Peds 2 Exam 2

Define autism spectrum disorders
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Terms in this set (129)
Define autism spectrum disorders
DSM 4- At least 6 characteristics in each of 3 categories:
1. Impaired Social Interaction
Marked impairment in nonverbal behaviors such as eye contact and gestures
Failure to develop peer relationships
Impaired expression of pleasure when others are happy

2. Impaired Communication
Delay or lack of development of spoken language
Impairment in ability to sustain conversation
Repetitive or stereotyped use of language
Lack of pretend or social imitative play (related to developmental level)

3. Restricted Repetitive and Stereotyped Behaviors
Preoccupation with one or more patterns that is abnormal in intensity or focus
Compulsive adherence to rituals or routines
Repetitive motor mannerisms
Preoccupations with parts of objects
Discuss the changes in the DSM-V in regard to diagnosis of autism
1. New name-all disorders combined as ASD (PDD-Pervasive Developmental Disorder, CDD-Childhood Disintegrative Disorder, Asperger's included as ASD)
2. 3 domains to 2: social/communication deficits
(oDeficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities. oDelays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosis.) and stereotypical behaviors (Fixated interests and repetitive behaviors)
Discuss current theories on reasons for increased prevalence of autism over the last 2 decades
1. More specifically defined autism spectrum disorder characteristics in DSM-IV
2. Development of better assessments of autism and autism spectrum disorders
3. Physicians, educational psychologist, teachers, and therapists are more knowledgeable of the behaviors of autistic children
4. Development of earlier screenings and tests for Autism
CHAT - Checklist for Autism in Toddlers
o Used by Pediatricians at 18 month old check-up
Identify the 4 areas of dysfunction in a child diagnosed with autism
1. Impairment in reciprocal social interactions
2. Impairment in verbal and non-verbal communications and imaginative play
3. Markedly restricted repertoire of activities and interests (stereotypic behaviors)
4. Disturbances of sensory and perceptual processing and associated impairments
Early theories behind autism (4)
Enlarged lateral ventricles (3rd and 4th ventricles)
Increased heart rate variability and increased respiration - disruption of the autonomic nervous system and brain stem function
Abnormal nystagmus responses
Arousal state irregularities and unusual response to novel stimuli during evoked potential studies
Anatomy and physiology of autism
There are alterations in the cortex, cerebellum, and brain stem that can explain many symptoms of autism, although they do not clarify the etiology of autism.
People with autism demonstrate an increase in total brain weight, brain volume, or both. The abnormal brain weight does not seem to be present at birth, but develops during the first few year, perhaps because of abnormal neural connectivity and lack of pruning.
Several areas of the brain show signs of gray and white matter hyperplasia in 2 and 3 year old patients.
o The frontal lobe showed greatest enlargement, as well as changes in the temporal and parietal while matter sections of the brain
o EEG results show reduced activity in both the frontal and temporal sections of the brain. These structural deficits could be involved with the language and social processing deficits seen in children with autism.
Children with autism may have a delay in frontal lob maturation and temporal-lob dysfunction that could be related to an autistic child's tendency to demonstrate exaggerated reactions and abnormal behaviors in responses to auditory stimuli.
Corpus Callosum irregularities in ASD
Irregularities have been found in the corpus callosum of subjects with autism, including a smaller size of body and posterior subregions of the corpus callosum
51 persons with autism showed size reduction of the corpus callosum (concentrated in posterior subregions)
Limbic System irregularities in ASD
Children with autism have been show to have irregularities in the limbic system, which is important for learning and memory. The amygdala is important for emotion, behavior, and social play.
Cells in the limbic system are 1/3 smaller than normal in people with autism and are found in excessive numbers. Particularly in the hippocampus, amygdala, mammillary bodies, anterior cingulated cortex, and medial septal nuclei
Cerebellum irregularities in ASD
Researchers have found a decreased number of Purkinje cells in the cerebellums of people with autism, the cells present are also smaller
The motor deficits that characterize children with autism can be related to abnormalities of the cerebellum and the frontal lobe.
ASD neurological deficits also common to what other diseases?
Fetal alcohol syndrome
Congenital rubella
Fragile X
Epilepsy (20-35% of children with autism exhibit a seizure disorder)
Genetic basis for ASD Autism affects 2% to 6% of the siblings There is a greater concordance rate for autism in identical twins than fraternal twins The concordance rate for identical twins was higher than 90%, for fraternal twins less than 10%. The preponderance of males with the disorder suggests an x-linked, dominant condition? (mom passing affected X chromosome to male child), but this needs further study. Specific gene research has focused on the following autosomes: o Chromosome 7 o Chromosome 15Which ASD theories have been researched?Genetic, anatomical theories (cerebellum, limbic, corpus callosum, brain abnormalities)ASD theories currently being researched1. Perinatal factors Abnormal presentation at labor, low birth weight, low APGAR scores 2. Toxin Exposure Thalidomide, valporic acid (anti-seizure med.) 3. Hormone disruption Pesticide DDT, other chemicals that disrupt the action of estrogen and hormonesASD theories with controversial/no research to backMMR vaccine-definitively NOT cause • Environmental? • Yeast infections • Intolerance to specific food substances. o Gluten intolerance (found in the seeds of various cereal plants such as wheat, oat, rye, and barley) and Casein intolerance (Casein is the principal protein in milk) causes intestinal permeability and allows improperly digested peptides to enter the bloodstream and cross the blood-brain barrier which may mimic neurotransmitters and result in the disorganization of sensory input. o Food allergies cause symptoms of autism or an insufficiency of a specific vitamin or mineral may cause some autistic symptoms. o Diets have reported to be helpful for children with autism, but their efficacy or safety have not been proven in any randomized, double-blind, clinical trials, mostly case studies. • Phenolsulphertransferase (PST) deficiency--theory that some with autism are low on sulphate or an enzyme that uses this, called phenol-sulphotransferase-P. This means that they will be unable to get rid of amines and phenolic compounds once they no longer have any use for them. These then stay in their body and may cause adverse effects, even in the brain. Treatment is dietary as well as epsom salts baths.Discuss the communication deficits seen in children with autismCommunication forms the basis for social and emotional connections to other people. Language is a system in which abstract and arbitrarily assigned symbols represent concepts. For communication to be effective within a child's social and cultural