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Interacting with Young Children Who Have Dyspraxia

Marie E. Anzalone, Sc.D., OTR & G. Gordon Williamson, Ph.D., OTR, Programs in Occupational Therapy, College of Physicians and Surgeons, Columbia University

  • Engage in periods of child directed play where you imitate and join into the child's activities without asking questions or initiating any demands. Follow the child's lead and allow time for the long latency of response found in some of these children.

  • Follow periods of child directed play with modeling of elaborated and expanded themes in related play activities (e.g. If the child is "cooking" in the kitchen, you can expand to setting the table and feeding the baby). This strategy will help the child build upon his play repertoire instead of relying on an inflexible preference for the familiar.

  • Rather than suggest solutions to a problem solving task during play, ask questions about next steps (e.g. "Wow, you are really good at climbing; now how are you going to get down?)

  • Modify the environment, rather than the specific task, to foster flexibility and creativity in play.

  • Differentiate between the child who has latency due to poor sensory registration (i.e. hyposensitivity) and the child who has a latency due to slow motor motor planning. The first child needs more sensory input to reach threshold, whereas the second child primarily needs time to plan. This distinction can best be determined by natural observation of the child during play or functional tasks.

  • Work on the child's organization and not yours! do "less" instead of "more" when it comes to adult directiveness.

  • Allow for repetition and practice. It usually takes the disorganized child longer to learn motor activities and the required practice can appear to be perseverative.

  • Progress the child from the stage of skill acquisition to fluency and generalization of the skill in order to achieve functional performance.

  • Reinforce successive approximations of desired behavior, but do provide honest feedback. Sometimes these children have difficulty evaluating their actions.

  • Be aware of the child who tends to escape from a difficult activity by abandoning the initial task goal for a "crash" solution (e.g., using aggression, refusals, or "accidents" to avoid having to complete a task). A crash solution may be indicative of a task that is too demanding and needs simplification.

  • Emphasize the fantasy and emotional themes within play. The disorganized child often has a wonderful imagination and can do more when attending to the process and pretense of the play, rather than attending to the actual performance of the activity.

  • Forecast transitions. Beginning and ending activities requires organizational abilities that may be difficult for the child.

  • Provide a routine that is reasonably predictable, consistent, and structured.

  • Enhance body awareness and motor control by increasing somatosensory input through gross motor activities (e.g., provide resistance to the child's movements by having the child push a heavy carriage, or walk up a ramp instead of a flat surface).

  • Engage the child in planning activities. If you build an obstacle course, the child may develop better motor abilities. If you and the child plan and build the obstacle course, the child gains organizational abilities, increased sensory experience, and self confidence.

  • Accept the fact that it usually takes the disorganized child more attention and effort to accomplish even simple motor tasks. Therefore, performance is often inconsistent. Do not assume that child is "not trying hard enough." The children are often working VERY hard to do even the most simple tasks.
PDF Download "Interacting with Young Children with Who Have Dyspraxia" Brochure (104KB)

Dyspraxia - Feeding - Low Threshold - High Threshold

Interacting with Young Children Who Have Sensory Based Feeding Disorders

Marie E. Anzalone, Sc.D., OTR & G. Gordon Williamson, Ph.D., OTR, Programs in Occupational Therapy, College of Physicians and Surgeons, Columbia University

  • Recognize that not all feeding disorders have a sensory basis. Some feeding problems may be due to medical factors, motor deficits, or emotional disorders.

  • Identify when sensory based feeding disorder began. This information can provide insight into the problem. For example, many children have difficulty changing from pureed to junior foods, others have had longer standing problems with food temperature..

  • Consult with the child's healthcare provider before initiating feeding intervention (e.g., physician therapist, nutritionist, nurse)..

  • Consider the complexity of sensory input during feeding. Feeding time should be as distraction free as possible. Schedule feedings when the adult is relaxed, the child is alert and responsive , and the environment is as calm as possible..

  • Try to have a predictable routine associated with the beginning and ending of meal times..

  • Use calming techniques prior to feeding if the child is hypersensitive. Sensory-based feeding disorders are frequently only one aspect of a more global sensory problem (e.g., hyper- or hypo-reactivity)..

