How Do You Write Your Sensory Integration Goals?

Want to know one of the biggest bummers as an occupational therapist? Getting an insurance denial calling your sensory integration intervention “experimental.” Our profession is actively moving into an entry level doctorate, and yet we are still facing feedback that makes it appear as if we’re practicing something we made up on the fly.

Of course, we all need to be using evidence-based practice, and it would be great if we could all actively contribute to the body of available research. But in the day to day grind it’s easy to get caught up in the moment, trying to solve problems, innovate creative solutions, and be the resource our families need. So how about that one thing we all have to think about as therapists, something we encounter every single day – our short term and long term goals?

When a child comes in for an evaluation due to sensory processing concerns, how are you writing your goals?

Are you writing that a child will tolerate a certain hierarchy of tactile input, or did you select a specific piece of clothing that they want to wear without aversion? Is their goal to tolerate a certain number of revolutions on a spin board, or a specific nystagmus response? Maybe you are using that wide range of norms for supine flexion and prone extension to guide your observations. Or are you simply choosing items from the PDMS-2 or other standardized test that they didn’t complete in the evaluation?

I have encountered every single one of these approaches in my practice, and I guarantee we are all doing things a little bit differently. Some of us look to measure the underlying sensory systems, others look to gauge the functional outcomes, and some do a little of both. So, what’s the right thing to do?

While I have noticed my goal writing evolve over the years (especially dependent upon the setting in which I worked), my focus has always been geared towards keeping goals functional and occupation based. I mean, isn’t that the whole reason a family is seeking intervention in the first place, when sensory processing issues have interfered with function and development? If we are documenting measurable progress towards functional goals, the evidence for OT intervention builds upon itself.

Although I have to admit, even this approach can create a delicate balancing act. Parents might feel confused when we discuss goals, as some prefer the fancy-sounding jargon, (I’ll admit, words like vestibular, nystagmus, and proprioception DO make me sound super smart), but what do those words really mean for their child’s life?

For example, a family might wish a child could tie their own shoes, but how could that be related to their sensory issues? I work to shape their focus to see that functional goals can be a way of measuring things like self-regulation for a high level motor planning task. Or maybe their child’s tactile processing is the thing that’s impacting their ability to hold a pencil, and as we address the underlying issue, the functional skill improves.

But alas, I can’t claim to know all the answers in a subject as nuanced and delicate as sensory integration and insurance approval.

So, how do you write your sensory goals?

Posted in Occupational Therapy, Sensory Integration | Tagged , , , , , , | 2 Comments

Accepting a “Weird” Pencil Grasp

As a pediatric OT, I most frequently receive questions about pencil grasps. In fact, I wrote an entire article about When to “Fix” a Pencil Grasp. However, we also need to talk about those children (or even adults) that aren’t ever going to achieve a grasp that looks “normal.”

I know, it might be one of those things that makes them stand out. For some children, the last thing they want is to have one more thing that presents differently than their peers. However, all too often I see an obsession to change and tweak a grasp to the point that it actually interferes with the other skills a child should be developing.

With that in mind, here are some factors to consider:

-Remember WHY you want or need to change a child’s grasp. If it’s just to make their handwriting neater – hold up for a moment. Research states that changing a pencil grasp will not directly impact a child’s handwriting legibility.

-Some children are dealing with factors that make a traditional grasp impossible. Finger length, joint mobility, muscle tone – this can all impact what a grasp looks like.

It is not a failure if a grasp doesn’t turn out as a classic tripod. As long as the joints aren’t strained, there is mobility in the fingers/hand, and there is no pain – they might have created a functional grasp on their own.

This is where an occupational therapist comes in very handy. We are skilled at analyzing a grasp to assess if it is functional, and if it needs to (or can be) changed.

Think about it – every time a child picks up a pencil, we are quick to say, “fix your fingers!” They shift it around in their hand for a few moments, trying to find the right fit. They can’t continue with the task until they look up and ask, “is this right?” Activities like writing or drawing can become a double motor planning challenge:
1) “Am I holding this pencil the right way?” and
2) “Am I writing this letter the right way?”