group, a shared language is needed. Deficits in communication seen in children with autism: Deficits in joint attention (cannot shift eye gaze between people and objects during play) The timing and reason for looking at others and making eye contact is atypical Child may not use the gesture of pointing Child does not vocalize, babble, or engage in verbal jargon Unusual speech tone and rhythm Difficulty attending to others facial expressions Infrequent crying, cooing, smiling Does not respond to own name Limited understanding of object labels Limited understanding of novel information Limited understanding of direction or instruction Pronoun confusion (speaks in the 1st person) Echolalia - child reproduces sounds that are identical to the model in both tone and rate of speech o Delayed echolalia - when utterances are repeated from past experience, could be an attempt to relate a need or want. (ie. the child states, "chocolate milk is good vs. I want some milk) o Immediate echolalia - when a child repeats what was just said. This can reflect the child's inability to comprehend what was said or to manage social demands. Limited use of words Use of unconventional means to request something (ie. biting, rocking, spinning) Crying not related to obvious needs or laughing not related to situationDiscuss the social skill deficits seen in children with autismSocialization includes the ability to effectively interact in social situations involving language, gestures (also eye gaze, facial expressions), cognitive, and emotional components. Socialization can occur in dyads, triads, or in groups. Children with autism spectrum disorders typically have difficulty with the range and quality of social acts: Use of unconventional behaviors, biting or hitting oneself or others Difficulty with transitions or anticipating future events Difficulty being soothed by others Difficulty understanding others reactions Difficulty engaging in play with others o Beginning play, remaining focused on play, joint attention during play Poor ability to use monologues during play situations Do not respond to others who initiate play or social interactions Respond with only rote answers during social situations as if taught the correct answer Initiates social interaction by unconvential language and nonlanguage methods (echolalia, self-biting, head banging) Cannon change means of communication to clarify intentDiscuss the stereotypic behaviors seen in children with autismThese behaviors can reflect a sate of anxiety, or indicate the presence of an obsessive-compulsive disorder, or reflect difficulty with ideation when attempting a task, or reflect the need to self-regulate to maintain a calm/alert state. Typical stereotypical behaviors seen in children with autism spectrum disorders: Rocking Hand flapping Head banging Biting Pouring Dumping Throwing Moving objects close to and away from eyes Moving objects within the peripheral field of others Spinning objects or self Putting objects in mouth Preoccupation with own hands Strong attachment to an object or part of an object Creating specific routines that are difficult to modify Need to arrange items in a specific way Self-talk Persistent review of specific parts of songs or movies Persistent sorting of objectsDiscuss the cognitive and learning skill of a child with autismChildren with autism spectrum disorders can IQs ranging from profound mental retardation to genius. It is difficult to accurately access the intellectual ability of children with autism due to communication, social, and behavioral deficits. Characteristic learning styles of autistic children include; Rigid thinking and difficulty comprehending abstract concepts Children find it difficult to assimilate, modify, and integrate old information with new information Children may think in "pictures" - take mental snapshots of events (ie. autistic child has a birthday party with Barney cake and decorations, opens birthday gifts. Same child goes to another child's birthday party but it is a Power Rangers party and autistic child cannot open gift because it is not "his" birthday party - child has a tantrum. Do you think the autistic child would classify the Power Rangers party as a birthday party?) Strengths in rote memory Preference for constructional play Limited functional object use Prefers solitary play o Limited in play involving ideation and problem solving o Many times play skills mirror developmental level Decreased imitation Hyperlexia - reflects the way the child attends to visual stimulation, noting stability and consistency in print. Child may read early by decoding words but have difficulty with reading comprehension (meaning).Identify the problem general problems ASD children have with tone, posture, and movement• underlying hypotonia • poor ability to sustain motor movement or grade muscle control • poor pelvic control • May show posturing or stiffness with movement • Poor motor planning and overall coordination • Child may be in constant motion or fatigue easilyDescribe the difficulties autistic children have with planning motor acts• An autistic child may have difficulty forming motor plans. • Rigidity, lack of flexibility, and intense desire for sameness can affect planning and sequencing • Child may opt for solitary activities due to failure to in group games requiring motor skills • Imitation is very difficult for autistic children, especially multi-scheme tasks such as "feeding a baby doll" or "bathing a baby doll" • Echopraxia - imitation by an autistic child that resembles copying of motor acts but little understanding of meaningDescribe the difficulties autistic children have with ideation• usually a significant problem in autistic children • starts with the child's difficulty interpreting cues from the environment and forming ideas for new motor acts • Autistic children tend to think very concretely and play is stereotypical and repetitive ways • Repetitive play limits exploration with the environment, thereby decreasing the possibility of new ideas • A possible preoccupation with certain objects can severely limit meaning interactions and use of toys in appropriate ways • Autistic children with ideational problems may have difficulty with transitions. A child who does not easily generate ideas may not be able to visualize the next activity in his/her mind.Describe the difficulties autistic children have with execution of motor acts• Once a motor act has been conceived and planning, some autistic children can demonstrate differences in movement that can compromise execution. • Difficulty initiating and sustaining motor movements • Poor anticipatory actions • Poor projection action sequencing (ie. hitting target, throwing beanbag to bullseye) • Poor safety awarenessDiscuss the use of Sensory Motor Circuits for autistic childrenA sequence of activities done repeatedly to allow learning to occur. It can be completed daily or a few times a week, depending on the child's environment and schedule. It can be completed in: • the child's self-contained classroom • the child's preschool program • the child's regular kindergarten or primary classroom What is involved: • Various sensorimotor activities are set up in centers • The child is taught sequencing and independent work skills needed to go through the circuit • The sensorimotor activities should include speech and language skills, sensorimotor, social, and academic areas • (ie. one center could be dress up involving 1 child fastening a zipper on a dressing vest worn by another child) • Try using a signal to stop and start the circuit (ie. timer, lights on/off, music)Discuss the use of sequencing and grading of motor tasks to teach self-care skills to autistic childrenUse task analysis skills to break down the parts of an activity in order to teach parts of a skill in proper sequence. Teaching motor skills to a child with autism is easier if the details of the activity are distinct and the child's abilities are observed. 