You most likely understand a therapist when they use the terms coordination, balance, and strength. However, do you understand the term praxis or dyspraxia?
Praxis can be broken down into three steps. Before a child can perform a motor action, two cognitive steps occur. The first cognitive step is ideation. Ideation is the ability to come up with new ideas for using your body and objects. In other words, is the child able to figure out what to do when they are presented with something new?
The second step is motor planning which involves planning out the sequence of motor steps to accomplish a task. Part of motor planning includes the timing of each step and getting the body into the various static and dynamic positions for each step moment by moment. In other words, now that the child has an idea of what they want to do, do they know how to put that idea into action in a timely and fluid way?
After these two cognitive steps have occurred there is then motor execution. Motor execution is the observable result of all these steps. In other words, was the child able to accomplish the task, and if so, was their performance within a range appropriate for their age?
The concept of praxis may be confusing for parents to understand if their child presents with high verbal skills or a vivid imagination but also presents with poor ideation in praxis. Ideation in praxis is specifically coming up with new ways to move or use the physical body in the physical world.
The other variable that may be difficult for parents to understand is the difference between praxis and motor patterns. The reason this can be hard to understand is because your child may be able to perform and even sometimes excel at one or more motor tasks i.e. riding a bike, or playing tennis, but then may not be able to perform a new motor task, even if that task is easier than the other tasks they excel at. Praxis requires focused attention in order to conceptualize and plan the novel task. The child’s level of praxis will not be revealed until the child engages in a novel task.
A motor skill (or a motor pattern) is a task that is familiar and has been repeated many times to the point that the motor pattern has become programmed into their muscle memory. When this happens, the child can perform those motor patterns automatically. For some children, if an element of a familiar task has been changed i.e. a longer rope, a smaller ball, someone else joins in, the task is done in a new environment etc., this may be enough novelty where praxis is needed and the child may have difficulty performing the task or may simply refuse to engage in the task.
One important contributor to the development of praxis is body scheme, which is a sensory-cognitive map of the physical self. Body scheme is developed through multisensory information with tactile and proprioceptive processing (sometimes referred to as somatosensory) being the biggest contributor to body scheme. Body scheme provides the child with physical safety to explore their environment, the ability to connect with the social world, to learn and develop motor skills, to refine movement, and influence regulation.
Issues with praxis may be referred to as motor planning issues or dyspraxia. Dyspraxia means difficulty with praxis even in the presence of normal intelligence and environmental opportunities. Somatodyspraxia means praxis issues that originate from issues with body scheme due to inefficient tactile and proprioceptive processing.
If praxis issues are present, it may take regular practice over a period of time to learn simple tasks and the child may need to re-learn the task on some level each time. Dyspraxia is easier to determine as occupational therapy services and programs are implemented since you often see this issue when the child is engaging in a novel task or engaging in tasks within a novel environment.
Dyspraxia can be addressed through sensory integration treatment and other sensory-based modalities.
Environmental and task modifications may need to be made at home and school to support the child while they build up their praxis skills. The child may also benefit from using cognitive strategies so they can better manage challenging tasks on their own. Lastly, engaging in a daily home program that supports the development of their sensory-motor skills is both important and helpful for long-term results.
Sensory regulation is the brain’s ability to turn sensory signals up or down to adapt and respond appropriately to everyday events.
Similar to a thermostat, people tend to have a baseline that reflects their general energy levels. A person can tend towards a low, moderate, or high energy level depending on how their brain is regulating sensory information. This general baseline gives us an idea of the person’s ability to regulate sensory information.
Even though we all have different energy level baselines, that doesn’t mean we never shift into the different types of energy states. To be adaptable, you want to shift from one state to the other based on the situation you are in. For instance, if you are excited and social while at a party, then that would be an appropriate energy level for that situation. However, if you are trying to go to bed, then that higher energy wouldn’t be helpful to you.
For the person with a moderate energy level as their baseline, it’s easier for them to regulate sensory information and respond to daily stressors. However, if a person tends to have a lower energy level that doesn’t rise much or if a person tends to have a higher energy level that doesn’t lower much, that might affect their performance, their feelings about themselves, and their relationships with other people. If this is happening, then typically it would be good to see an occupational therapist to help them build their sensory regulation skills because their difficulty with sensory regulation is impacting their quality of life.
The goal of improving sensory-regulation skills is not to stay in an even energy state at all times. It is also not to change the person’s personality. The goal is to teach someone to monitor their energy levels as they go about their day and then use specific tools to return to an optimal state for the situation they are in while still being their wonderful selves.
Another important note is that sensory regulation is just one piece of self-regulation. Self-regulation is the ability to regulate both sensory information and our emotions. Other parts of the brain help us regulate our emotions and help us make decisions.
The brain is a complicated organ that we continue to study and understand. Sensory processing is a complex process that occurs in the brain. I wanted to come up with a simple way to explain the process.
To do this, let’s think of our brain as an online store, the sensory information as the products available to order, and the packages as what is sent out for delivery after an order has been made.
Normally on the store’s website, there are pages of different types of products made for different uses. Some of those “sensory products” will come from our environment such as sight, sound, touch, taste, and smell. Some of the sensory products will be “store brand products” coming from inside the body such as movement from the inner ear, proprioception from the joints and muscles, and interoceptive input, which is the felt sense that tells you what’s happening in the body like temperature changes, hunger, thirst, needing the restroom, etc.
The sensory products are scanned and selected by the person as they go about their day. Some of these sensory products are hand-picked such as “you may like” while others are just there and you must shift through what is relevant for you and what is not.
The sensory order gets sent through the brainstem, which is the main delivery route for sensory products (except for smell which has its own special delivery), and then gets dispersed to the various departments of the brain store.
