Grade and Placement : Form completed by : Please mark an X ... Pre-Referral Form... · OT...

OT PRE-REFERRAL FORM: INTERVENTION STRATEGIES Compiled by Claudia Ginsberg-Brown, MS, OTR and Theresa Schmotzer, OTR

Student name : ____________________________________ Current support services : ____________________________________ School of attendance : ____________________________________ : ____________________________________ Grade and Placement : ____________________________________ Form completed by : ____________________________________

Please mark an X in the box corresponding to the interventions that you have implemented consistently for a period of 6 weeks. Feedback about the outcome of using interventions can be written in the COMMENTS box following each section.

POOR POSTURE/ FALLS OUT OF CHAIR/ SLUMPS SIGNIFICANTLY (all ages) It is important that students that present with this type of problem have maximal opportunities to engage in physical gross motor play and activities that promote strength and endurance (climbing, swimming, tumbling, martial arts, etc).

Proper positioning: adjusted the seat and table height as follows:

• Soles of the feet should touch the ground: can adjust the height of the table legs or place a phone book wrapped in packing tape/duct tape and using Velcro to secure to the floor.

• Desk height should be placed 2” above elbow position when child’s arms are at his/her side.

Allowed student to use an alternatives to conventional seating such as: 1. Standing to do work. 2. Sitting on a therapy ball with a stand (should be closely supervised). 3. Using a “sit n’ move cushion (inexpensive alternatives with a similar effect include a camping cushion or a partially inflated beach ball).

Facilitated upright posture by having the child work on a slanted surface such as an easel or slant board (can be made by using a 3” binder or cardboard box cut at angles with non-skid material underneath). *OT Department can provide a sample or written instructions on how to make this slant board.

COMMENTS:

OT PRE-REFERRAL FORM: INTERVENTION STRATEGIES

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MIDLINE CROSSING DIFFICULTY: SWITCHING HANDS WHEN REQUIRED TO CROSS THE MID SECTION OF THE BODY (pre-K to 2nd grade)

Child avoids crossing the middle of their body. Look for: switching hands to draw/color/print on opposite side of midline, moving into positions to get object on opposite side of midline without reaching across the body, picking up items on left side with the left hand and transferring to the right or vice versa for right handed students, or student starts to print on one side of page and switches hands at midline.

Had child use only one hand to pick up objects placed on the opposite side of his/her body : Leggos, building blocks, puzzle pieces.

Played “SIMON SAYS” game with emphasis on moving arms/legs across the body to the opposite side, encouraging movement in diagonal patterns.

Engaged child in “patty cake” game.

Set up table-top/game/play activities/manipulatives to require child to use LEFT hand to pick up and place items on his/her right side, and to use the RIGHT hand to pick up and place items on his/her left side.

COMMENTS:


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FACILITATING HAND DOMINANCE & PROPER GRASP: STUDENT SWITCHES HANDS WITH DRAWING/ WRITING (K-1 or after age 6)

The dominant hand manipulates objects while the non-dominate hand is used to stabilize objects. There is a problem if the student is not consistently using the same hand to write, cut, and eat. Using the same hand for a specific skill promotes more refined skill performance. Switching hands is an integral part of normal child development and should not construed as a problem at the Pre-school level. Identified dominant hand. You can often tell which hand is more skilled by watching

After identifying skill side (dominant hand), have the child wear a bracelet or ring on that hand so that you can promote/encourage use.

Maximized opportunities to engage in BILATERAL tasks that require the student to use their preferred hand to manipulate and non-preferred hand to stabilize the activity. Suggested activities include:

cutting opening/closing jars pushing a car or train around a track (non-dominant hand supporting body on the floor) nuts and bolts activities

using a toy hammer and nails, screw driver lacing cards stringing beads placing stickers pouring water or sand bowling drawing with templates, rulers, or stencils using an egg beater or winding toy scooping or spooning into a container placing coins in a bank or slotted container throwing a ball or beanbags digging with a hand shovel sweeping the floor or raking leaves have student wear a sock on the non-dominant hand to use as an eraser while using a dry-erase board, slate board, or chalk board

Facilitate writing grasp development, wrist extension, and shoulder stability by engaging in the following (using a vertical or slanted surface whenever possible):

painting with a brush or with fingers on an easel or slanted surface using tongs using felt boards placing magnetic letters/numbers manipulating small game pieces sand and water play

Comments:


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INEFFECTIVE PENCIL PRESSURE / MAKING LINES THAT ARE TOO LIGHT OR TOO DARK (K-1 or after age 6)

Poor pencil pressure will result in writing that is not legible because it is too light. Use of excessive pressure can result in fatigue, cramping, and/or poor endurance due to muscle strain from applying too much pressure. Underlying causes may include poor grasp, poor strength, poor ability to grade pressure (proprioception). Modifications, adaptations, and exercises most often successfully address this problem.

