Development of Visual Perceptual Skills: Visual Spatial Relations

Visual spatial relations have a strong impact on a child’s academic skills. As mentioned in my previous post about Visual Perceptual Skills: Real Life Applications, this particular skill has to do with understanding the relationships of objects within the environment.

When this is an area of difficulty for a child, we often hear concerns from parents about letter reversals or poor alignment of letters on the page. While you can quickly search the internet for worksheets and activities that address spatial relations, I wanted to take this time to point out a few underlying factors that also have a lot to do with the development of this concept: Laterality and Directionality.

I know, I know, what would life be if professionals didn’t have these long-winded words to reference? Allow me to break down each of these concepts so they might make a little more sense as to how they play a role in visual spatial relations.


Definition: the awareness that there are two different sides of the body.

This awareness is developed as the child gains a thorough understanding of their body scheme. It begins around age four, but the ability to correctly name their right and left sides might not stick right away. It’s not uncommon to see a five year old guessing, “is this my right hand?” In fact, it’s really around age 8 or 9 when the majority of children are consistently identifying these sides of the body.

When a child develops handedness, they are able to more efficiently plan fine motor activities. That’s because one hand automatically feels like the correct hand to use and the other doesn’t. This also creates an important point of reference for development of spatial concepts.

I know many of us know children well into ages 10 and up that still have difficulty in this area. These children might have more difficulty with things like reading and writing, which is set up from left to right. (Think about this – we have no real reason why we read from left to right – that’s just the way it is, so when a child has difficulty with these spatial concepts, reading or writing in this directional pattern might not feel as automatic.)


Definition: understanding the concepts of right/left/up/down/in front/behind as projected into space.

While laterality is more of an internal understanding of these direction concepts, directionality is the ability to send these ideas outside of the body. Children start by understanding these concepts in relation to themselves, i.e. “the dog is on my right,” and then later are able to relate this to two objects, i.e. “the pencil is to the left of the paper.” One of the hardest levels of this concept is identifying the right/left sides of someone in front of them.

Think about how many directional references children receive in their day. They are told to write their name on the top right corner of the paper, turn right out of the classroom to go to the office, or pass their test to the person on their left.

Also, think about the important concept of number and letter recognition. To you, a chair is still a chair, even if it’s flipped upside down on a desk. In that same theory, to a child who has not gained directionality concepts, a “p” can still be a “p”, even if it’s flipped upside down as a “d” – and thus you might be able to understand their confusion.

So while many activities exist for development of visual spatial skills, it’s also incredibly important to assess foundational building blocks and their potential impact on functional outcomes.

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Tested in OT: Floam Fumbles

I am not immune to the fancy trends of tactile play.

So yes, I absolutely had to try creating the floam slime that seems to be everywhere. Call it nostalgia for my childhood days of playing with Nickelodeon Floam and Gak – do people remember that? It was totally a thing, trust me.

The only problem is that there are approximately 27,000 slime/floam recipes available online. Where in the world is a therapist to start? Follow along with me, friends, for I have tested three different recipes, and only one was a total disaster.

Making floam was on my list of things to try forever. It’s a great activity in occupational therapy for different reasons – following directions, managing materials, mixed consistency tactile input, fine motor precision to help me clean up hundreds of tiny Styrofoam beads… So what was stopping me? For the love of crafting, I could NOT locate liquid starch anywhere. (One of the main ingredients for most floam recipes.) It was not at my local Wal-Mart, grocery stores, drug stores, anywhere.

So out of pure necessity I started with a recipe using Borax as the “active” bonding ingredient:

Look! We made a glue rock! Ugh, this one was a nightmare. We combined all the ingredients into a zip-lock bag and mixed them up, which was a fun process. But perhaps we used too much Borax, because the glue became really stiff and the beads would literally shoot out of the floam as the children played with it. In all fairness, they thought it was hilarious. The cleaning crew? Probably not so much.