Once that sensory order has been placed, the brain then has to look at that order to see what’s on the list, determine what those items are, and what they mean. Special instructions are then created that will go into the delivery package with the sensory products so the person knows what to do with the products once they are ready to use them.
Now the brain is a very savvy business owner and committed to being environmentally conscious, so it’s not going to send you out one package at a time with one product. The brain is going to put all the products together with the best instructions on how to use these products in combination.
Once you receive your package, you open it and use the products to take action. The items in the package along with their special instructions will help you to take action with your body, engage in daily activities, and socialize with those around you. In other words, these are the things you need to interact with your environment.
As you interact with the environment, you go back to the online store where you continue to browse, purchase, and use the sensory products. This is a continual cycle that keeps you hopefully living your best life!
Everyone has their own unique “online brain store” that will dictate what products are available and how efficient the brain store is with managing incoming orders, communicating between departments, and providing you with the best-delivered products with instructions possible.
Pediatric occupational therapists are trained to analyze an individual’s online brain store and how it is functioning so we can make sure their sensory shopping is a pleasant and effective experience!
If you asked me 3 years ago if I would be an author, I would have most definitely have said, “No way!” It started very innocently. A child I was working with was struggling with her friend. The more she tried to connect with her, the more her friend pulled away. We discussed that our energy takes up space, other people can feel our energy, and sometimes it can feel too much, even when we have the best of intentions. I explained that if she just made her energy a bit smaller, her friend might feel more comfortable, and they could spend more time together.
I thought these points were important to understand. I often use books and activities to further explain concepts to the kids. The trouble was I couldn’t find anything explaining how our energy takes up space and how people feel that energy, so I wrote her a story. The child liked the story and it helped her. I had some other kids that I thought would also benefit from this concept so I read the story to them. They also liked it. A handful of parents mentioned I should publish the story and with enough encouragement, I decided to start the publishing process.
From there, it was a long windy road to self-publishing. I had no idea what I was getting myself into! My years of being a novice occupational therapist were several decades behind me, but when it came to writing and publishing a book, I was right back at the starting line and the race to the finish line has not linear, but a course with winding roads, hills, and let’s be honest, sometimes I felt like I was climbing a mountain! Don’t believe me? Just take a look at the picture above and the final cover of my book and you can get a sense of where I started!
I bring up this point because it is important to know that something being hard and not being good at it right away, does not mean you shouldn’t do it or that you aren’t capable. Even if you never master that one thing you put so much effort into, there is something about challenging yourself and continually learning that can be highly valuable in discovering more about yourself.
Here are things I learned from writing Zoey and Her Amazing Energy Bubble! and what I’d like to pass on to you:
Let life surprise you! Every time I think I have life figured out, it decides to shake things up for me! Having no idea what I was doing during this process, I had to just trust the steps I could see in front of me, hoping the next steps would reveal themselves as I went along. I am still in the process as I approach the launch of my book at the end of the week and I navigate what happens next. I am not too sure you ever get to the end of anything, but maybe that is ok. What matters is that you are taking those steps forward!
Expand your I am (fill in the blank). You are constantly discovering who you are through your experiences. Challenging yourself with new experiences keeps you open to who you could be. I am a writer. Even though I write all the time as a therapist, I didn’t consider myself a writer, but now I do! I never thought I’d be a publisher, but I am now! I didn’t think I could make and edit videos for social media. Now I can! I had no idea I had that in me. What do you have hidden inside of yourself?
Look for your helpers. I had a mix of experiences along the way. Some people were so incredibly helpful and others were not. Although I don’t like to admit it, even the people who were not helpful to me, were an important part of the process because I learned important things about myself and it strengthened my discernment to make better future decisions. Of course, we love it when we find our village. Those people who understand us and support us in reaching our goals. I was so fortunate to have connected with some amazing people with whom without their help, my book wouldn’t have existed. Don’t let bad interactions stop you and keep looking for those helpers!
Step towards your fears when you are called to action. At first, I wrote this story for one child. Then that turned into multiple children. Then I thought I would publish this book and then whoever happened to randomly find it, could enjoy it at their leisure. What I didn’t know was that it was time for me to come out of my comfort zone and speak up. I know for the energy bubble concept to be powerful, it needs to be learned by all kids. It’s time we start to teach the concepts and tools we teach to our neurodiverse children to their peers as well. It is time a time when accommodation is just not enough for many of our children. Inclusion can’t happen unless peers are helping peers. It is time we have books that explicitly teach social-emotional skills so that we don’t leave behind the kids who won’t get the hidden message in many children’s books. We can all help in our own ways to make the changes we wish to see in the world around us. Zoey is a vessel for me to be a voice for kids of all abilities on a level I couldn’t have imagined 3 years ago. When the opportunity comes, take action! If not you, then who?
Be a good model. I ask kids all the time to do hard things and they tell me they can’t, all the time. It is so rewarding to watch them overcome obstacles and gain skills to become their best selves. I think it’s really important for us to show them through our actions that we too are doing hard things. Let’s talk about it, let’s work through it, and let’s celebrate each other as we navigate through the challenges we face in life!
Use your gifts to help others. No matter your gifts and talents, they are needed. There is something about you that no one else possesses. Sometimes we take our gifts and talents for granted, assuming that everyone has them, but that is not true. It might not always be clear what we should be doing, but if it’s helpful and feels right, then pursue it.
I hope Zoey and Her Amazing Energy Bubble! has a positive impact on those who read it. I hope the concept helps them understand themselves better and helps them feel empowered to manage what shows up in their day. I hope this concept promotes healthy relationships with others and builds a sense of compassion for each other’s needs. Learning to co-regulate is one of the most important things to learn in life. When we can co-regulate, we can create healthy living with one another.