1. Select a task that develops a needed skill. Consider the sensory, cognitive, language, and social components needed. 2. Break the task into part. Consider which parts should be done by or for the child. 3. Identify needed adaptations. Think about the following areas to grade the task: 1. The sequence 2. The size of shape of the tool 3. Position of the tool, furniture, or material 4. Speed, length, or repetition of a trial 5. perceptual or cognitive components 6. amount of instruction, demonstration, or assistance given 7. place where the task is performed 8. amount of choice or problem solving involved 9. cooperation or teamwork needed with other childrenDiscuss PECS• Many autistic children do better with visual cues than verbal cues. These children understand pictures with words with more ease than voiced commands. • PECS must be done EVERYWHERE - in school, in therapy and at home. Autistic kids NEED / thrive on consistency. • Use PECS system everywhere in the environment (ie. bathroom, activity table, kitchen...) • PECS board is especially important in therapy sessions. Use symbols are cards the child uses in other environments • The PECS communication book and schedule boards start with pictures and then move to words over time. Initially the pictures may be actual photos of the actual objects the child uses, then may move to more abstract drawings.Discuss ABA (applied Behavior Analysis)The seven essential elements of an ABA-based program: • The program must be applied. The behaviors have some social significance. • The program must be behavioral. The environment and physical events should be recorded with precision. • The program must be analytic. There should be clear and convincing evidence, through carefully collected data, that the intervention is responsible for a change in a behavior. • The program must be technological. The techniques that one uses should be described completely enough to allow for duplication by another individual. • The program must be conceptually systematic. There should be relevance to established and accepted principles (for example, the principle of operant conditioning, appropriate behavior receive rewards). • The program must be effective. The program should seek to change the targeted behavior to a meaningful degree. • The program should display some generality. A change in behavior should be seen in a wide variety of environments, or should spread to a wide variety of related or similar behaviors.Discuss Greenspan's FloortimeFloortime is also known as "developmental, individual-difference, relationship-based" therapy. Floortime is based on the natural development of emotion and human interaction in children. It assumes six milestones of typical emotional and communicative development and attempts, through intensive play and interaction, to guide children through each of these stages. • Floortime is about building relationships. These relationships, then, provide a meaningful context within which those skills and behaviors make sense and which allows for countless natural opportunities for practice and teaching. • Approach - the DIR (Developmental, Individual-Difference, Relationship-Based/Floortime approach. The focus is on helping children master the building block of relating, communication and thinking.Discuss TEACCH (Treatment and Education of Autistic and related Communication Handicapped Children)Structured teaching via the TEACCH method was developed by Professor Eric Schopler and many of his colleagues at the University of North Carolina at Chapel Hill. The TEACCH method is not considered an actual therapy but rather a therapeutic tool to help autistic individuals understand their surroundings and is widely used in school settings. •Physical structure-Physical structure refers to the actual layout or surroundings of a person's environment, such as a classroom, home, or group home. The physical boundaries are clearly defined and usually include activities like: work, play, snack, music, and transitioning. •Scheduling-A schedule or planner is set up which indicates what the person is supposed to do and when it is supposed to happen. The person's entire day, week, and possibly month, are clearly shown to the person through words, photographs, drawings, or whatever medium is easiest for the person to comprehend. •Work system-The work system tells the person what is expected of him/her during an activity, how much is supposed to be accomplished, and what happens after the activity is completed. The goal is to teach the person to work independently. The work system is also organized in such a way that the person has little or no difficulty figuring out what to do. For example, the activity or task should be performed from top to bottom and from left to right. •Routine-According to the TEACCH method, the most functional skill for autistic individuals is a routine which involves checking one's schedule and following the established work system. This routine can then be used throughout the person's lifetime and in multiple situations. •Visual structure-Visual structure refers to visually-based cues regarding organization, clarification, and instructions to assist the person in understanding what is expected of him/her. For example, a visual structure may involve using colored containers to assist the person in sorting colored materials into various groups or displaying an example of a stamped envelope when the person is asked to place stamps on envelopes.Define Asperger's SyndromeFirst described by Hans Asperger in 1944, an Austrian psychiatrist. He described this disorder as an "abnormality of personality" that he called autistic psychopathy. Dr. Lorna Wing first used the term Asperger's Syndrome in the early 1980's when attempting to explain children who presented with classic autistic features when very young, but later developed fluent speech and a desire to socialize. Her research focused on these children's lack of empathy and inappropriate, one-sided interaction with little to no ability to form friendships.Explain the differences between Asperger's Syndrome and AutismThe difference centers on the degree of the child's ability in socialization and communication, language is intact although sometimes "atypical". Cognitive ability is usually average to above average. There is some controversy over whether Asperger's should be classified separately from Autism. Some argue that Autism and Asperger's share the same core difficulties and differ only to the degree to which they are expressed in children. Some experts refer to children with Asperger's as having a "dash of Autism".Identify the social and behavioral characteristics common in children with Asperger's Syndrome1. Social impairment (extreme egocentricity) o Inability to interact with peers o Lack of desire to interact with peers o Lack of appreciation of social cues o Socially and emotionally inappropriate behavior o Comes too