Listen, I know there are precisely 1 million references out there for ways to work on pencil grasps. Everyone has their own tricks and techniques that they swear by. Stickers, grippers, visual cues, songs and rhymes, special pencils, rubber bands, socks with holes cut in them… just to name a few. These are great, but we have all had situations in which NONE of these techniques stick.

In fact, while attempting to incorporate these techniques, I have observed some children fall even further behind in visual motor tasks such as writing, drawing, or coloring because they have become paralyzed by their grasp. When I see this happening after a significant amount of time or intervention, it might be time to move into an adaptive frame of reference. This might include only giving them very short crayons that they can’t manipulate in an incorrect way, allowing a modified or adaptive grasp, or sticking with a supportive gripper. Something that takes the pressure off of the child every time they have to pick up a writing utensil.

So maybe we accept an adaptive tripod. Maybe a gripper does the heavy lifting for a while as they focus on other skills. Maybe their thumb wraps around a little more than others. Maybe they use four (or even five!) fingers instead of three. Increasing acceptance of non-traditional grasps that are still functional might save a few headaches, tantrums, and increase compliance with other fine motor tasks.

Posted in Handwriting, Occupational Therapy | Tagged , , , , , , | 2 Comments

Remember These 5 Things When Buying a Gift for a Child with Special Needs

In this season of gift giving, you’ll find many wonderful resources floating around the internet that provide gift ideas for children. However, amongst all of this information, I wanted to offer a different perspective – specifically, things to keep in mind when buying a gift for a child with special needs.

1. Don’t get stuck on the recommended age numbers printed on a box.

-“But it says recommended for ages 2-4, we can’t possibly get this for a 6 year old, can we?”
Don’t get hung up on these numbers! Kids develop skills at different rates, and for children with special needs, it’s more important to choose activities they are developmentally ready for, not just what their age suggests.

(I should probably mention that those age recommendations can be important to avoid a young child choking on small parts, but other than that – get them something they’ll actually be able to play with!)

2. Don’t take offense if a child doesn’t react to your gift the way you hoped.

-Opening a gift in front of someone can be a social pressure that a child might not be comfortable with.

-Getting something new might not be appealing right away. It might become their favorite toy later, once they have a chance to explore it on their own terms.

-Sensory preferences might impact how a child interacts with a toy. Loud noises can be aversive, various textures can be difficult to handle, and lots of visual input can be over-stimulating.

-Delays in fine motor skills might make it difficult for a child to put pieces together. Visual motor delays might make it difficult to follow the printed instructions. Multi-step directions can be overwhelming. So a child might be super excited for a new toy, but have difficulty asking for help when things are too tricky, or they might become frustrated by the fact that they want to play but can’t quite master the task right away.

-A child might use a toy in a different way than you intended. Maybe you bought a cool Lego kit that you want to build together, but they find joy in simply sorting the pieces into categories or colors.

3. If a parent recommends something out of the ordinary, just roll with it. 

-Yes, some kids just really want a whole collection of staplers, and that’s ok. Maybe they collect picture frames, catalogs, or books on very specific topics. You might feel strange offering something as a gift, but the child might light up as soon as they see it.

4. Technology is cool, but not always the best choice. 

– I get it, that Leapfrog thing allows them to know all of their letters at like 18 months, but frankly, from a developmental standpoint, my OT friends and I would love to see kids actually playing. You know, like using imaginations, manipulating real objects, back and forth play with peers…

-Many parents are already trying to limit screen time for their children, and getting a new/exciting gift that promotes MORE of that might actually be a headache for them.

5. Keep allergies, medical restrictions, or contraindications in mind.

-There’s nothing worse than being given something that looks absolutely amazing, only to find out you can’t really have it. Some children are incredibly sensitive to certain allergens or ingredients, so you’ll want to make sure that you aren’t giving something that the parent will immediately have to take away.