It was time to up my game. With still no liquid starch in sight, I watched several online tutorials in order to make my own. I can’t even comment on how much extra effort this seemed to be requiring of me. But I got out a pan and corn starch and boiled away, way more proud of myself than I should have been.

Homemade liquid starch vs. the real thing.

Spoiler alert – this did nothing. Like absolutely nothing. Did I not use enough corn starch? Did I manage to boil water incorrectly? Did I have a magic touch that turns any DIY crafting experience to complete trash? There’s no way to know for sure.

After driving to a Wal-Mart the next town over, I finally located the liquid gold starch I needed. And thank goodness – this ingredient was the winner of the entire process:

So, this totally looks like a bowl of Funfetti cake mix. The only other difference for this round (besides using liquid starch) was mixing in the Styrofoam beads before adding the starch. This helped everything mix together a little easier with less mess.

The results were fantastic! A little slimy, but not too much residue left behind when playing with it, which was great for some children that are apprehensive to messy play. It stretched well and actually retained the little beads while being tossed around.

There was one more recipe to try, which called for using shaving cream instead of water. In the process of real life trials, we managed to go waaaay overboard with the recommended foam beads on this one:

This trial might have been the favorite overall. While recipe #2 was sort of slimy, this one was more fluffy. Plus, there’s something about spraying shaving cream that children absolutely LOVE. As far as adding more beads went, there seemed to be a sort of saturation point with the mixture where they just wouldn’t mix in anymore. So it won’t really hurt to add more, they just might end up sticking to your hands and the bowl instead.

So to recap, here’s the final results: 1 glue rock and 2 actual floam creations. A fairly successful test run if you ask me.

To see other Pinterest Test Pins, click here.

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What to Know About Scheduling Pediatric Therapy

It’s fair to say there’s a lot more than meets the eye when it comes to scheduling and maintaining productivity in a pediatric therapy clinic. In the name of transparency, let’s discuss a few things that both families and therapists have to consider when making a therapy schedule work.

Finding a weekly appointment time can be challenging:

Therapy is a commitment, and not necessarily a light one, as it typically requires a weekly appointment for an extended period of time. Making sure caregivers can get a child to and from said appointment all while juggling work, extra-curriculars, homework, and sibling schedules can be difficult.

After the initial evaluation, I typically ask when an “ideal” weekly appointment would be. I need to stop doing that, because I often find myself immediately following up with, “yeah, I don’t have that.”

After-school appointments are hard to come by due to their popularity. Often, people will resolve to start their therapy sessions at a less ideal time, with the hope of getting first dibs on a coveted after-school appointment as soon as it opens up. Others might instead opt for a week-to-week schedule, calling in to see what cancellations the therapist has for the week.

I have to note that lately I’m seeing less therapists even offering those after-school hours due to the fact that they have to pick up their own kids or might only work part-time. Some clinics mandate that therapists offer certain later hours, or the extremely rare Saturday time, but these are still difficult to come by.

Many children end up getting pulled from school for therapy:

Therapist schedules are usually slammed first thing in the morning or late in the afternoon. Those awkward middle-of-the-day appointments are great for younger children who aren’t in school yet, or maybe children in feeding therapy that need sessions around meal times.

However, I’ll throw out that I have had some really great sessions with school-age kids mid-day if their parents can swing the hassle of getting them in and out of school. Depending on the child, sometimes missing an hour out of the middle of the day is least disruptive to their academic schedule, and they might be able to return to school with more focus and better regulation.

Others find that missing the last 20 minutes of the day or arriving a few minutes late in the morning is beneficial as well. A talk with the child’s teacher can reveal what part of the day (if any) is easiest to miss once a week.

Some schools are incredibly open to this idea of children missing a bit of their day for an appointment, while others are very particular about students being pulled out, coming late, or leaving early.

I’ve had parents ask if it was “worth it” for their child to miss part of their school day to come to therapy, and I can understand their concern. I’m obviously a bit biased, but receiving direct 1:1 services in the clinic should be beneficial to the child’s overall skill development, and should support the skills they need in the classroom. We just want to make sure it works out so they aren’t missing other important resources in their school day.