  • Remember that the face is the most sensitive area of the body, so touching in or around the mouth can be very threatening to the child. Minimize nonessential touch.
    • Avoid frequent wiping of the mouth during feeding. When you must wipe the face, use a firm pat instead of a light swipe across the mouth, or let the child wipe the face independently
    • Give the child time to close the mouth on the spoon and remove food rather than scraping food off of the upper lip or teeth.

  • Introduce changes in food texture slowly..

  • Position the child in a stable supportive chair during feeding to provide postural stability and to minimize extraneous sensory stimulation (e.g., use a high chair or a Tripp Trapp chair)..

  • Recognize that during feeding the rules are different. You may want to work initially on sensory processing problems during non-feeding times since nutritional concerns must take precedence during the actual feeding..

  • Introduce toothbrushing slowly and playfully. Toothbrushing provides a natural opportunity to work on oral tactile sensitivity. Try infa-dent (i.e. a soft finger cot with short bristles available from Nu-tec, 1-800-868-8338), or the Nuk Toothcare System (i.e., a graded sequence of textured, chewable rubber brushes) rather than a traditional toothbrush..

  • Parents must be centrally involved in all feeding related interventions. It is best to work within the family's comfort level and style. Make minimal changes in daily routines as you work toward collaboratively agreed upon goals..

  • Respect culturally-based feeding practices (e.g., prolonged breast feeding, cradling during feeding)
PDF Download "Interacting with Young Children with Who Have Sensory Based Feeding Disorders" Brochure (104KB)
Dyspraxia - Feeding - Low Threshold - High Threshold

Intervention with Children Who Have Increased Sensitivity (Low Threshold)

Adapted from Zeitlin, S., & Williamson, G.G. (1994). Coping in Young Children: Early Intervention Practices to Enhance Adaptive Behavior and Resilience. Baltimore: Paul H. Brookes.

The following suggestions are designed to:
  • decrease or prevent sensory overload
  • achieve an optimal level of arousal
  • support effective social and environmental engagement.

These intervention strategies can be used with low threshold children who manifest as either hyperreactive or sensory avoidant. The difference in intervention between the two types of children is related to how one interacts with the child, how one grades and modifies tasks, and how the child is expected the generalize observed changes in sensory threshold (e.g., the sensory avoidant child may demonstrate more exploration while the hyperreactive child may be less overwhelmed by sensory experiences). It is critical that a trusting relationship be built so that the child is confident that the adult respects his or her sensory tolerance and will not impose aversive sensory input.

  1. Watch for early signs of distress. If there are signs of discomfort, stop the activity and provide time for recovery. (slowing the pace, rather than stopping the activity is sufficient for some children but not others.).

  2. Use a calming technique that is effective with the child and be consistent in its application (i.e., stay with a procedure and do not jump from one to another). Examples include:
    • Firm pressure on the skin such as during massage (avoid light touch that is excitatory)
    • Slow repetitive rocking of the child held in a vertical position in the adult's arms or on the adult's lap over the knees (gentle patting on the child's back can also be soothing)
    • Rhythmic motion (e.g., rocking infant seat, wind-up infant swing, ride in a stroller or automobile)
    • Swaddling (in a young infant)
    • Soft melodic lullabies or "white sounds" (e.g., fan pointed away from child and out of reach)
    • Sucking on a pacifier (if acceptable to parent)..

  3. Encourage the child to develop self-comforting behaviors (e.g., mouthing, cuddling a soft toy, hugging hands against chest, using transitional objects such as a blanket or teddy bear, snuggling into a quiet place such as the corner of the crib, engaging in a favorite play activity)..

  4. Consider the complexity of the sensory input during interaction. Some young children may only be able to handle one sensory modality at a time (i.e., looking, listening, touching OR moving, but not two together). Other children may require specific multi-sensory combinations (e.g. rocking while being hugged or held)..

  5. Notice that the child's difficult behavioral pattern does not condition the adult to avoid presenting appropriate developmental challenges (e.g., avoiding textured foods or making disciplinary demands, overuse of a walker that the infant prefers, avoiding novelty in the environment)..

  6. Grade environmental stimulation (e.g., avoid overcrowding, loud noises, glaring light)..

  7. Engage the child in activities of high interest; sensory tolerance increases when the child enjoys the task..

  8. Provide a routine that is reasonably consistent, predictable, and structured. Rituals can help the child predict what is about to happen and to make adjustments (e.g., forecasting transitions, bath time or night time rituals)..

