.

Unlike typical children, atypically developing children are not able to judge space around themselves. They might bump into other people or objects.  They may enter into other person’s intra-personal space which is considered weird and uncomfortable by most of the people. Such a child might be considered strange however reason behind this action is not his intentional bad behaviour but the lack of body awareness. 

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People's strange reactions cause anger,depression and emotional liability in the child since he is not doing all this deliberately or intentionally but indirectly trapped by his own body.

The perception of judging ordinary tasks such as the weight of a coffee mug, holding a pencil efficiently in order to write, poor balance while standing, tripping while walking, difficulties in planning actions are some of the examples of poor proprioception. 

Moreover, children with poor proprioception usually slip from their chairs while sitting in classrooms or other settings. These children have affected body positions and difficulties in organising their sensations therefore falling is usual. Providing Wobble cushion or wobble wedge provides combined tactile-proprioceptive input helping the child to sit appropriately. Moreover, it helps in preventing slouch and increases attention on the task. These resources can be purchased from different websites such as Amazon  at cheaper prices.

Other weighted items such as weighted vests or weighted lap pad provide calming effect on the child. They support child to stay in place and focus well

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on given task.

Other classroom activities to can be Brain Gym and yoga exercises to improve child’s focus in academics. Mediation has very calming and long lasting effect.

Sensory Diet designed by Occupational Therapist is essential to be incorporated in child’s schedule specifically to meet the needs of the individual's own nervous system.  Its purpose is to help the person become more focused, adaptable and skilful.  It is the combination of alerting and calming activities that helps in organising child’s behaviour and needs.

Home activities can include jumping on a trampoline, riding scooter or bicycle, participation in running, jumping, hopping activities, obstacle courses, sand play, hopscotch play, gymnastics, horse riding.

                                                                   

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