close to others - "treats others like furniture" o Approaches others only to have own needs met o A clumsy social approach o One-sided responses to peers o Difficulty sensing feelings of others o Detached from feelings of others 2. Narrow interests o Exclusion of other activities (due to preoccupation in one activity/topic) o Repetitive adherence to routines o Excel at rote memory - learning information without meaning (don't assume a child understands information that may be "parroted" back to you) o preoccupation with part-objects or nonfunctional elements of play materials (such as their odor, the feel of their surface, or the noise/vibration that they generate); preoccupations may change over time, but not in intensity 1. themes of transportation; trains, airplanes 2. dinosaurs 3. maps 3. Repetitive routines o Unusual behaviors towards others o Distress over changes in small, nonfunctional, details of the environment 4. Speech and language peculiarities o No clinically significant general delay in language 1. single words used by age 2 2. phrases used by age 3 o Superficially perfect expressive language; overly formal; speak in a monotonous tone o Hyperverbal - speak incessantly on a topic of interest only to themselves o Odd prosody, peculiar voice characteristics o Impairment of comprehension including misinterpretation of literal/implied meanings o Often appear to talk "at" you rather than "to you" o Repetitive patterns of speech o Abnormalities in inflection - speak too loud 5. Nonverbal communication problems o Limited use of gestures o Clumsy/gauche body language o Limited facial expression o Inappropriate expression o Peculiar, stiff eye gaze, stareIdentify the motor planning difficulties typically seen in children with Asperger's Syndrome• Poor body scheme • Poor somatosensory processing • Difficulty coordinating both sides of the body • Avoid motor challenges • Poor sustained postural control (holding positions) • Poor anticipation of movement in space • Poor grading and timing of movement • Muscular weakness, poor enduranceIdentify the sensory modulation and regulation difficulties commonly seen in children with Asperger's syndrome• Tactile (typically poor tactile processing, hypo or hyperresponsive) • Auditory (typically poor auditory processing, hypo or hyperresponsive) • Visual (**typically a strength) • Vestibular (tend to seek vestibular experiences, hyporesponsive) • Proprioception (poor body awareness, hyporesponsive to preoprioceptive input)Discuss treatment strategies that could be used for a child with Asperger's Syndrome• Keep all your speech simple - to a level they understand. • Keep instructions simple ... for complicated jobs use lists or pictures. The visual sense is usually a strength for children with HFA or Asperger's. • Try to get confirmation that children understand what you are talking about/or asking - don't rely on a stock yes or no - that they like to answer with. • Explain why they should look at you when you speak to them.... encourage them; give lots of praise for any achievement - especially when they use a social skill without prompting. • In some young children who appear not to listen - the act of 'singing' your words can have a beneficial effect. • Limit any choices to two or three items. • Limit their 'special interest' time to set amounts of time each day if you can. (Social Story) • Use turn taking activities as much as possible, not only in games but at home too. • Try to identify stress triggers - avoid them if possible -can a sensory diet be used to diffuse the issue? Anger and tantrums may become an issue, especially in school settings. • Find a way of coping with behavior problems • Teach them some strategies for coping - telling people who are teasing perhaps to 'go away' or to breathe deeply and count to 20 if they feel the urge to cry in public. • Begin early to teach the difference between private and public places and actions, so that they can develop ways of coping with more complex social rules later in life.Understand why the diagnosis of Asperger's Syndrome will not appear in the DSM-V•Asperger's syndrome will be subsumed into Autism Disorder (Autism Spectrum Disorder) •'Asperger syndrome' is used loosely with little agreement: Williams et al. (2008) survey of 466 professionals reporting on 348 relevant cases, showed 44% of children given Asperger, PDD-NOS, atypical autism, or 'other ASD' label actually fulfilled criteria for Autistic Disorder Research field currently reflects two views: •1st View: That Asperger disorder is not substantially different from other forms of 'high functioning' autism (HFA); i.e. Asperger's is the part of the autism spectrum with good formal language skills and good (at least Verbal) IQ. Note that 'HFA' is itself a vague term, with under specification of the area of 'high functioning' (performance IQ, verbal IQ, adaptation, or symptom severity). •2nd View: That Asperger disorder is distinct from other subgroups within the autism spectrum. Klin suggest the lack of differentiating findings reflects the need for a more stringent approach, with a more nuanced view of onset patterns and early language (e.g. one-sided verbosity, unusual circumscribed interests). •review concludes there is little evidence that Aspergers is distinct, and that current IQ is the main differentiating factor. •follow-up study suggests that language impairment at 6-8 years might have greater prognostic value than early language milestones, and Szatmari et al (2009) argue (on the basis of later developmental trajectory) for a distinction between ASD with (autism) versus without (Aspergers) structural language impairment at 6-8 years.Define joint attentionCluster of behaviors with goal to communicate with another person about a third entity in a non-verbal way. Requires alternating gaze and gestures.2 components of joint attentionresponding joint attention and initiating joint attentionResponding joint attentionchild's response to parent's point or gaze shiftInitiating joint attentionChild seeking another's attention to share an event, objectWhen does alternating eye gaze appear between object and parent?9mthsFxns of alternating eye gaze (2)1. Protoimperative requests - requesting (or rejecting) objects/events 2. Protodeclarative requests - sharing, showing, or commenting on objects or events. Includes gestures-pointing, showing, giving. Calling attention to an object or event.What kinds of pointing can kids with ASD do (2)?Point to request, referential pointing when non-social (pointing to pics in book)What kinds of pointing can kids with ASD not do (1)?Point to share/commentDefine "theory of mind"Understanding the perspective of others. Awareness that others have feelings. Sharing, comforting, showing empathy.Age theory of mind occurs~4yrsDefine visual perceptionthe total process responsible for the reception and cognition of visual stimuli including components of visual reception and visual cognition. These functions demonstrate the interaction between these 2 components: • Respond and adjust to retinal stimuli (requires anatomic and physiologic integrity) • Move both the head and eyes to collect "raw" visual data (occulomotor and vestibule-ocular control) • Effectively interpret visual information (visuoperceptual ability) • Respond to visual cues through efficient limb movement (visuomotor ability) • Accomplish integration of all these abilitiesDefine Visual-receptivetaking in