  9. Rather than imposing stimulation on children, provide some choices that are within their tolerance zone (e.g., "Do you want to play in the sand or finger-paint?"). One can also expand upon the child's self initiated activity to provide sensory challenges..

  10. Hypersensitive responses to sensory input are sometimes inconsistent. Recognize that sensory input may be cumulative and that an exaggerated response may be a result of the whole day's input and not just a single touch or type of sensory experience. Schedule "breaks" to enable recovery and calming, even if the child has not shown intolerance. PDF Download "Interacting with Young Children with Who Have Increased Sensitivity (Low Threshold)" Brochure (104KB)
    Dyspraxia - Feeding - Low Threshold - High Threshold

    Intervention with Young Children Who Have Decreased Sensitivity (High Threshold)

    Marie E. Anzalone, Sc.D., OTR & G. Gordon Williamson, Ph.D., OTR, Programs in Occupational Therapy, College of Physicians and Surgeons, Columbia University

    The following suggestions are designed to:
    1. enable the child to attain desired sensory thresholds;
    2. achieve an optimal level of arousal and attention;
    3. support effective social and environmental engagement.

    These intervention strategies can be used with high threshold children who manifest as either hyporeactive or sensory seeking. Some important differences between these two groups do exist. Special attention should be taken to facilitate initiation of exploration in the hyporeactive child who tends to be passive and unresponsive. In contrast the sensory seeker must expand exploration beyond the immediate sensory experience. The sensory seeker may also need some help in managing risk-taking behavior.

    1. It is important to differentiate between a child who is truly hyporeactive and the child who has a low threshold but is sensory avoidant. The hyporeactive child will gradually alert with tactile or self controlled vestibular sensation, but the sensory avoidant child may withdraw even further with additional sensory input. You may want to try taking away input (e.g., decreasing auditory or visual input) before adding stimulation to differentiate between the two..

    2. Begin play sessions with arousing input to "jump start" or provide "grounding" for more independent gross motor exploration, social interaction, or manipulative play. The following arousing activities can be graded based on each child's unique response to foster this sensorimotor readiness; tactile exploration (e.g. sand or water play); "heavy work" such as pushing or pulling a beanbag chair or barrel; jumping on a trampoline; roughhouse play..

    3. Some children who are hyposensitive may have slow responses to sensory input. They will react, but do so gradually. Make sure that you provide enough time for the child to plan and initiate a response before you provide additional commands or sensory input..

    4. Engage child in activities of high interest; sensory reactivity increases when the child is motivated to participate. A novel situation or object is particularly motivating..

    5. Engage in child-directed play, no matter how simple or purposeless it may initially seem. Imitation of the child's play can provide insight into the sensory properties of the activity and can support social reciprocity. This strategy can be accompanied by descriptions of the child's action (e.g., You are jumping off the step. This strategy can be accompanied by descriptions of the child's action (e.g., You are jumping off the step. Oh look, you are in the pillow. Now you are going up the ramp. I am crawling up the ramp too..."). Try to avoid questioning or directing the child while engaged in this type of play..

    6. Remember that children learn through self-initiated exploration, so do not let the hyposensitive child's slow orientation or flat affect prompt over-directiveness on the part of the adult..

    7. Model appropriate and progressively more subtle affective reactions during play. Avoid inauthentic, and exaggerated emotional expressions by the adult..

    8. Look for the child's subtle attempts at nonverbal communication. Hyporeactive children are frequently delayed in expressive language..

    9. Complete circles of interaction through descriptive language, gestures, and turntaking..

    10. Provide sensory input gradually for these children to avoid overstimulation. While it is important to assist the child with a high threshold to attain desired sensory threshold for orientation and attention, it is equally important to avoid provided too much input that can lead to over-arousal. This is often the problem experienced by the sensory seeker who often demonstrates poorly modulated arousal or attention..

    11. Avoid imposing input on the hyposensitive child. Some sensory input, such as light touch, can be very powerful and cause an exaggerated response hours after it was provided (e.g., flushing, sweating, sleep difficulty, or sleepiness)..

    12. Provide the opportunity for free play with a group of peers who can model and initiate engagement in developmentally appropriate play.
    PDF Download "Interacting with Young Children with Who Have Increased Sensitivity (Low Threshold)" Brochure (104KB)
    Dyspraxia - Feeding - Low Threshold - High Threshold