5:00 is a dreaded appointment time for everyone:

With only so many after-school hours in the day, the last resort is adding an appointment at or after 5:00.

I’d love to hear if others out there have had consistently good luck with these later appointment times. In my experience, the child is often exhausted, the therapist is exhausted, and the session can turn into a battle of wills. Some older children have done well in this time slot, but overall, it’s a tough time for many children to try to do therapy. These later times should be reserved for those children that can still receive maximum benefit from the timing of the session, which might just be a matter of trial and error.

Transitions between appointments can be tricky:

I promise you that no one can make a mess like a pediatric therapist.  It’s almost as if you look around the room after about 45 minutes and think, “how did this happen?” It seemed like such a good idea to bust out that sensory bin at the time, but now the rice has wedged itself into every available crevice of the room and my next patient is walking in the door.

While trying to clean up between patients can throw off the schedule, therapists might also find themselves jumping from a session with a 6 month old baby to a session with a teenager, so switching gears can take a moment. Some might also be running in the door from a home health visit in the community, or unexpectedly locked in an intense conversation with a parent at the tail end of a session. All I can say is that your therapist will try their very best to stay on the established schedule.

Running behind for one patient sets the whole day off:

When you are scheduled back to back, those run-overs make it difficult to catch back up. Sometimes a parent is late in picking up, or a conversation just goes long. In order to give everyone their fair session, it often means running behind most of the day if the therapist is the one starting late.

However, I think it’s important to throw out that if a caregiver brings a child to a session 15 minutes late, this does not mean the session automatically extends 15 minutes late as well, unless the therapist specifically states they can see the child longer than their scheduled appointment time. This miscommunication has happened on multiple occasions in a back to back scheduling scenario, which leads to unexpected setbacks.

Cancellations can make or break a day: 

Maybe it’s just me, but it feels like cancellations are an “all or nothing” part of my day.  Either everyone comes, or 75% of my day cancels like a domino effect. Some clinics have strict cancellation policies which require that missed sessions are rescheduled, or perhaps a fee is assessed for “no-shows” or last minute cancellations.

To be honest, these policies often work well to keep people accountable for their scheduled sessions. (Not just for our sustainability as a practice, but if you miss a lot of sessions, it’s hard to prove medical necessity to insurance providers.) Although on the negative side, it also leads to a lot of sick kids coming to therapy. There’s nothing worse than little Johnny coughing in your face saying, “I didn’t go to school today because I was sick!” So I encourage people to cancel when necessary, with the intent of making up the session if possible.

And also, while talking about cancellations, I know things often come up last minute when it comes to children, but the more notice you give your therapist that you can’t be there, the more opportunity they have to offer your time to someone on a waiting list.

Un-billable time has to be limited: 

In an ideal world, every evaluation would have a sit-down meeting with a parent afterwards to go through the entire write-up. This doesn’t always happen. Why? Productivity. I’ve seen various expectations of productivity in different clinics, which I’d say average around 75-80%. That means only around 20% of my day can be spent outside of billable treatment hours for things like paperwork, phone calls, parent meetings, treatment planning, set-up, etc. Therapists often find themselves doing a lot of things on their personal time to keep up with the work flow. So if it takes a while for a therapist to type up an extra note or communicate with another therapist, it likely has to do with finding that elusive “extra” time.

Therapists understand the commitment involved in bringing a child to therapy, and regardless of the challenges that can arise from scheduling, seeing the progress from week to week hopefully makes those sessions worth the extra effort!

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Techniques for Coloring in the Lines

Coloring in the lines? That’s so…conformist! Ok, so maybe it’s an important skill when it comes to fine motor control and spatial awareness. Recently, I’ve found myself working on this skill quite a bit, so I went to Pinterest to find a few new ideas to refresh my approach a bit.