visual information **Approximately 70% of sensory receptors in the human body are allocated to vision** Visual-receptive components depend on the integrity of anatomy and physiology of the eye structures (ie. cone, rods, pupil, optic nerve, etc).Define Visual cognitive abilitiesthe processing and interpretation of visual stimuli is a mental process involving cognition, which gives meaning to the visual stimulusDiscuss fixationVisual receptive component - the ability to maintain visual gaze on person or object. This is a prerequisite eye movement for higher level skills of tracking and scanning. Requires conjugate eye movements.Discuss pursuitsVisual receptive component visual tracking of a moving object, involves the continued fixation on a moving object so that the image is maintained continuously on fovea (located near the retina, it s the point of sharpest and clearest vision in the eye, it transmits the signal to the optic nerve). •Typically seen as a child is following a ball throw to him/her, enable coordinated motor act of catching the ball. •Pursuits are seen in infants 7 weeks of age (tracking parent), but is not fully developed until 16 to 18 years. •Requires control of eye movements (oculomotor integrity)Discuss saccadesVisual receptive component visual scanning, the rapid change of visual fixation from one point in the visual field to the other. Seen in tasks of reading and copying, especially important for success in both tasks! •The brain can't handle all the visual information available to it, ¾ of the visual information available to the brain is ignored. •When we read, we don't take in large amounts of visual information •In reading, the eyes "jump" from word to word so that when each word is fixated, it is processed rapidly and the next eye movement is planned. •Saccadic eye movements start to develop during 2 to 5 months of age, but are typically inadequate until about 7 years of age. Many 5 year olds have difficulty performing saccadic eye movements accurately. •During reading, we move our eyes from one fixation (word) to another fixation (word) by saccadic eye movements. When we move to the next word, the cognitive information continues, but the visual information should terminate (thus allowing for new visual information to be processed). ~75% of children with reading disabilities have deficits with overlapping words.Discuss acuityVisual receptive component - the ability to discriminate the fine details of an object with clarity. 20/20 means that a person can perceive as small an object as an average person can perceive at 20 feet.Discuss AccomodationVisual receptive component the ability of each eye to compensate for a blurred image. The process used to obtain clear vision (ie. to focus on objects at varying distances). Typically only takes a split second for accommodation to occur.Discuss binocular visionVisual receptive component The ability to mentally combine the images from the 2 eyes into a single perception. The 2 prerequisites for binocular vision include alignment of both eyes on object and the size and clarity of these 2 images are compatible. When this occurs the brain can combine the 2 images into a single perception.Discuss convergence/divergenceVisual receptive component the ability of both eyes to turn inward toward the medial plan and outward from the medial plane.Discuss the importance of visual saccades to reading and copying skills.•When we read, we don't take in large amounts of visual information •In reading, the eyes "jump" from word to word so that when each word is fixated, it is processed rapidly and the next eye movement is planned. During reading, we move our eyes from one fixation (word) to another fixation (word) by saccadic eye movements. When we move to the next word, the cognitive information continues, but the visual information should terminate (thus allowing for new visual information to be processed). ~75% of children with reading disabilities have deficits with overlapping words. •**by improving a child's eye movement, you can help improve a child's reading and copying speed and efficiency** •Typically a person can read 250 words per minute or about 4 words per secondDescribe a child who is having difficulty with visual saccades. Eye movements include head movements when reading Frequently loses place when reading Omits words when reading Skips lines when reading Is a slow reading, has to re-read lines that are missed Poor reading comprehensionDescribe visual attentionVisual cognitive component the selection of visual input •Alertness - the child's natural state of arousal •Selective attention - the ability to choose relevant visual information while ignoring the less relevant information; it is conscious, focused attention •Visual vigilance - the conscious mental effort to concentrate and persist at a visual task. The skill is exhibited when a child plays diligently with a toy or when writing a letter, completing homework. •Divided, or shared, attention - the ability to respond to 2 or more simultaneous tasks. This is seen when a child is engaged in 1 task that is automatic while visually monitoring another task.Describe visual discriminationthe ability to detect features of a stimuli for recognition, matching, and categorization. Includes the ability to note similarities and differences among forms and symbols and relate these back to information previously stored in long-term memory. •Recognition - the ability to note key features •Matching - the ability to note the similarities •Categorization - the ability to mentally determine a category based on noted similarities or differences (ie. vehicles, animals, birds....)Describe form consistencythe recognition of forms and objects as the same in various environments, positions, and sizes. It enables a person to recognize objects even when there are differences in orientation or detail. The child's ability to identify the letter "A" whether it is typed, printed, written in cursive, or italicized. •Dramatic improvement between 6 and 7 years of ageDescribe figure-groundThe differentiation between foreground and background forms and objects. It is the ability to separate essential data from distracting surrounding information. The ability to attend to 1 aspect of visual field while perceiving it in relation to the rest of the field, to attend to what is important. •Improves between 3 and 5 years of age; stabilized growth between 6 to 7 years of age.Describe visual closurethe identification of forms or objects from incomplete presentations. This enables a person to quickly identify objects, shapes, and forms by mentally completing the image or my matching it to information previously stored in memory.Describe spatial perceptionsthe determination of spatial relationships of figures and objects to oneself or other forms and objects. It is important in understanding direction and positional concepts such as out/in, on/off, up/down, in front/behind, left/right. Important when providing handwriting instruction. • Development complete by 7 to 10 years of ageDescribe visual imagerythe ability "picture" people, ideas, and objects in the mind's eye, even when the objects are not physically present. A foundational skill for reading comprehension.Identify commonly used tests for visual perception and visual motor skills.MVPT (Motor Free Visual Perception Test) VMI (The Beery Test of Visual Motor Integration) BOT (Bruinicks-Oseresky Test of Motor