Since the arrival of technology, we are spending much more time sitting and looking up close at 2D environments such as phones, tablets, and televisions. A study was published in Preventative Medicine, (Varma et al., 2017) involving 12,500 people 6-84 years of age. The participants wore activity trackers to measure how long they were active and sedentary throughout their day. The outcomes indicated that 19 year olds spent as much time in a sedentary state as 60 years old individuals! The study also indicated that 25% of boys and 50% of girls ages 6-11 did not engage in the recommended amount of 1 hour of moderate to intense level of exercise per day.
If this is the case, what activities are our children and teens doing on a daily basis? How are they using their time? According to the Common Sense Media website (www.commonsensemedia.org, 2019) , a survey of 1600 children and teens revealed the average 8-12 year old spent almost 5 hours on screens per day and the average teenager spent 7.5 hours on screens per day. This number did not include additional screen use for school or to complete homework. I think this answers what children and teens are doing with their time!
As caretakers of children and teens, we must then assess what ill effects technology and media have on their health and well-being. According the Common Sense Media website, ill effects of prolonged screen time include addiction to screens, loss of focus, lower empathy and social connection, and health problems such as eye strain. The researchers indicated that parents must educate their children and teenagers about the ill effects of technology and teach them how to moderate its use.
Occupational therapy can address these present concerns. One focus area of occupational therapy is sensory integration, which is our brain’s ability to recognize, interpret and organize information obtained through our senses. Our sensory systems have an intimate relationship with each another. The systems work together to give us a sense of where we are in space and influence how we relate to our surroundings. Sensory-motor experiences are critical to brain development. Unfortunately, a child minimizes their movements, exploration, and interaction with the world when sitting for many hours in front of a screen. They deprives their brain of the rich sensory experience of the real three-dimensional world. Their view is fixed on a two-dimensional object and they are missing out on what’s around them!
What about vision and technology? The visual system is the primary sensory system being used during screen time. The increased time looking at screens has taken a toll on our eyes, both short-term and long-term. There is evidence that outdoor play reduces the incidence of near-sightedness (myopia) in children. The American Optometric Association (www.aoa.org, 2020) states that the rate of myopic school-aged children continues to rise. The AOA states that 1 in 4 parents have a child that is near-sighted and 75% of near-sighted individuals were diagnosed between the ages of 3-11. The AOA recommends that family members receive annual comprehensive eye exams. Myopia can increase the risk of retinal detachment, early cataract development, and glaucoma. Therefore, early detection is important.
Furthermore, the importance of vision in child development is multi-layered. A child may have 20/20 vision, which is considered “perfect vision”. We call this visual acuity or how clearly the child can see. What is often missed is assessing a child’s functional vision. One important area of functional vision is visual perception. Some examples of visual perception are: finding objects within a background, identifying objects based on their parts, and determining the spatial orientation of objects. Another area of visual function is eye motor skills and coordination of movement between the two eyes. A child who is unable to visually fixate in one spot or track words across a line to read is a very frustrated child. I see a variety of negative behaviors in children when visual challenges are undetected and untreated.
As an occupational therapist, I want to do my part to guide children towards healthy development. Many occupational therapists can provide assessment and treatment to address visual perceptual challenges. A therapist who is trained in sensory integrative treatments typically uses a ground-up framework by assessing how the child processes different types of sensory input. We often see that children with poor vestibular processing also have poor visual perceptual skills. Assessment of balance, postural imitation, and bilateral coordination skills gives us a sense of the child’s visual perception. We also look at reflexes like anti-gravity postures, which can also tell us how the other sensory systems are interacting with the child’s functional vision. We also look at fine motor skills and handwriting skills to gain more specific insight into the organization and precision of the visual system.
Once we have gathered the appropriate information, we treat targeted areas to improve sensory-motor functioning. Part of the therapy process involves providing a home program to promote healthy sensory function at home. The program may be a schedule of sensory-motor activities, modifying or eliminating unhealthy habits, and educating the family and child on how to develop their sensory systems for long-term success.
Occupational therapists can work with children on ocular-motor exercises (e.g. shifting eyes from one spot to another) and visual-perceptual activities (e.g object finding board games, block design games, mazes, and handwriting). We can address upper-body coordination skills to assist with improving ball skills. Occupational therapists can perform visual screenings to determine if further examination is needed by an optometrist. Occupational therapists are not licensed to work with lens prisms or color lenses unless under direct supervision of an optometrist. Visual therapies can be quite powerful on the central nervous system. When we work with the eyes, we are really working with the mind.
Occupational therapists may not be able to treat all of your child’s vision struggles so it is important to receive further assessment by a developmental optometrist if your child presents with more complicated visual challenges. Engaging in both occupational therapy and vision therapy either simultaneously or sequentially can be beneficial. Despite some overlap of therapies provided by both disciplines, an optometrist and an occupational therapist will bring their unique perspective and expertise when working with your child.
Developmental optometrist Dr. Felicia Lew has kindly offered more insight into her work as a vision therapist. She gives us further insight into what a parent would expect from vision therapy.
Dr. Lew, what is the difference between a developmental optometrist and an ophthalmologist?
Good question, as there seems to be some confusion about this. First, the similarities. Both optometrists and ophthalmologist evaluate and treat eye conditions that do not require surgery. These include infections, glaucoma, and removal of foreign bodies. Both optometrists and ophthalmologists also administer comprehensive eye exams.
Second, the difference – surgery. Ophthalmologists operate. Optometrists do not. Ophthalmologists undergo extensive surgical training, and usually specialize in particular types of eye surgery. The most common form of pediatric eye surgery is to correct misalignment of the eyes. This is done by cutting the muscles surrounding the eyes and then repositioning them. Optometrists spend all their time in graduate school learning about the eyes and vision system, as well as related subjects such as optics, pharmacology, and neurology. Optometrists’ training also emphasizes optical correction, which allows them to help patients correct their vision without surgery with devices such as glasses and contacts.