I picked three different techniques to try, as outlined below, all of which provide some sort of boundary to reinforce the idea of coloring “inside” vs. “outside” of a shape:

Full disclosure, I have also tried this technique in the past using Wikki Stix to outline the shape, (Remember when I tried to make those myself? Yikes. I can still smell the chemical reaction…) and they provided a similar boundary to the 3D art paint. However, I found the Wikki Stix to be a lot more obnoxious because the kids that applied more pressure to their coloring would send those things flying off the page.

My top pin-spirations (Oh my, is that a word? Is it bad I sort of like it? Let’s move on…) was from a blog called HeyDay Living which focused on trying Montessori techniques at home, and an awesome post from The OT Toolbox about line awareness.

So, how did they work out? Check out this example:

Embroidery Hoop
This was a HIT! The children repeatedly asked if they could try this one again and again. They felt incredibly successful, which makes sense, because this technique provided the highest amount of assistance.

The high boundary of the hoop provided:
-more success staying within the guidelines.
-increased tactile feedback when they hit the edge.
-high awareness of “inside” vs. “outside” the lines.
-an easy edge to grasp with their helper hand for bilateral coordination.

3D Art Paint
Who doesn’t love glitter? Wait, let’s rephrase that: Who doesn’t love glitter suspended in paint that doesn’t get everywhere?

This was another technique that kids were excited to try, simply because it looked so cool. “Do you have more?” they would ask, rooting around my pile of papers. And let’s face it, any time you have a child asking for more repetitions of a challenging skill, you are winning.

Plus, with this technique, you can play around with high or low contrast, trying different paint and paper color combinations until you find the right cue for the child.

School Glue
This is by far the lowest amount of assistance. It’s low contrast, adding just a slight tactile edge to the shape. My heavy-handed colorers burned right through that edge with little awareness. It is best used with those that just need a little cue or increased awareness of the guideline.

These techniques are basically a hierarchy of assistance. I might start with the hoop, move to 3D paint, then on to glue as the child gains control and understanding of the concept, eventually moving away from any additional cues at all.

The downside of using the 3D art paint and the school glue is that you must prep these at least a day ahead of time; that stuff is not going to dry within a session. OR… just dedicate an entire morning to gluing and painting tons of papers, using every available surface of your home as a drying rack, like I did one Sunday. Whatever floats your OT planning boat!

(If you want to check out previous Pinterest Test Pins, click here.)

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10 Realities of the OT Brushing Protocol

If you are familiar with occupational therapy in a pediatric or sensory setting, you have likely been introduced to “the brush.” But how much do you really know about this intervention tool?

1. You’re not supposed to call it “brushing.”

Officially, this intervention is called the Wilbarger Deep Pressure and Proprioceptive Technique, or DPPT. The term “brushing” is supposed to be avoided, because the goal of the intervention is to provide deep pressure, and the creators have noted that “brushing” doesn’t accurately represent that intention.

2. The technique was developed for sensory defensiveness.

The creator of the technique, Patricia Wilbarger, MEd, OTR, FAOTA, is a leading expert on sensory defensiveness. (This is basically when the nervous system over-reacts to stimuli that would not typically be perceived as negative or harmful.) The entire technique takes around 3 minutes, and includes deep pressure input applied to the child’s hands, arms, back, legs and feet, followed by joint compressions to the extremities. This is typically followed up by engagement in “sensory diet” activities.

While the technique was created based on this concept of sensory defensiveness, many occupational therapists introduce the DPPT as a way to provide deep pressure input to sensory “seekers” or those with higher thresholds for sensory input.

3. There’s only one brush officially recommended by the creators.

The Therapressure brush was designed specifically for the DPPT, supposedly for its ergonomic shape and appropriate bristle density. It also tends to make it more expensive. (Of course, anything with the term “therapy” applied to it instantly becomes more expensive.) However, in the reality of practice I’ve seen tons of brushes used other than the official Therapressure brush.