Proficiency) TVPS (Test of Visual Perceptual Skills) THS (Test of Handwriting Skills)MVPTappropriate for children and adults ages 4 through 85 years. Designed to assess visual perception without reliance on an individual's motor skills, the MVPT-3 is particularly useful with those who may have learning, cognitive, motor, or physical disabilities. The MVPT measures skills without copying tasks. It contains many new, more difficult items at the upper end for older children and adults. Tasks include matching, figure-ground, closure, visual memory, and form discrimination. Stimuli are line drawings. Answers are presented in multiple-choice format. Responses may be given verbally or by pointing. Standard scores and percentiles are provided.VMIappropriate for children and young adults ages 3 to 18 years of age. Designed to assess a person's ability to integrate visual and motor abilities. The Short Format and Full Format tests present drawings of geometric forms arranged in order of increasing difficulty that the individual is asked to copy. A normative sample of 2,512 individuals age 2 to 18 years was used for standardization. The short and long format tests should take only 10-15 minutes to complete and the supplemental tests taking only 5 minutes each. The Short and Full Format tests can be administered individually or to groups.BOTSub-tests 7 and 8 deal directly with visual motor abilities (Visual-Motor response and Upper Limb Speed and Dexterity).TVPSsimilar to VMI assessment, more figures and scoring is involves more criteria.THSprint and cursive handwriting assessment, looks at letter formation, reversals, and speed of formation in comparison to peersVisual probs associated with autism1. Poor visual registration 2. Oculomotor dysfunction 3. Poor visual attention 4. use of peripheral vision over focal vision **Has strengths in form and space perception - puzzles**Visual probs associated with CP1. Strabismus 2. Oculomotor problems 3. Poor ability to control and direct eye gaze **children with athetoid CP have FEWER visual perceptual disorder than other types of CP**Visual probs associated with cortical visual impairments•Children with CVI can present very differently •One child with CVI may have limited responses and skills, •Responds only to light sources or a bright red toy •Another child with CVI may demonstrate visual difficulty only in complex environments or with novel or visually cluttered materials. •Milder forms of CVI may not be detected visual difficulty is attributed to such factors as communication-language or motor delaysVisual probs associated with learning disabilities1. Poor visual attention 2. visual-cognitive problemsVisual probs associated with prematurity1. Retinopathy of Prematurity 2. Cortical visual Impairment 3. Poor visual acuity 4. Strabismus 5. AstigmatismVisual probs associated with TBI/stroke/tumor1. Homonymous hemianopsia 2. Poor body awareness, position in spaceDiscuss the differences developmental and compensatory approaches to treating visual perceptual problems1. Developmental •Higher level skills evolve from integration of lower level skills •The identification and remediation of deficits in lower-level skills needs to occur before proceeding to higher level skills 2. Compensatory •Classroom materials or instructional methods are modified to accommodate the child's limitations •The environment can be altered or adaptedIdentify ideas to remediate visual problems for preschool/kindergarten children•Organize the classroom activities to help children develop the readiness skills needed for visual perception •Educate teachers on using a "multi-sensory" approach with children who struggle with shape, letter, and number recognition oMake letters with textured materials oUse mediums for painting letters.... •Develop body-in-space concepts •Pair children with one child can model the desired behavior in motor and visual activities. •Kinesthetic activities: oDuring story time, give a child a prop that relates to the story oProvide letter cubes to make words oUse glue lettersIdentify ideas to remediate visual problems for elementary school children•Begin at the level of the "Visual Hierarchy" where the child is experiencing difficulty (think about the visual pyramid) •Reduce visually distracting and competing information in the environment oReduce glare by excluding glossy paper, shiny table surfaces ouse high interest material to improve visual perceptual skills •Make the classroom environment less "busy" •Use study carrels if child needs to reduce visual stimulation to focus and be attentive oHow do we do this without segregating the child??? •Work on child's positioning to assure the child has a stable postural base in which to focus and attend oUse bolsters, add seat backs, make sure child's feet are weightbearing onto the floor or a stool/block •Encourage different positions for visual activities. Each position should place child in a good alignment an offer adequate postural support. •The child may benefit from color coded worksheet to assist him/her in attending to what visually goes together.**make sure child is not color-blind** •Use kinesthetic approach oPlay games like Boggle, Scrabble oEncourage child to participate actively while they read by writing while reading, underlining key words or placing an asterisk next to key wordsIdentify strategies to help with visual attention deficits•Provide sensory based activities before and after activities that require visual attention •Try to use activities that are intrinsically motivating to students to help the child maintain attention to task. •Reduce extraneous environmental stimulation •Integrate the tactile sense with visual activities to help with eye-hand coordination and attention •Compensate for poor visual attention: oCover the entire page of a worksheet except for the activity or part on which the child is working, use a solid black sheet to cover 1 line at a time. oReduce competing auditory and visual stimuli - have child wear earplugs or headphones oUse pastel colored paper to reduce glare oUse color by marking or circling the specific work on a sheet that needs to be completed by the child.Identify strategies to help with visual memory deficits•Child will need repeated, consistent experiences •Work with families and teacher to repeat activities at home and school •Group information in a way that will provide retrieval cues and help child remember information •"Chunking" - organizing information into smaller units •"Maintenance rehearsal" - repetition, helps short term memory, but may have no long term effect (ie. repeating a phone number...) •"Elaborative rehearsal" - relate new information to knowledge already stored in long-term memory •Mnemonic devices - use of songs, rhymes, or acronyms •Help the child notice differences in visual stimuli to promote storage of information into memory •Play games such as concentration, the "what's missing" game •Start with short simple tasks and gradually reduce the complexity as the child becomes more successfulIdentify strategies to help with visual discrimination and figure ground deficits•use task analysis to design an intervention program, grade the activity from simple to complex •help child identify and attend to the most relevant stimuli •Teach children to visually scan and attend to the identifying features of objects or forms •Teach children to visually scan or search picture (left to right, top to bottom) •Use