Developmental optometrists are a sub-group of optometrists who take a more holistic approach to vision care known as “vision therapy.” They obtain a doctorate degree in optometry and then pursue further training through organizations such as the College of Vision Development and the Optometric Extension Program. Most developmental optometrists begin their careers as traditional optometrists. But then they realize that vision care is much more than helping patients see 20/20 and making sure patients do not have eye disease.
A traditional optometrist usually spends 30 minutes or less with a patient for a comprehensive eye exam. A developmental optometrist, however, may spend several hours with a patient, spread over several appointments, to complete a comprehensive eye exam, a developmental eye exam, and a functional vision evaluation. In my practice, I watch a child’s eyes and look to evaluate issues such as (1) whether the eyes work together as a team, (2) blinking, (3) reading difficulty, and (4) sensitivity to sensory stimuli. I also evaluate head and body posture, balance, and interactions with surroundings. I thoroughly assess eye movement and alignment with the aid of computerized tracking equipment which utilizes sensors to detect and record eye position. I also evaluate visual perception and processing areas such as visual memory, visual closure, directionality, visual figure-ground discrimination, and writing skills.
Following such a comprehensive evaluation, a developmental optometrist will create a treatment plan that does not include surgery or drugs. The goal of vision therapy is to rewire the connections between the eyes and the brain more efficiently. This leads to improvements in the patient’s life which can include a safer and more stable visual world, interest and engagement in surroundings, enjoyment of reading, faster completion of schoolwork, and cosmetic and functional alignment of the eyes.
Developmental optometry’s less traditional approach has gained much attention in recent years. World renowned institutions such as the Mayo Clinic and Harvard’s Boston Children’s Hospital have been implementing programs in developmental optometry and vision therapy.
And this just makes sense. In his book Brain Rules, developmental molecular biologist John Medina explains that vision “trumps all the other senses,” occupying more space in the brain than the other senses combined. Given its importance to overall health and wellness, we need to address all the complexities of the visual system when fostering learning and development in children.
What type of specialized therapies do you perform to improve visual perception?
My toolbox is overflowing. In addition to prescribing glasses and contact lenses in the traditional sense, I can use lenses, prisms and filters to modify sensory perception. For example, I can place lenses in front of the eyes to enable a patient to more accurately identify sounds and locate where the sound came from. I also use a lot unique gadgets and gizmos for vision training which keep a child visually challenged – and having fun at the same time.
Both in-office and home therapy incorporate games and activities which give feedback to a child to make them more aware of how their eyes and brain work together. Many activities integrate the other sensory systems so a child can make connections between the senses to better understand their surroundings. When appropriate, I use computer programs like virtual reality games to provide controlled increases in complexity and difficulty to improve visual skills.
When do you think it is appropriate for a child to work with both you and an occupational therapist?
Good question – and difficult to answer because each child is unique. I will recommend seeing an occupational therapist or other professional if the concerns that need to be addressed are beyond my scope of practice. I find collaboration with occupational therapists and practitioners of other disciplines invaluable to a holistic approach.
Do you recommend vision therapy before occupational therapy or vice versa?
The general rule is that a child with developmental concerns should have a developmental eye and vision evaluation in addition to evaluations with other professionals to identify whether the areas which need improvement are primarily related to vision. If so, I would probably recommend vision therapy first.
However, I see many children after they have seen an occupational therapist. I appreciate this, because it means that they already have done work in areas related to vision development such as primitive reflexes. This primes them for what I do. Often, occupational therapists will refer a child to me if they think there should be more emphasis on the visual system.
If you could pick one habit to change in order to improve a child’s visual health, what would it be?
Ah, an easy one — less screen time and more real-life play, especially outdoors. Playing in free space is so important for healthy development.
That being said, some newer studies indicate that computer games can aid the development of vision skills. Also, exposure to blue light – which digital screens emit – boosts memory, alertness and cognitive function, but too much can cause eyestrain, poor sleep and possibly macular degeneration.
So, a moderate amount of screen time is OK. But focus on playing outside.
Deciding to start occupational therapy services with your child can feel overwhelming. It takes a great amount of trust in the therapist and the process. We are talking about your child’s life and well-being so we must approach their needs with the upmost of care.
We are living in a time where clients have more access to information and therefore want more choices and more explanation. Clients will ask me about differing opinions about certain approaches or perhaps a new gadget or therapy they saw online. To be honest, I am also being inundated with online information and I’m often researching what approaches and tools are effective and which are ineffective. It is very easy to become skeptical, defensive, indecisive, and
sometimes paralyzed in a state of overwhelm with everything coming at us. It is also very tempting to click on a quick fix or become fixated in our view points because the algorithms in our social media feeds keep bringing up the same or similar content. With all this information, it sometimes can distract us from the most important part of therapy, which is the therapeutic relationship. Humans really are interdependent. Information is great, but it really isn’t helpful unless we know how to use it or know how to apply in a way that is meaningful to your child.
I believe that the relationship I have with my clients is the foundation for all the good work that is to follow. When entering into any relationship, we must hold ourselves accountable, have empathy for each other, and work on developing strong communication with one another. With these aspects in place, we can effectively work together to help your child learn and grow.
Let’s explore these three aspects a little more. First is taking responsibility for our actions. As a therapist, I’m upfront with my clients about my responsibilities and the client’s responsibilities. Some are written in policies and some are discussed in person. This ensures that we are all in agreement about how we are going to contribute to the therapy process. If we get off track, this allows us to have a discussion about the challenges occurring, assess our plan, and then refocus back to our individual responsibilities.