4. You should be taught by someone with specialized training, but that’s hard to do.

One of the most important components of this intervention is applying the “right” amount of pressure, which is why learning in-person is key. However, finding a way to get trained as a therapist is hard to do these days. I haven’t seen consistent seminars offered by the Wilbargers for a long time. However, after some searching, I was able to locate one training seminar… in Ireland. So you might just have to settle for being trained by someone who was trained by someone years ago. (This just happens to be how I acquired my “hands-on” training on the subject.)

5. It’s a high intensity intervention.

The recommendation is to complete the technique every 90-120 minutes of a child’s waking hours. Yes, you read that right. Sometimes that recommendation alone is enough to scare a parent away from trying it. According to the theory, this is the amount of time the positive, modulating effects of deep pressure and proprioception last in the nervous system.

6. Even if you follow the protocol, there are several factors that make it difficult to implement.

There are many nuanced components of this technique. The amount and consistency of pressure, how you move the brush across the skin, how you transition between the arms/legs/back, keeping track of the brush when you take it home… it’s a lot to remember and complete with confidence.

Parents have come to me saying they just couldn’t get their child to engage at home the way we could in a session. Sometimes parents or children have anxiety with the anticipation of applying touch, and the process suddenly becomes a whole big “thing” or source of stress. We never want to force any intervention on a child, especially within the context of sensory integration theory.

We also typically ask parents to try it at the recommended frequency for at least two weeks in order to gauge effectiveness. However, I rarely see follow through for the entire two weeks. Often, if results aren’t seen right away, the technique is quickly abandoned.

7. There are things you aren’t supposed to do.

This is where that whole training thing comes in handy. There are areas of the body to avoid with the brush, such as the stomach or face. Completing the protocol sporadically might cause more issues than it helps. Using too light of touch might actually tickle or scratch as opposed to provide deep pressure. There may be individual precautions due to other diagnoses related to nervous system function. The list goes on…

8. There are many versions or variations online, which is not a good sign.

A quick internet search will lead you to YouTube videos, online tutorials, or various different websites. In fact, almost every OT I’ve ever met has their own DPPT “worksheet” to give parents in order to explain the protocol. And guess what? Every one of those is slightly different. Information is passed between therapists, collected from different settings, and becomes somewhat of a game of intervention “telephone.” For something we describe as a protocol, one might expect more uniformity in the execution.

9. The evidence that it’s effective is virtually nonexistent.

Harsh reality time: The evidence, if you want to call it that, is largely anecdotal. You’ll hear many therapists and parents swear that it works based on their own experiences, but high quality studies just don’t exist. Weeks, Boshoff, & Stewart (2012) screened over 300 research studies related to the effectiveness of the Wilbarger protocol. After a systematic review, their results concluded that there wasn’t “high quality evidence” to support or refute this technique. As therapists that should be relying on evidence based practice, this can raise some serious questions about whether or not we should be implementing this technique in our daily practice without further evidence of its effectiveness.

10. Regardless of the evidence, there is a high demand for this intervention.

This technique has kind of become “that thing pediatric OTs do.” I’ve seen it implemented in every clinic I’ve ever worked in, with slight variations, of course. Some parents come in with the sole purpose of being trained. And in all fairness, as a student, I was simply taught by other trained therapists that it was an effective intervention. However, after many unsuccessful attempts to appropriately implement the technique into home programs, and keeping up with the literature, I’m less inclined to rely on this technique as a “go-to” in practice.



Weeks, S., Boshoff, K., & Stewart, H. (2012). Systematic review of the effectiveness of the Wilbarger protocol with children. Pediatric Health, Medicine and Therapeutics, 3, 79-89.

Wilbarger, J.L. & Wilbarger, P.L. (2002). Wilbarger approach to treating sensory defensiveness. Section in Alternative and Complementary Programs for Intervention, Chapter 14. In Bundy, A.C., Murray, E.A., & Lane, S. (Eds.). Sensory Integration: Theory and Practice, 2nd Ed. (pp 335-338). Philadelphia, PA: F.A. Davis.

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Pencil Grasp Basics – An Infographic

Considering the fact that handwriting problems are the primary reason for referral to occupational therapy services in school-age children (Schwellnus et al., 2012), I wanted to put together an infographic with a few “pencil grasp basics” to keep in mind. I hope you find the information helpful!