magazine pictures, remove a part, have child find what is missing" •Reorganize the child's worksheets with color coding of sections that are important •Worksheets can be cut-up and reorganized •Gradually fade-out the restructuring as the child becomes more successful so the child can return to regular class work •If child is having difficulty copying from the board, reduce clutter on chalkboard. Use colored chalk for high relevance items •Reduce the amount of print on a page, number of math problems on a pageIdentify 5 prerequisite skills a child should have before beginning handwriting instruction1. small-muscle development 2. eye-hand coordination 3. the ability to hold utensils or writing tools 4. the capacity to smoothly form basic strokes (circles and lines) 5. letter perception (recognizing forms, noting similarities and differences)Understand the progression of pre-writing developmental tasks from scribbling on paper to printing own name on paper.10-12mths - scribbles on paper 2 years - imitates horizontal, vertical, and circular marks on paper 3 yrs - copies a horizontal line, vertical line, and circle 4-5 yrs - copies a cross, right oblique line, square, left diagonal line, left oblique line, some letters and numerals, may write own name 5-6 yrs - copies a triangle, prints own name, copies most lowercase letters and most uppercase lettersIdentify 3 important components that will affect handwriting performanceIn-hand manipulation skills, shift, and rotationHow visual input affects handwriting performanceVisual receptive components - fixation, saccades, pursuitsHow tactile, proprioceptive, and kinesthetic input affect handwriting performance•Provides information regarding grasp of writing tool, eraser, writing medium, surface •Provides feedback related to extent, weight, and direction of movement, allowing appropriate pencil pressure and directing writing toolDiscuss how muscle tone affects handwriting.Allows sustaining an upright position with upper extremity stability and mobilityList the 5 occupational frames of references that can be used for handwriting intervention.Neurodevelopmental, acquisitional, sensory integration, behavioral, biomechanicalAge of palmar supinate grasp1-2yrsAge of digital pronate grasp2-3yrswhy an OT would consider changing a child's grasping pattern on a writing tool.1. handwriting results in muscular tension and fatigue 2. handwriting formation or speed is impeded by inefficient grasp 3. the child's cannot use controlled and precise finger and thumb movements if the web space is closed 4. the child holds the pencil too tight with too much pressure, breaks the lead off the pencil, makes holes in the paper, and needs to "shake-out" the hand repeatedly due to fatigueIn-hand manipulation skillsthe action produced by the hands in relationships to objects held or grasped by the hand Classification: •Translation - linear movement of the object in the hand from the finger surface to the palm or the palm to the fingers •Finger-to-Palm Translation - an object is held by the distal fingers and the pad of the thumb and moved into the palm •Palm-to-Finger Translation - an object is moved from the palm area to the distal finger surface. The thumb moves from a pattern of flexion to extension Examples: Picking up a quarter and manipulating it to put in a bank, drink machineShiftoccurs at the finger and thumb pads with alternating thumb and finger movement. Typically used for fine adjustments to an object after grasp or after use of another in-hand skill. It is used for refinement of an object between the thumb and fingers. Examples: child holds a marker at midpoint and moves fingers down towards the writing end. Shift with stabilization involves holding one object while shifting another in the same hand.Rotationan object is moved around one or more axes, the movement occurs near the pad of the fingers. •Simple rotation - an object is turned or rolled between the pads of the fingers and thumb, the rotation is less than 180 degrees. Typically the object is rotated to about ¼ or ½ its circumference •Complex rotation - rotation of an object that requires isolated movements of the fingers and thumb. The object is typically turned 180-360 degrees. Then the object is stabilized by the thumb, the fingers are moving, when it is stabilized by the fingers, the thumb is moving. Examples: Simple rotation - unscrewing a jar lid, rolling ball of clay at finger tips Complex rotation - picking up marker from table and rotating 180 degrees or greater to orient writing side towards paperHow form constancy and visual discrimination affect handwriting skillsDiscrimination between letters, numerals, and words that are similar (ie. b/d, saw/was)How position in space affects handwriting skillsInfluences spacing between letters, word. Influences alignment on letters and words on paper. Influences use of marginsHow vestibular input affects handwriting skillsRegulates head position in space (stable base for vision), regulates arousal state for learningHow strength affects handwriting skillsImpacts the ability to grasp an maintain positional consistency of the writing tool over timeHow postural control affects handwriting skillsInfluences the ability to make postural adjustments while writing in various positionsHow crossing the midline affects handwriting skillsAssists the child in learning to write in a horizontal plane across the midline of the body without interruption or distractionHow bilateral integration affects handwriting skillsEnable the child to use symmetric and asymmetric hand movement to hold writing tools while stabilizing the paperHow laterality affects handwriting skillsAllows consistent and superior use of one hand for writingHow praxis affects handwriting skillsInfluences the capacity to plan, sequence, and execute letter forms and arrange letters to build wordsDescribe the neurodevelopmental FOR for handwriting•This FOR focuses on those children who have inadequate neurodevelopmental organization exhibited by poor postural control, automatic reactions, and/or limb control. •These poor responses are influenced by problems in muscle tone, inadequate righting and equilibrium responses, poor proximal stability at the shoulder joint. •Focus of treatment: Postural activities to regulate muscle tone and prepare limbs for writing 1. Increase tone - sitting on a "chair" ball(bouncing), play on a sit-in-spin, jumping on a mini-tramp, and perform simple calisthenics (ie. arm push-ups in chair, on wall) 2. Decrease tone - slow rocking on ball or in a chair, listening to slow music via headsets and tape, relaxing visual imagery activity Activities to improved proximal stability and co-contraction through the neck, shoulders, elbows, and wrists 1. animal walks 2. calisthenics - push-ups, elastic tubing or theraband, holding yoga positions, tug-o-war with friend 3. routine daily tasks - cleaning black boards, pushing heavy object around room, carrying out the trash 4. alternate positions during writing - prone on floor requires weight bearing on the forearms for writing 5. in-hand strengthening activities - knot tying games, games with ropes/stringDescribe the acquisitional approach to handwriting•Handwriting can be improved through practice, repetition, feedback, and reinforcement •The child cognitively understands the demands of the handwriting task •The child refines the writing skills and works on alignment, spacing of letters •The child finally