Empathy is another important aspect in a partnership. As human beings, we know that life can bring us both joy and challenges. Our goal is to try to be fully present and on top of our responsibilities so we can make good gains in therapy. However, there are going to be times where that doesn’t happen and we must show empathy towards one another. As the therapist, I might make a mistake in a report or forgot to send out an email out. Perhaps I misunderstood something you said and took a situation in the wrong direction. These things will happen
from time to time. As the client, maybe you really want to get your home program going, but you realize you don’t have a strong support system to do that. Maybe you really want to work on setting a different boundary with your child, but you are tired from a long day at work and you don’t feel you have the energy to deal with a meltdown. None of us want to be dealing with tribulations, but they are indeed part of life. So, whether big or small, we need to have patience and be understanding with one another. It’s important to take accountability when we miss the mark, but it’s equally important to know our strengths and limitations so we can come up with a reasonable plan that we can all follow.
Lastly, partnership requires good communication. Effective communication includes accountability. We need to check in with how things are going and make sure we are working toward our goals. Empathy is also part of good communication. The words we choose and the tone we use to deliver those words, sets the stage for how strong our therapeutic relationship will be. Bringing accountability and empathy into our communication allows us to speak with honesty about our needs so we can be the best support team for your child.
A partnership is an investment. It is an exchange of effort and belief in one another. It is a chance to reconfigure life’s challenges into something fruitful. It is about both you the parent and your child leaving therapy empowered with skills and confidence. It keeps me motivated to study and learn new things to bring to the therapeutic experience. A strong partnership leaves me more experienced, wise, and skilled so I can help the next family with the same level of passion.
So, let’s be good models for our children. Let us get away from divide and disconnect and choose connection and collaboration. Let us show them good boundaries and how to be accountable. Let us show them how we can be empathetic towards each other. Let us show them how we listen to each other and that we are responsive to each others’ needs through
our actions. These skills can not only be learned in their therapy sessions, but through our simple interactions.
Cleaning up the facts about The Wilbarger Deep Pressure Protocol (Therapressure Protocol)
By Michaela Gordon, OTR/L
At my first job, I remember seeing these white brushes. I knew they were for some sort of tactile stimulation, but I did not use them with students. I moved to CA and here, I would also find the white brushes! I was shown the protocol at an in-service. I didn’t fully understand the neurological underpinnings of the protocol, but I thought this was a great tool, so I started using it with clients.
I later realized after taking the class, it is really important to go to the training because you need to learn about the mechanism of pressure, which is difficult to conceptualize from verbal or written directions. Also, when I trained families in delivering the protocol, I typically had to review the technique with them 2-3 times before they could execute the procedure in an effective way on their own at home.
I was excited when Pat Wilbarger and her daughter Julia were coming to the area to teach the neurological foundations and the application of their protocol. Pat was one of the first pioneers in the field of sensory integration and she created this protocol to help children with sensory defensiveness. Sensory defensiveness is when the brain perceives non-threatening sensory signals as a threat, causing chronic, undue stress to the individual. During the class, Pat said something that helped me to truly to understand the importance and intent of the protocol. She said, “This sensory defensiveness is serious stuff! This is a matter of quality of life for these people so you really need to understand what you are doing.” It’s a matter of quality of life. I will never forget that. It’s a matter of being able to function in the world and being able to let others close to you. It matters.
There are lots of misconceptions about the Wilbarger Deep Pressure Protocol from its purpose to its details. I am hoping to clear some of these misconceptions up. First, the protocol is often called the “brushing protocol”, which sometime leads both non-trained professionals and non-professionals to miss the objective of the protocol, which is to provide pressure. Some individuals also confuse “brushing” with lymphatic dry brushing, which is surface, light-touch brushing with a different type of brush, which is counter-productive to addressing sensory defensiveness. Pat developed a specific brush where the bristles are a particular shape and texture as well as a rounded handle to ensure good delivery of deep pressure. This pressure is without scratch, tickle or itch.
Second, the purpose of the brush is to apply specific PRESSURE to the skin. It is not light touch or a massage. It is all about specific pressure. The brushing procedure is followed by joint compressions, which is also specific PRESSURE delivered to the proprioceptive (joint/muscles) system. Doing both is important so the brain can properly interpret and integrate the messages from the sensory signals. The tactile stimulation is given with pressure, but even so, can over-arouse the system. The joint compressions that follow are given to provide grounding input without overstimulation so the individual can benefit from both types of stimulation.
I often get complaints about the frequency the Wilbarger Deep Pressure Protocol has to be delivered, which is to be performed every 1.5- 2-hours throughout each day for at least 4-6 weeks or until symptoms resolve. I can assure you that this is not to torture you or your child. If you want to change physiology, the body needs consistent input that is delivered at a specific frequency and duration over time. So the more you can follow the protocol, the more likely your child’s physiology can shift.
Another missing piece is the sensory diet. This is Pat Wilbarger’s coined termed for providing other types of sensory inputs throughout the day along with the therapressure protocol. Again, we are looking to shift sensory input into informative data versus false alarms that puts the individual into distress. The person needs an opportunity to get organized input on their own in conjunction with the therapressure protocol that is delivered by an adult or themselves. Individuals with sensory defensiveness are often avoidant or distressed by daily activities so they do best with predictable, planned sensory activities. Over time, the person will be more likely to seek out and engage in a variety of activities that fulfill their sensory needs. However, until their physiology changes, they will need support and encouragement.