For example, some kids can’t even touch gluten, and spoiler alert, – gluten can be hidden in SO many things you’d never expect (i.e. Play-doh brand, certain glues, soaps, etc.). Flashing lights or vibration can induce seizure activity in some children, and some sensory input might negatively influence muscle tone or arousal level. Regardless, it’s worth checking in with a parent to make sure.

With all of that in mind, I hope you have the opportunity to brighten a child’s day this season. Happy Holidays to all!

Posted in Lessons Learned, Occupational Therapy | Tagged , , , , , , | Leave a comment

Can a Child be “Too Old” For Therapy?

Is it too late? Is it possible to make any progress at this point? Can things still get better?

We hear these questions quite a bit in pediatric therapy. Parents are often shocked to hear that we work with children well into their teens. In fact, in our world, the concept of “old” is relative. (Although I did recently have a child ask if I was eighty years old the other day, which is beside the point, but still…ouch.)

To put this in perspective, I once had a referral for an 11 year old with handwriting difficulties. His parents reported that they wanted to work on the issue while he was “still young.” Sure, in terms of life, 11 years is obviously young, but to a therapist, in reference to letter formation? An 11 year old is already pretty old!

With this scenario in mind, I wanted to discuss what it means to have an “older” child in therapy.

Yes, change is almost always possible!

We operate under the idea of neuroplasticity – or the idea that the brain can change. You might have heard of more recent research that states the brain doesn’t even fully develop until around age 25. So basically, there’s always room to grow. The more important question is – how much work will it take, and how much is a family and child willing to follow through? Listen, it’s not impossible, it just gets more difficult sometimes. Why? Well, see below:

Re-learning an old habit is more difficult than creating the right one from the start.

Things might be easier when a child is younger because we can implement strategies before habits are made and before we’re working against something already in place. You’ll have to admit, it does seem a bit easier to learn something brand new, rather than learn it, practice it, memorize it, and then re-learn it a completely different way.

That 11 year old handwriting referral is a perfect example. He has had plenty of time since pre-school to develop bad habits and ingrain inefficient writing patterns. Re-learning letter formations would take time and tons of repetition to become automatic again.

The same goes for parents. If you are learning behavioral strategies, or understanding something like sensory processing issues for the first time, it will take a bit to get used to your new frame of reference and how you interact with your child.

Participation and age might be inversely proportional.

This isn’t always true. I have plenty of older children that LOVE coming to therapy. But it’s important to keep in mind that as a child gets older, they have more say in their day to day lives. If they aren’t willing to participate, or aren’t interested in making changes, progress might be limited.

I have actually met teenagers who are gung-ho about changing their handwriting. One in particular worked EVERY day on practice to change letter formations, and honestly, the results were amazing. However, if you are pulling teeth to even get a few practice trials, then you likely aren’t going to see much change.

This is also true of sensory processing skills. If an older child doesn’t want to participate, or doesn’t buy into the idea, they aren’t going to get the same benefits as a young child that is excited to engage in therapeutic activities.

Other barriers might be more important than age.

A few of the biggest factors that influence progress are things like follow through of home programming, consistent attendance in therapy, active participation in sessions, and of course, diagnosis and medical history. These factors can be so much more important than an arbitrary age.

The focus of therapy might change with age.

As a child gets older, the focus of therapy might switch from habilitative to adaptive. What does that mean? Basically, if you can’t fully make changes in a certain area, there are ways to adapt situations to make them easier. For example, maybe a child needs to write on larger lined paper or use highlighted areas for writing. Maybe instead of changing their pencil grasp, you find an adaptive writing utensil. Maybe instead of telling time, you use a picture schedule. There are SO many ways to make positive changes in a child’s life; the difficult task is knowing when to push forward, and when to adapt.

Posted in Occupational Therapy, Therapy Process | Tagged , , , , , | 1 Comment

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.

Posted in Visual Perception | Tagged , , | 4 Comments

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!

Posted in Insider Information, Occupational Therapy | Tagged , , , , , , | 1 Comment

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.)

Posted in Occupational Therapy, Pinterest Test Pins | Tagged , , , , , , | 4 Comments

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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