Facilitated proper grasp (see section , page 5)

Increased hand strength by:

writing in clay using a hole punch clothes pin games playdough or clay activities digging with a shovel in sand or dirt pouring liquids push ups before writing tug-o-war moving classroom furniture hanging from a bar bowling climbing

Increased awareness of pressure by giving more feedback using a variety of mediums and activities: Do warm-ups for writing such as:

rubbing hands together clapping stretching shaking out hands squeezing a stress ball or flour filled balloon practice coloring with colored pencils/ crayons pressing lightly (using black to make gray, red to make pink, green to make light green) using a vibrating pen for warm up writing activities (5-10 minutes) tracing/drawing with your index finger in sand, clay, or on a carpet square writing over sandpaper writing in watercolor paint writing on window screen material without going through using a mechanical pencil without breaking the tip

Comments:


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POOR WRITING POSITION/ NON-FUNCTIONAL GRASP: (1st grade or older)

Children hold their pencil a variety of different ways. If a student uses a modified grasp that allows for the fingers to move freely to form letters, he/she is holding the pencil adequately. There is a problem if: all five fingers are on the pencil, if the wrist is flexed (bent toward the palm), if the elbow is floating off the table surface, or if fingers are hooked around pencil. Younger students should be using pre-school crayons, primary markers, sidewalk chalk to draw and scribble—Pre-K is too early in the typical development of the hand to force the use of pencils—can lead to grasp problems in the later grades.

Provided a vertical surface or three ring binder slant board.

Provided pencil grips (specifically for students 6 years or older).

Had the student hold a penny, paper clip or other small object against the palm with the ring finger and pinky, leaving the other three fingers available for proper placement (tripod grasp) on the pencil/pen.

Engaged student in activities that emulate the position of a tripod grasp such as:

games and activities that require pinch tweezer games using pencil grips manipulating nuts and bolts twisting on/ off caps such as on a tube of toothpaste using ½”- ¾” chalk pieces or broken crayons to color and make lines lacing activities using an eye dropper (e.g. with food coloring on a paper towel) clothespin activities

Comments:


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PROBLEMS WITH PRE-WRITING / BASIC STROKES: (Pre-K and K)

Developmental sequence of learning to write begins with: 1) tracing, 2) imitating demonstration, 3) copying from a sample Understanding concepts of directionality (e.g. up, down, around, top, bottom, left, right, across) is critical for the development of both writing AND reading skills Other foundational components include utilization of a functional grasp and the use of the non-dominant (or “helper”) hand to stabilize paper (remember that writing is a bilateral activity!)

Difficulty with concepts of directionality: Right/Left: had student wear a bracelet or band on his/her left wrist to identify the LEFT side placed a vertical strip of tape on the floor and play a game using the concept of stepping left or right of the line. highlighted the left and right margins of lined paper with green and red respectively (green for GO and red for STOP) had student perform large motor movement activities from left to right e.g.: making rainbows or drawing lazy eight’s using dry erase markers on a board or sidewalk chalk on the ground engaged student in games that include directional concept such as “Simon Says” and “Hokey Pokey” continue to use terminology that is consistent with a handwriting program (e.g. Handwriting Without Tears: “bump the line,” “dive/slide down,” “magic “c” offered cross word puzzles or Scrabble for kids had student complete vertical and horizontal mazes going top-to-bottom and left –to-right had the child follow along with a finger while a story was read them Diagonal lines: used boxes to make X’s emphasizing corner-to-corner concept had student draw alternating plus signs and x’s played tic tac toe utilized graph paper reinforced formation of diagonal lines from the top-down rather than from the bottom-up practiced Dot-to-dot connection drawings Up/Down: used color codes to identify top/bottom of each line (analogies such as touching the sky and ground can be used for prompts or reminders) engaged student in jumping and or hopping up and down using songs that teach directionality

Difficulty Forming basic strokes: had the student fill in missing parts of pictures and letters practiced dot-to-dot pictures and letters practiced with index finger to write in the air wrote with a stick in the mud, in the sand with a finger/hand, water used secret code markers to uncover lines/letters

Comments:


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PROBLEMS WITH LETTER FORMATION : (K-1)

Letter recognition is essential to the child’s ability to write letters. Without letter recognition, children will draw letters (make shapes) which have NO meaning or relevance to them. Consequently, proper and consistent letter formation is unlikely to occur. Be sure to provide age appropriate paper. Lines should be widely spaced for K level letter formation. Conventionally lined paper should be reserved for use with the upper elementary grades. Difficulty with letter formation:

Had student practice: air drawing with fingers in a tripod grasp large total arm movements of writing letters in the air with eyes open and then with eyes closed drawing letters in dry mediums such as sand, flour, sugar, or rice on a flat surface (cookie sheet or baking pan) printing with index finger on carpet squares printing over tactile surfaces such as sand paper or window screening material with crayon, chalk, or pencil printing letters in mediums such as shaving cream and sealed zip-lock freezer bags full of colored hair gel printing on a vertical surface to reinforce wrist extension and the concept of up and down making letters using language consist with a handwriting program and having student verbalize direction of movement for letter production making letters using a vibrating pen (available at Wal-Mart) Referred to interventions listed in Pre-Referral Intervention Manual (PRIM) section 70 page 147

Letter reversals: Illustrate difference between “b” & “d” by using fisted hands and thumbs up position so right hand is d and left hand is “b”. If they know how to print an upper case “B” lower case “b” should fit inside of upper case “B” and that “d” starts with an “a” Keep a “cheat sheet” of commonly reversed letters on the child’s desk using the same color for all letter that begin on left (b, h, p) and another color for the

right (d, q, z). Referred to interventions listed in Pre-Referral Intervention Manual (PRIM) section 63 page 134

Far point copying (Copying for the board/ overhead/ easel): Put a copy of overhead on student’s desk Provide NCR forms for another student to take notes as a back up in case notes are illegible or incomplete Put student at front of class Keep whiteboard clear of clutter, write information to be copied in large print and in dark color Eyes checked if child seems to be squinting Use different colors for chunks of words or change in when going to the next line down. Referred to interventions listed in Pre-Referral Intervention Manual (PRIM) section 60 page 129

Comments:


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PROBLEMS WITH SPACING AND ALIGNMENT

Difficulty with spacing, floating letters, and alignment (Grades 1 to 4):

Used graph paper asking the student to leave one box open as a space between words. Exaggerated the space between words of a model for the student to copy from in order to differentiate spaces between words vs letters Used a popsicle stick, index finger, M&Ms, Skittles, stickers, Cheerios (decorate for reinforcement) between words Had student review their own work and self correct Wrote a sentence with incorrect spacing and asking the student to read it exactly as it is written. (i.e. Th eca tra nup thet ree.) Circled the words as they should read and ask the student to rewrite the sentence with appropriate spacing between letters and words. Used paper with raised lines, or use a hot glue gun or glitter glue to make raised- line paper Highlighted the space between lines Referred to interventions listed in Pre-Referral Intervention Manual (PRIM) section 62 page 133 & section 64 page 136 Tried differently lined paper or graph paper Used a colored index card with rectangle cut out as a guide for remaining on the lines Used a vibrating pen for increased awareness

Comments:


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DIFFICULTY HOLDING/ USING SCISSORS (AGE 4 AND UP)

Use correct size scissors appropriate for the child’s hand size. Have a variety of adaptive scissors available (e.g. spring-loaded, loop scissors, easy-grip scissors in a variety of sizes; see catalogs like therapro.com). Scissor skills typically emerge by the 2nd year of preschool. Inability to open and close scissors with one hand. Child attempts to use both hands on the scissors: Began with using materials that only require a snip i.e. cutting up a straw, card stock, construction paper, marshmallows, fruit roll ups, licorice,

beef jerky, play dough, ect…

Worked up to cutting across paper, start with 2”, 4”, and 6” strips, then straight-line shapes, and circles. Start with thicker lines such as an 1”, ¾”, ½”, and work up to more narrow lines.

Used a tweezers to pick up small objects

Prompted student to use non-dominate hand to stabilize object/paper

Used turkey baster to blow air on cotton balls in racing game

Played pretend games with puppets (which have thumb moving opposite the rest of hand)

Taped paper on a vertical surface so student cuts in an upright direction which promotes wrist extension and prevents maladaptive positions

Practiced using tongs to pick up small objects. Egg decorating tongs are great to practice with—sold at local discount stores during Easter season

Wrapped a rubber band around the scissors at the intersection of the two blades causing resistance in the opening process. (use caution if child has an exceptionally weak grasp or juvenile arthritis)

Used terminology e.g. “thumbs up” and placed a sticker on student’s thumb fingernail (both hands so student sees the stickers while they are cutting)

Prompted the student to rest elbows on table to provide stability at the shoulder and elbow (see , pg 10).

Comments:


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PROBLEMS WITH SHOULDER STABILITY

Children with poor shoulder stability often look like they hold activities very close to their body and avoid reaching. Another compensatory mechanism can be seen during writing activities, children look like their shoulders are shrugged and arm is raised and out away from the body.