It must be noted that Pat Wilbarger figured out something remarkable. While working with her friend and colleague Jean Ayres, she realized that some of these children were avoidant of treatment versus naturally gravitating towards sensory stimulation that met their needs. Pat was also able to determine that the timing of sensory input was important. Her clinical findings indicated that children generally needed to be engaged in sensory input every few hours in order to keep the integration process going. Due to this discovery, she realized that it wasn’t enough to treat a child just in a clinic, but sensory stimulation needed to be continued in homes and schools. That is why it is important for parents, therapists, schools and other adults in the community working with the child to communicate in order execute the sensory diet and therapressure protocol. As they say, “It takes a village!”
So do the sensory diets and the therapressure protocols require some planning and effort? Yes. Can it feel stressful and at times tedious? Yes. However, I think the missing link is that parents, teachers, therapists etc. may not have gotten the message I received and that is, “This sensory defensiveness is serious stuff! This is a matter of quality of life for these people so you really need to understand what you are doing.” I think when we keep the intent of what we are trying to achieve out in the front, it keeps us on track. We do the best we can to deliver consistency to the defensive/avoidant individual. We do our best to come up with a plan that can be realistically implemented. It doesn’t need to be perfect. The goals just needs to be clear and we have to keep working at it.
Pat Wilbarger has absolutely left her mark on this earth. Both she and her daughter Julia have gone all over the world delivering their knowledge and expertise on sensory defensiveness. I have seen with my own eyes the difference this method can make for individuals with sensory defensiveness. They regain confidence and joy. They begin to understand themselves and connect with others.
A thank you to Pat and Julia Wilbarger for all they have taught me and the rest of the OT community.
“Never doubt, that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has.” -Margaret Mead
Do you ever hear a kid say, “You don’t get it. You don’t know how it feels to be me!” That is the truth. We don’t know what it feels like to be them. We can only empathize and try to relate based on what we are experiencing. When it comes to sensory defensiveness, children are over responding to sensory input, which causes a fight, flight, or freeze response. It is not necessarily the actual stimuli that is the issue, but rather the way the sensory signal is being processed when it reaches the higher level pathways of the brain.
We all have some degree of sensory preference and sensitivity. And some sensitivity is good. If you were walking across a street and noticed that a car was both close and coming at you, it is a smart move to run as quickly as you can! However, if you are walking across the street and you hear a car way off in the distance, but your brain says, “Run, you are about the get hit!” when that is not the case, then the brain has just sent you a false alarm, which can be confusing and distressing. If the brain is constantly misinterpreting non-threatening sensory input as a danger, this can impact the child’s confidence while interacting with the world and can give them a sense that the world around them isn’t safe and at the very least, uncomfortable.
Here are the types of sensory defensiveness one might be feeling:
Tactile defensiveness. This is the most recognized type of defensiveness. These children have strong reactions to touch information. They may complain about hygiene routines. These complaints can include brushing their teeth or hair hurts, bathing is uncomfortable, clipping their nails or getting a haircut is painful. These children complain about their clothing, refusing to put on their socks and shoes or only wanting to wear a specific piece of clothing. These children may also have difficulty with accepting touch from others so they avoid hugs or they will report that others have hurt them because normal touch felt like a push or some other assault.
Auditory defensiveness. This is also a widely recognized sensitivity. These children put their hands over their ears to block loud noises. They may refuse to go into public places or use the restrooms because of loud sounds like music or the toilet flushing. These children may be bothered by everyday sounds at home and school so they avoid situations, have meltdowns, or become aggressive due to the noise.
Movement defensiveness. In the OT world, we call this gravitational insecurity where the child develops great anxiety when experiencing movement. These children do not feel comfortable moving through space, especially if their feet leave the ground. In babies, they may be fearful to stand or walk. In toddlers and children, you might see them avoiding riding their bikes, climbing playground equipment or using swings. These children usually crawl upstairs versus standing. You will often seem them keeping both their hands and feet on the ground when scared or unsure. They often cling onto parents and teachers for dear life and can’t bring themselves to go enjoy play with the other children.
Visual defensiveness. These children are often sensitive to light. They may ask to turn the lights off or you’ll see them squinting or rubbing their eyes. Their parents may need to put a screen up in the car to block the sunlight. These children may become overwhelmed with fast moving environments or fast moving television shows. These children can be easily startled by visual stimulation, especially peripheral stimulation they weren’t expecting.
If you are someone without defensiveness, these scenarios may not make sense to you. Perhaps you are a good integrator of sensory stimulation, but your child or student is not. Instead of the sensory signals informing the various parts of the brain in a rational way so the child can learn, play, and relate, these signals are heading right to the watchdog of the brain, the amygdala. The brain tells the child, “Danger, danger! You must protect yourself!” These constant false alarms can be overwhelming over time and can impact the child’s emotional well-being and their ability to participate in everyday life tasks. It can take a toll on relationships and make the child feel like there is something “wrong with them”. So when a child says, “You don’t know how it feels to be me,” you may want to answer, “You’re right, I have no idea how it feels to be you AND we are going to figure out how make this better.” In other words, we are going to figure out how to get your brain and body working in a more integrated manner.
Here’s the good news! We know that using sensory integration treatments and tools, we can retrain the brain to better understand the sensory signals so they are correctly informing the child as they interact with the world. Several things need to happen in order for this to be accomplished. The right tools need to be identified, the tools need to be implemented with frequent consistency, and the child needs to want to participate on some level. If that can happen, it is amazing how the nervous system can shift and the defensiveness can either be reduced and in some instances completely resolved.
It is an honor to help children overcome these challenges. It can really have such a positive impact on their quality of life, yielding to a more comfortable and confident child. If your child or a child you know presents with sensory defensiveness, I encourage you to get them to an occupational therapist.
As an OT, I have searched endlessly for an effective behavioral approach for children with sensory processing challenges. I was lucky enough to meet Joe Newman, author of the book Raising Lions. In a short period of time, I was on a trajectory to work with him, adopting his philosophy to address behavioral challenges, and assisting families in the Santa Barbara community with using his approach.
