Speech Therapy Today

Dyspraxia: an Occupational Therapist's perspective.

Written by Jill Christmas author of Hands on Dyspraxia

As Jill takes us through her client types, outlines what the challenges are and explains about the characteristics of Dyspraxia, it is clear that Dyspraxia can be a challenging issue to deal with. So, I hope this article can help to identify more children who can be diagnosed earlier and helped.

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DYSPRAXIA - an Occupational Therapist's perspective.

About the Christmas Children's Clinic

Jill established the Christmas Children's Clinic in Kent in 1984.  The Clinic offers comprehensive assessments, therapy intervention, also, insets for schools and parental advice for children with a range of difficulties, including the condition of Dyspraxia.

The small team of Occupational Therapists, have had the privilege of working with between 2,000 and 3,000 children over the last 15 years - many of  whom display aspects or the actual condition of Dyspraxia, and/or allied issues.

The Challenges

The majority of children referred to the Clinic, although of average or above average intelligence, have been perceived as struggling with a mismatch between their innate skills and their fine and large motor output. This type of challenge, in tandem with other clusters of difficulties, can fall within the profile of Dyspraxia or a Developmental Co-ordination Disorder.

These children often experience particular challenges when they start school and have to deal with the recording of information, handwriting, concentration, focus, organising themselves and their work, as well as participating in a range of physical activities. 

Handwriting is, in fact, a high level executive skill, and problems with this can sometimes be an indicator of an underlying developmental immaturity. If the  child is under six years of age, they may not be ready physiologically for formal schooling, although within the norm for their overall development.

The challenges that a child or young person presents with, may or may not be within the formal diagnosis of Dyspraxia.  Nevertheless, if the child's sensori-motor difficulties are preventing them from functioning within their potential, they may need to be more fully assessed by for example, an Occupational Therapist. This can assist in identifying both the child's strengths as well as their difficulties.

Their challenges can be easily missed and misunderstood when an intelligent child is performing within the norm, but not up to their own potential.  

In Jill's experience, understanding and sharing what the issues are makes a real difference to the child, the family and the school. For example, when it is realised that the child is not just being lazy, oppositional or awkward but is  identified as having definite motor or sensory challenges, they can then be supported appropriately.

About Dyspraxia

The term Dyspraxia means difficulty (dys) in planning and carrying out automatic voluntary movements (praxis).   

There are three main components to Dyspraxia:

  1. Ideation: The child's ability to think and plan what they want to do either in physical terms or mental planning. This stage may be either easily managed by the child, or they fail to be able to  organise their thoughts in order to plan and execute the activity. Some children with Dyspraxia may not have difficulty with this aspect.

  2. Motor planning: The ability to organise the body's movement  for use.  This is dependent on the body receiving the right information through the child's different sensory systems. For example: via vision, hearing, touch, taste, smell, body awareness (proprioception), and balance and movement system (vestibular). If the child cannot automatically take in, process, filter and organise information from all these systems (sensory integration), then their motor or physical response will be adversely affected.

  3. Execution: If the child has difficulties in the above area, then they will find it difficult to execute movement, judge distance, the force they use (when for example, throwing and catching a ball) and may have a poor spatial sense of their own body position and body scheme in relation to their environment.

The following challenges may be observed in a child with a sensori-motor Dyspraxia:

  • The child may have managed all the milestones of sitting, crawling and walking but at a slower rate and outside the normal time frames expected.

  • They may have a poor sense of where their own body scheme and body position is in space (proprioception) and have a tendency to trip, fall over, bang into things and be heavy footed or handed.

  • Hand writing will be poorly executed with untidy letter formation and position on the line. The pressure exerted may cause the child's hand and arm to tire easily. The child will then be reluctant to write and complain of discomfort in their hand, wrist, arm, neck or shoulder.

  • The mechanics of handwriting often cause discomfort to the child as a result  of unstable, hyper-mobile (over flexible) joints, resulting in an immature whole hand, pen grip.  Also the child may not have been encouraged to refine their grip into a dynamic tripod (three fingered grip) on the pen in the early years. The lack of an angled work surface can also cause postural problems.

  • The child's work is often messy and poorly organised and although they have good ideas they often find it difficult to express them on paper.

  • The child may quickly experience a considerable lack of self confidence and loss of self esteem. This can result in a reluctance to engage in school and home work which may be perceived by teachers or the family, as the child being lazy. (This may be the case in some situations)!

  • It is vital to support these children in a positive and pro-active way and support them in their many strengths in order to avoid frustration and any subsequent emotional and behavioural problems which can arise.

  • The child with the more 'sensory' based Dyspraxia may also have difficulty with hand control in respect of manipulating and doing up laces and buttons due to reduced touch sensation and co-ordination of their fingers and thumbs.

  • They may have poor 'oral motor' skills (control of the muscles of the mouth and tongue) and their speech may be unclear.

  • They may be reluctant to engage in sports and games, as a result of lack of stamina, poor limb co-ordination, judging timing and poor spatial awareness.

  • Organisation of both themselves and their equipment maybe poor and they often lose or misplace their possessions.

  • Sequencing activities and following instructions may be difficult for them. They and their clothes may be messy and untidy, and there is a general lack of awareness of presentation.

  • Some days may be better than others in terms of performance and this can be a cause of  frustration to both the child and the people dealing with them.

  • They may have a heightened perception of sound, vision or taste, but in other areas such as a sense of their own body scheme, tactile (touch) and pain registration - may have under-reactive sensory systems. They may be over reactive to any physical light touch, but not notice when they have hurt themselves. They may unwittingly use excessive force when playing and easily break things.