performs the writing tasks automatically without much thought •Focus of treatment Structured progression of introducing and teaching letter and numeral forms. Each child's program can be individualized to work on "problem" letters Combine newly acquired letters with previously mastered letters provides a meaningful context in which to teach letter formation (ie. make a word with the letter versus just writing a string of unrelated letters) Includes modeling, tracing, copying, composing (a word or sentence), and self-monitoring and correcting own mistakes Cues (either visual or auditory) should be faded as the child successfully masters a new letterDescribe the sensory integration FOR in handwriting•Controlling sensory input through selected activities to enhance the integration of sensory systems for effective motor outputs •Using a variety of sensory experience, mediums, and instructional methods •Provide novel material for child to practice letter formation Color changing markers Paintbrushes Weighted or vibrating pens Mechanical pencils Chalk • Vary writing surfaces Chalkboard Painting easel Baking sheets with sand or rice (trace letters with finger) Textured wallpaper Finely meshed screensDescribe the behavioral FOR in handwriting• Adaptive writing behaviors can be learned in a reinforcing environment • Reward child with a special certificate for meeting handwriting goals • Use a "handwriting group" or club with 3-4 children to develop writing and social skills • Develop readable material for a purpose Address an envelope to send a letter to a friend Write a valentine Make a list of toys for Santa or birthdayDescribe the biomechanical FOR in handwriting•Sitting posture - the child should be sitting with feet firmly planted on the floor. The table surface should be 2 inches above the flexed elbows when the child is seated in the chair. •The OT may start handwriting intervention by adjusting heights of desks and chairs, providing needed foot rests for children, adding seat cushions or inserts, repositioning a child's desk to face the chalkboard straight-onAge for static tripod grasp2.5-4yrsAge for dynamic tripod graspMay be seen in children as young 3 but mostly seen in children 4 and older... May not be established until 6 years of age.Identify the key information and items that need to be gathered when completing a handwriting assessment1. Student handwriting samples • Spelling lessons • Mathematical worksheets • Homework • Compare child's work to those of same age peers in class completing the same type of work 2. Interviews with parent, teacher, and other team members • Helps build rapport with teachers and parents • Helps provide a picture of the child's capabilities, behaviors, and struggles at school or home 3. Review of the child's educational and clinical records • Past academic performance • Any special testing accommodations • Any other educational or medical reports from previous years 4. Observation of the child when he/she is writing •Note child's self-regulation and organizational abilities • Transition between activities • Classroom or home arrangement (noise, lighting, instructional media) • Note problem areas: 5. Evaluation of child's actual performance of handwriting • In-hand manipulation • Legibility components • Speed of handwriting • Ergonomic factors • Domains of HandwritingIdentify the legibility components of handwriting Letter formation (poor stroke sequence) Alignment - placement of letters and words on and within the writing margins Spacing (between letters, between words) Size consistency Over and under extension of lines Poor re-trace strokes Incomplete closure of letters Reworking of letters Reversals Case consistencyIdentify the domains of handwriting (5) Writing the alphabet and numerals from memory Copying; near-point (nearby model) and far point (distant vertical model) Manuscript to cursive transition Dictation CompositionRecognize commonly used standardized handwriting assessments1. The Test of Handwriting Skills (THS) 2. The Evaluation Tool of Children's Handwriting (ETCH) 3. The Children's Handwriting Evaluation Scale (CHES) 4. The Diagnosis and Remediation of Handwriting Problems (DRHP) 5. The Minnesota Handwriting Assessment (MHA)Understand the debate between teaching manuscript versus cursive writing during beginning handwriting instruction.2. The Debate on Teaching Manuscript Writing First... 1. Manuscript writing is simpler and easier to form (less height variation in each letter) 2. Closely resembles print of textbooks and reading materials 3. Beginning manuscript is more readable than cursive 4. Manuscript is easier to discriminate than cursive letters 3. The Debate for Teaching Cursive Writing First... 1. Cursive allows for faster and more automatic writing 2. Reversal of individual letters is more difficult 3. Cursive is faster than manuscript 4. The fluid lines may be easier for children to write than stop and start manuscriptIdentify possible interventions for spacing between letters1. Use finger spacing with index finger 2. Use small sticker between letters 3. Teach "no letter" touching ruleIdentify possible tips for teaching left-handed writers1. Position the paper on the desk so it is completely left of the child's midline. Avoid having the child cross over the midline or reach to right side while writing. 2. Angle the paper so that the L side is higher than the right and the forearm lies parallel to the paper. Encourage kids to learn how to position paper themselves. To ensure correct positioning, affix tape to the desk to provide an outline of the position in which a paper should lie. 3. Samples for the child to copy should lie on the right side of the paper, not the left.Identify common alternative to handwriting for children that are severely dysgraphic1. Keyboarding programs to teach keyboarding at an early age. Many times children become proficient keyboarders and can use portable typing devices in school settings such as an Alpha Smart: 2. Child is able to dictate versus write answers to questions to a teacher, teacher's aid, or into a tape recorder. 3. Child receives copies of material versus being required to handwrite own notes.ID possible interventions for spacing between words1. Make space with a rubber stamp, larger sticker 2. Use a dot or dash with a markerID possible interventions for spacing on paper1. Use grid paper 2. Write on every other line of paperID possible interventions for placing text on lines (alignment)1. Use raised line paper (or make with colored glue) 2. Use visual cues to prevent over or under extensionsID possible interventions for size consistency1. Use individual boxes for lettersID possible interventions for near-point copying1. Highlight the text on the worksheet to be copied 2. Teach students to copy 2-3 letters at a timeID possible interventions for far-point copying1. Enlarge letters to be copied for better viewing 2. Start with copying nearby letters, work up to far copying 3 Attach alphabet strip on desktop if copying letters from the board is problematicID possible interventions for composition1. Be certain child can form letters from memory first 2. Talk about story before writing, use picture from magazines, books to help compose storyID possible interventions for speed1. Begin assignments before peers 2. Work on speed gradually, make sure child feels successful 3. Use a timer, put child in charge of timer to help them to learn concept of time