It is the responsibility of all adults working with children to address behavior. In my opinion, it is important that the child and the adult feel emotionally safe to express themselves and that everyone feels respected. Without these healthy boundaries, deep connections will be difficult to foster and children will struggle to understand the balance between their needs and wants and those of others.
In my practice I work with many children that have sensory modulation challenges. Sensory modulation refers to the brain’s ability to respond appropriately to incoming sensory stimulation in order to maintain an appropriate level of alertness so that the child’s responses match the situation within a reasonable range.
Some children over-respond to sensory stimulation causing strong emotional reactivity, impulsive action, and intense physical responses such as crashing, bumping, excessive touching, excessive movement, and/or loud singing or talking. These children often have poor emotional control and can become oppositional and irrational in their behavior. On the other end of the spectrum are the children that are under-responsive. These children are passive and often miss sensory cues. They have difficulty with keeping up with peer interactions and often need support to complete daily activities. These children are prone to having passive tantrums. Due to their chronic low arousal, they become accustom to others initiating tasks for them or in some cases doing the tasks for them. It can be challenging for adults to recognize these children’s level of ability because they will express they don’t know how to do something or that the task is outside of their abilities even when it’s possible that they could do the task.
I believe we need to recognize these children’s struggles, but we can’t let this block us from seeing their capabilities. These children need both empathy in regards to the challenges they face, but also good boundaries and effective tools so they can learn needed developmental skills.
In OT, we work with children with sensory modulation challenges by presenting them with different types of therapeutic sensory activities that have either an excitatory and/or inhibitory properties so the child can learn how to get into and maintain a level of alertness that allows them to interact with their environment in a meaningful and productive way.
When working with children with sensory modulation challenges, we also have to address the behaviors that arise due to the nature of these challenges. With the Raising Lions approach, I have found success in helping children learn impulse and emotional control because of the opportunities that the method’s 1-minute breaks provide. Here is why I feel the method is effective:
It’s relational. As an occupational therapist, we work not only with the whole person, but the dynamical responses within the child’s relationships. Raising Lions is a relational approach. It respects the child’s autonomy, but also works towards interdependency with others.
It’s non-judgmental. Children with sensory modulation issues are usually up against a lot of criticism because their behaviors are typically inappropriate during their daily interactions. Raising Lions approach provides boundaries in a non-judgmental way so the child doesn’t start to take on the image of the villain, class clown, or helpless victim to name a few.
It’s a non-stimulation protocol. Getting stickers, losing tokens, and long explanations are all excitatory mechanisms for a child with over-responsive modulation issues. These approaches may work short term, but usually become ineffective over time. The child heavily relies on these systems and they often do not correct the actual issue, modulation. The Raising Lions method allows the therapist to stop all activity in a very neutral and natural way.You can then have the child re-enter the activity or therapeutically change the factors to achieve what we call the “just-right challenge” so the child can achieve regulation. Basically, it allows the child an opportunity to harness his/her ability to manage incoming stimuli without adding more stimulation, which prevents over-stimulation.
It gives the parents and the child a blue print and clear options. Children with modulation issues typically don’t respond to standard parenting practices such as timeouts, sticker charts, and long talks about behavior. It’s because these children are responding to impulses and their actions are typically ahead of their thinking. The child’s states of dysregulation can dysregulate the family system, leading parents to strategies such as bribing, threatening, caving in or other desperate attempts to gain control of the situation. Raising Lions helps parents to learn to stay calm and neutral. It helps the parent to regulate and detach from the child’s behavior, which creates an environmental opportunity for the child to learn how to modulate in small durations of time. It helps the parents do the same, and the therapist and…it’s a win-win!
Examples of how I use the protocol in therapy sessions:
I want to get Johnny ready to do some coordination activities, but he’s crashing and rolling on the floor and grabbing everything in sight. His mother tells me he started off his day like this and also reported he had a hard day at school. I’m thinking he is over stimulated and I want to give his sensory system some organizing input. He decides out of a choice of two activities that he wants to bounce and roll on a therapy ball while listening to a song with a steady beat. While doing this, Johnny starts to sing in a loud voice and he begins to slam his hands loudly against the ball. Instead of telling him to stop, lower his voice, or take the ball away, I ask him to take a minute. I turn off the music and wait for him. When he is done, we return to the task. I continue to do this until he shows modulation while on the ball. Johnny is learning to regulate in two ways. One he is taking the small breaks which allows him to make a different choice in how he’s interacting during the task and two, he’s learning how to use offered tools in an effective way to positively influence his neurology.
I have asked Suzie to start practicing her letters in her handwriting book. She has already done some preparatory sensory work to get her ready for this task, but Suzie really dislikes writing and she definitely doesn’t like to use a pencil grip. While writing, I notice her move the pencil grip up the pencil. We have already discussed the purpose of the grip and she knows it is part of the process so I don’t lecture her. I ask her to take a minute. She returns and I then notice that she is writing the letters excessively large and she is looking at me to see my reaction. I calmly ask her to take another minute and when she returns we redo those letters. Using the Raising Lions approach in this situation is helping Suzie move through the discomfort of using muscles she is not use to activating due to the grip and it is also helping her to learn emotional control during a non-preferred task.
Bobby is playing a game with his sister Katie. He is really competitive, especially when he’s playing his sister. Before starting, we discussed whether his alertness level was high, low or just-right. He tells me his engine feels high and he picks an activity from a choice of 2 things (running and crashing into the bean bag or jumping on the trampoline). I know Bobby has trouble sitting still so I also give him a cushion with texture that gives him a consistent regulating input. However, Bobby starts to lose and I can see a change in his behavior, which is the start of a potential explosion. I ask Bobby to take a minute. His sister then laughs and makes faces at him while he’s taking a minute so I ask Katie to take a minute as well. In this situation, the Raising Lions approach is used to give Bobby a moment to pause before the anger of losing sets in and gives him a chance to make another choice. It also lets him see that there are boundaries for his sister too, which helps him to see his sister also needs minutes to adjust her behavior. I find this a powerful choice especially for children that are frequently in trouble or villainized.