  • The child may be movement seeking and constantly 'on the go' or fidgeting. Alternatively they may appear in a world of their own, engaged in their own thoughts.

  • Children with Dyspraxia who are often reluctant to engage in school sports and games may experience teasing and in some cases bullying from their peers as a result of their poor motor skills (sometimes in tandem with poor speech expression), as they tend to 'stand out' in a crowd if their Dyspraxia is more pronounced.

The following challenges may be noted in a child with a motor Dyspraxia or Developmental Co-ordination Disorder:

The child with motor Dyspraxia or Developmental Co-ordination Disorder may also experience some of the previously mentioned difficulties.

  • The child may have sat and walked reasonably early but missed out crawling during their developmental progress. (Crawling, in the opinion of many practitioners, helps the child to integrate both sides of the body and cross pattern movements, assists eye and hand co-ordination, builds postural stability at the shoulder and hip, assists wrist extension and the web space between thumb and first finger for refined movement and a tripod pincer grip).

  • They may not have a clearly dominant or preferred hand and may change hands for pen and tool use after the age of 5 or 6.

  • When holding a pen, the child may use an immature palmar grasp round the barrel of the pen and find it difficult to gain a dynamic tripod (three finger grip) on the pen. This pen grip incurs whole wrist and arm movements instead of the finger and hand muscles and makes it more tiring for the child - particularly in extended work.

  • They may have difficulty co-ordinating both hands for use, and tend to 'forget' the supporting hand in class, placing it down by their side rather than steadying their work.

  • The child may find it difficult to sit for extended periods and may fidget, stretch their legs, prop their head on their arms, sit on their feet or half stand when writing to ease mechanical discomfort.

  • They may shift on their seat or rotate their whole body when writing as they have difficulty writing or drawing across the mid-line of their body. This indicates a lack of bilateral (two sided) integration.

  • When using a knife and fork they may have difficulty in isolating arm from hand movements, lifting their elbows in the air when attempting to cut food. (usual in a young child).

  • Associated mouth movements may be noted when cutting with scissors, and/or 'mirror' movements might be seen. For example, when the child is bouncing a ball the opposite side of the body may unconsciously 'mirror' the action.

  • General co-ordination may look a little unusual due to difficulty co-ordinating both sides of the body for use. Learning to ride a bicycle or swim may take them longer than their peers. They may be good at some sports, such as ski-ing, in which they use both sides of the body symmetrically, but may still find cross pattern movements difficult.

  • Some immature whole movement patterns may be observed as a result of poorly integrated, underlying reflexes which are normally inhibited by the brain within the first two years of the child's life.

  • There can be an overlapping profile with Dyslexia or Attention Deficit (Hyperactivity) Disorder, and in some cases issues with social communication challenges.

  • Many children do appear to have some immune system weakness which can result in allergies, eczema, glue ear, hay fever. This may benefit from the advice of a Nutritional Therapist experienced in this area.

  • An experienced Osteopath or Physiotherapist specialising in paediatrics may also be of value in assessing the child's musculo-skeletal system to ensure that there are no underlying mechanical problems, particularly if the child has poor tone and hyper-mobile joints which can lead to reduced postural stability.

  • Speech and Language therapy may assist the child with poor diction.

The role of the Occupational Therapist in working with children with Dyspraxia and allied conditions.

An occupational therapist may or may not be a specialist in Dyspraxia and allied conditions, but if so, is in a excellent position to evaluate the child's strengths and challenges in order to provide advice and practical support. It is particularly helpful if the therapist has an understanding of any sensory integrative challenges that a child may have, in order to inform and support both the school and the parents.

Occupational Therapists can provide a comprehensive assessment of the child with motor co-ordination and allied challenges, and contribute to, or provide, a diagnosis. They provide advice in report format with attendant strategies for the child in their daily life as well as within the school setting.  Therapy may also be helpful, to address the highlighted needs of the child.

Close liaison with school staff, feedback from parents and the issues raised by the child themselves, all assist in gaining a comprehensive profile prior to a full assessment.

The following assessment  tools are some of many which may be utilised by the Occupational Therapist in order to provide a practical profile of the child with Dyspraxia:

  • Clinical observations - including the child's engagement with the environment, balance systems, postural strength and stability, ocular-motor skills, body position awareness, co-ordination of the two sides of the body, tactile skills, eye, hand and ear preference, fine motor control, oral motor skills, presence of aberrant reflexes, sensory issues.

  • Observations and feedback from activities of daily living or life skills for example, dressing, knife and fork use, bathing, sleeping and toileting issues.

  • Evaluation of physical skills screening using standardised tests, to include large motor movements, manual dexterity, static and moving balance, ball and targeting skills amongst others.

  • Standardised tests of Visual Motor Integration - testing the combined skills of visual perception and motor recording using the medium of paper (handwriting) or technology.

  • Standardised Visual Perception Testing which includes the more cognitively based skills of visual memory and visual sequential memory.

  • Sensory profile to evaluate the child's level of response to environmental stimuli and the impact it may have on their functioning within the classroom or at home.

  • A range of assessment tools to help the child and their parents evaluate their own performance strengths and challenges.

By Jill Christmas

By the way, if you would like to purchase Jill's book - Hands on Dyspraxia, it is just £39.99 you can click here for information and ordering details.

Occupational Therapists Specialising in Paediatrics
April Cottage, 20 Manor Road, Rusthall, Tunbridge Wells, Kent TN4 8UE
Tel: 01892 510257
Fax: 01892 529614
E-mail: enquiries@christmaschildrensclinic.co.uk
Web: www.christmaschildrensclinic.co.uk

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