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Why School and Clinic Therapists Can’t Easily Communicate

School is officially back. That means new teachers, new classrooms, new IEPs, and new therapists. It’s also that time of year when parents ask their clinic therapists to “touch base” with their child’s school therapists.

So, how do you connect your child’s school and clinic therapists?

Easy – you don’t.

Ok, ok, so it’s not that cut and dry, but it sure feels like that sometimes, doesn’t it? Allow me to tell you, this communication is not nearly as easy (or helpful) as you might be thinking. While we can all appreciate the theory of why we need to communicate, the real world tends to get in the way of our good intentions.

To give a better perspective on this topic, let’s talk about the basic challenges of this request.

  • Yes, you absolutely have to fill out release forms.

This is not a casual chat. This is protected health information that we are being asked to share and discuss. It might not feel that way when we are working in pediatrics and the education realm, but I frequently have to remind parents that we need signed releases to speak to each other on both ends. There is often a delay in even initiating contact with another therapist while we wait for the proper forms to be signed and returned.

  • It’s almost impossible to get a hold of each other.

School and clinic schedules are basically incompatible. They work the school day, and we are slammed with after school appointments. We could maybe, just maybe, catch each other at a cancellation, or late in the evening. But we often have families to go home to, kids to pick up, and we are constantly just missing each other.

Speaking of schedules, we are both swamped. School therapists are unsung heroes. They carry extremely large caseloads (50 kids a week, anyone?) have meetings, paperwork, and travel time between schools. In the clinic, we are usually scheduled back to back with patients, with a lunch break typically used to cram in notes or paperwork. Finding that time to reach out to someone is definitely a challenge, but it doesn’t mean we don’t try!

All of this boils down to the fact that our communication typically consists of a quick conversation that starts, “I just have five minutes…” or a string of emails returned a few days/weeks/months apart from one another. It’s not ideal, but it’s what we’ve got.

  • There are only a few things we really need to discuss.

To be honest, there isn’t much we need from one another. We are both professionals specializing in our respective treatment settings. We have assessed your child in the setting in which we work with them, and have developed a treatment plan accordingly. So what would prompt a collaborative conversation?

-Specific problem solving.
Maybe there is an area that the child is struggling with in school or in the clinic that we just can’t figure out. Teaming with each other, we might be able to come up with a creative solution, or maybe one of us stumbled upon an awesome and unique technique that we really need to share.

-Prompts/Programs we are using.
This can be a simple report. Are they using Handwriting Without Tears? The Alert Program? Which pencil grip are they using? Any specific adaptive equipment? If we can use similar techniques, it helps the child reinforce consistent concepts across all settings. (Although don’t expect these techniques to always match up, as I’ll explain below…)

  • No one wants to be told how to do their job.

Let’s be honest, this is a touchy subject. I’m certainly not going to call a school OT and tell them what to do with a child, although I have had parents request I do just that. Regardless of a therapist’s approach to teaming with another professional, the very nature of these calls can lead to uncomfortable and defensive conversations which don’t feel productive at all.

There will always be therapists that disagree with each other’s courses of treatment. Some are strictly against pencil grips. Some disagree with certain aspects of sensory integration theory. Some want a child to learn their name in upper and lowercase, some will start just with upper case. It’s the nature of pediatric occupational therapy – there are multiple evidence-based frames of reference to choose from, and there isn’t always a general consensus on the “best” course of action when it comes to many of the areas we work on.

  • We both follow a different set of rules.

By the definition of our practice settings, we work on different things. A school therapist must work on goals that are directly related to a child’s academic performance. In the clinic, we don’t have those bounds. So that means what the school therapist must work on doesn’t always match up with what we are working on in the clinic. The rules are simply different.

With all of that being said, we will still continue to try our best to connect and work together. To my wonderful school OT colleagues, I fully appreciate how hard you work – you guys are amazing. Let’s talk soon. 🙂

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