Raising Lions has been such a wonderful addition to my therapy practice. I am now able to slow down and to make more purposeful decisions in approaching children. Although most of the children I work with are initially upset about taking a minute to reset, they start to recognize the pause instead of the punishment, the choice instead of the demand, and the relationship instead of just themselves. When this starts to happen, so many other positive changes occur. Here’s to all the Lions!
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Occupational therapists are known for using the term, the just-right challenge. The term was originally coined by occupational therapist, Dr. Jean Ayres, and later used in other occupational therapy frameworks. The just-right challenge means the activity we are engaging in is not too easy and not too hard. We don’t want our daily activities to be too easy. This leads to boredom, impedes our ability to learn new skills, and doesn’t create enough stress to build our resilience. If activities are too hard, this causes too much stress and lead to avoidance of the activity.
As we know, life does not always provide us with just-right challenges, but in the therapeutic setting, the therapist is attempting to create an environment that allows for a healthy level of challenge, that leads to some level of success and encourages the child to come back and try again. The therapist will then teach you, the parent, how to create these just-right challenges at home. Over time, as the child masters these just-right challenges, it teaches them to be more adaptable in all sorts of uncontrolled life situations.
Sounds easy enough, right? Well, it can be easy for us adults to identify what a just-right challenge feels like, especially since we have had years of experience life experience to guide us. However, it can be challenging to determine that for our children. Regular meltdowns, battle of the wills to avoid tasks, and other creative ways to avoid non-preferred tasks can really leave us adults scratching our heads about whether we are providing the right opportunities for success.
When making decisions about what activities we want to expose our children to, we will naturally wonder if we should select activities based on preference. It is important to know your child’s strengths and really highlight those! We all have a purpose, talents, and gifts. Put them in just-right situations and let them shine!
However, it is equally important not to avoid all activities that they don’t like. I can’t tell you how many times I have had a parent or a child tell me that they “just aren’t really a sports person”. In reality, the child was lagging in the fundamental motor skills to participate in those sports. Once we worked on these skills in therapy, some of these children ended up finding a sport they loved and went on to be really great athletes! Even if this doesn’t happen, trying a variety of activities gives the child information about their activity preferences, gives them information about what types of challenges they respond best to, and teaches them to move outside their comfort zone.
Let’s go through some pointers to help us learn to create just-right challenges for our children:
1. One important thing to remember is that what seems easy to you, the adult, is not necessarily easy for your child. Whether you are playing a board game or riding bikes together, you have done these activities (or similar activities) many times before. For your child, these tasks are all relatively new, so you want to keep a beginners attitude when playing with them.
2. Your child may not have the same interests as you! Now, this doesn’t mean they shouldn’t try an activity, but it is ok if they don’t share the same enthusiasm you have for a particular activity. The more pressure you put on them, the less joy they will find in the task.
3. Make a list of child’s strengths and weaknesses. In what situations do they thrive and in what situations do they struggle?
4. Determine how your child likes to be helped. Do they like you to be direct? Do they want your physical help? Do they get mad and tell you they want to try it themselves? Do they need more space? Do they need a little push into new things or to keep trying? Do they complain a lot, but then feel proud or happy when they succeed? Would they rather someone else like a coach or teacher help them?
5. When approaching non-preferred or difficult tasks, it’s best to break down the task into easy, manageable steps. Let the child feel confident with one aspect of the task before adding on the next step.
Example #1: When learning to jump rope, first lay the rope down and just practice jumping over it. Once they have that down, have them pick up the handles and practice jumping over the rope. When they can do that step, teach them to touch the handles up at the top of their head. And for the last step, have them swing the rope over their head for one full cycle of jumping rope.
Example #2: Your child is afraid to ride their bike. You have been pushing them to ride out onto the street, telling them it is not scary, encouraging them that they can do it. You see they can sit on the bike and even pedal the bike, but looking down that long sidewalk seems daunting to them. This is telling you, the challenge is too hard, even if it doesn’t make sense to you. You would make the challenge easier by practicing pedaling in the driveway. Then the next challenge would be riding to a cone you put out or a certain crack in the pavement. With each mastery, the child goes a little further, and eventually they can ride their bike throughout the neighborhood.
Example #3: Your child despises handwriting. They may cry and scream, refusing to participate. Once you get them to the table, they scribble on their book or do everything but practice making the letters. You might not know if they find the task boring, meaningless, or maybe it is really hard for them. You decide to cut a strip of the top row of letters on the sheet so there are less letters to practice and less visual information. Perhaps you decide to make the challenge more fun by offering them a wiggle pen to give them some tactile input. You might also show them how to make the letter, followed by having them trace the letter, and then asking them to make the letter on their own.
6. Just-right challenges add up! It might seem at times what you are doing isn’t making a difference or that it’s taking a long time to master a skill. However, all children benefit from persisting and embracing challenges. Remind your children of how far they have come and how far they can go.
7. Allow frustration and failure. These are ok things to experience and they will not hurt your child! I am not talking about extreme frustration and failure because that’s not just-right. It can be so hard to watch a child struggle, but when you let them experience a healthy level of frustration, you are sending them the message that you trust them, you believe in them, and that you are there supporting them while they figure it out. It’s very empowering to the child!
“Nature does not hurry, yet everything is accomplished.” -Lao Tzu