As an accommodation, positioned student to rest elbows on table during table top activities and fine motor manipulation tasks

Engaged student in fishing magnet puzzles and games

Encouraged all games that require weight bearing such as wheelbarrow walking, crawling through mazes and tunnels, climbing, tug-a-war, pull-ups, monkey bars, ect…

Had the student produce work on a vertical surface. Next best thing would be a slant board.

Engaged student in cooking or pretend cooking that require stirring thick materials (brownie mix, bread dough, mud)

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PARTICIPATION WITH MESSY MEDIA

Children who appear to experience anxiety or stress when asked to participate in activities like finger-painting, shaving cream or sand box, play, crafts that require glue or other sticky / messy / wet substances, may be exhibiting hyperactive tactile sensitivities. These children sometimes appear like they really want to participate with their peers but are afraid to. Children who do demonstrate tactile defensiveness respond best to firm touch when being assisted or guided.

Offered the student maximal opportunity to participate without doing anything he/she is reluctant to do such as: set up, handing off tools, using a tool instead of direct contact, generally exploring the media without touching. Offered positive reward and/or praise for participation but DID NOT force the student to participate Offered the student plastic gloves to protect his/her hands. Offered many opportunities for the student to complete ONLY the last step of a messy project or activity and followed cooperation with praise and positive feedback/reward Had the student paired with a child who enjoys tactile media. Offered other opportunities for preferred tactile activities such as: finding magnetic letters in dried beans or rice, water play, sand box. Offered an opportunity for the student to wash hands with a washcloth or wet towel next to them during activities. Offered free time with sensory activities including those which are known to be the least desirable to the student

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STUDENTS WHO CRASH, BUMP, PUSH, STOMP, JUMP OFF HIGH PLACES, EXHIBIT EXCESSIVE MOVEMENT WHILE SEATED and/or BITE

Students who exhibit these types of behaviors may be hypo-responsive to proprioception and therefore respond to opportunities for proprioceptive input throughout the day. If behaviors do not change, behaviors are likely due to some other factor or combination of factors.

Provided sensory breaks throughout the day offering opportunities to: stomp, hop, skip, tug, push, pull, and jump. An extensive list of activities available from CUSD OT. Used activities that can prevent behaviors: pushing a cart, moving a pile of books (one to three textbooks at a time), taking a note to the office. Put the student at the front of the line or the end of the line. Taped off area around each student’s desk to demonstrate personal space. Used a rolling pin to roll out play dough. Allowed student to use fidget toys at his/her desk.

See on page 13. Used items suggested by a CUSD OT such as: weighted vest, move-n-sit, disco sit, or pressure vest. Allowed student alternative positioning for work such as: standing, kneeling, and lying on carpet. Used a timer to indicate transitions.

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EXCESSIVE CHEWING OF NON-FOOD ITEMS

Offered the child an alternative but more appropriate to chew such as: refrigeration tubing (available at Home Depot). A three-inch section can be placed over the end of a pencil or pen, other suggestions such as chewy tubes can be recommended by a CUSD OT as appropriate.

Provided sugar free chewing gum if the child can be responsible. (Special permission should be obtained from the campus principal).

Allowed student to “munch” on chewy or crunchy foods during snack time. (Bagels, beef jerky, licorice, chewy candies, skittles, starburst, chips, pretzels, carrots, celery, apples). Parents may provide these items for snack time. Beware of dietary restrictions.

Allowed the student to keep a sports water bottle on his/her desk.

Referred to interventions listed in Pre-Referral Intervention Manual (PRIM)

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POOR ABILITY TO ATTEND

Offered fidget toys: koosh ball, paper clip, straw, play dough, chewing on straw.

Allowed student to have a sports water bottle at his/her desk.

Provide a move n’ sit cushion or disc-o-sit round cushion for the student to move in his/her seat without disrupting the class.

See on page 13.

Placed student at front of class, and away from windows, doors, and other distractions.

Asked student questions often to keep him/her engaged; Try to have interactive lessons.

Tried changing environment with increasing or decreasing lights, and or background noise (music).

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‘MELTDOWNS,” RESISTANCE TO, OR UPSET WITH TRANSITIONS

Gave, or allowed the child to hold, a transition object of their preference prior to transitions such as a: stuffed animal, koosh ball, or sports water bottle.

Used a daily picture schedule for each child by his/her desk.

Gave a warning or countdown prior to transitions such as “we have one minute left or ten seconds and follow that with a count down 9, 8, 7, 6, 5, 4, 3, 2, 1.”

Used a timer for activities.

COMMENTS:

Grade and Placement : Form completed by : Please mark an X ... Pre-Referral Form... · OT...

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