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Playdough, connect four, bingo, crawling through tunnels...why is my child “just playing” when they see an occupational therapist (speech therapist or physiotherapist)? Why do therapists use play when working with kids?
 
Play is a “childhood occupation” (Bundy and Lane, 2012 and Alesandrini, 1949).  Play is what kids “do”.  They learn through play experiences, interacting with objects, their environment and people.  Children explore, imagine and discover as they experiment with space, size, their own bodies, force, strength, time, colour, shape, distance and more.  They develop a range of skills through play.  Read more about specific skill areas from my colleagues in the Functional Skills for Kids Series.  A lot of childhood learning is incidental, as kids do not realise they are learning whilst they are playing.
 
Play is fun – it is intrinsically motivating...that is why children keep playing (Parham, 2008).  Have you ever heard the expression “time flies when you are having fun!”? When a child is engaged with an activity that is fun, it can motivate them to repeat the activity or experiment with variations of the activity. The internal drive of a child through play can help them to connect and engage in the world (Cornelli Sanderson, 2010).

The Developmental Progression of Play Skills | Mama OT
Building Fine Motor Skills Through Play  | Sugar Aunts
Gross Motor Skills and the Development of Play in Children | Your Therapy Source
Playing with Friends: Supporting Social Skills in Play  | Kids Play Space
Using Play to Increase Attention | Miss Jaime OT
Help! My Child Won’t Play - Adapting Play for Individual Kids | Growing Hands-On Kids
How Play Makes Therapy Better | Therapy Fun Zone
How the Environment Shapes the Way Kids Play | The Inspired Treehouse
Why is my child “just playing” when they see an OT?  | Your Kids OT
​

How Therapists Use Play in Therapy!
 
After a comprehensive assessment (refer here for anoverview of assessment) the therapist in collaboration with others (parents, teachers, other therapists) will set goals for individual children. Based on these goals, therapy sessions are planned to meet these in a number of different ways. 
 
We are always looking for the just right challenge for your child to extend them in learning skills without overwhelming them in the process.  We may be working on ways to compensate for difficulties they are having, provide additional support or modify activities if appropriate.
 
We use “play” as a medium to achieve goals, although sometimes the “play” may be the goal itself!
 
Play as a medium to achieve goals.
Therapists are great at task analysis.  We “analyse” tasks and activities and play ... to figure out what skills are needed to perform these tasks.  Therapists also work out what skills may develop as a certain task in performed or how it may be adapted to work on certain skills. 
 
Read about how these games have therapeutic benefits.

• BINGO
• Puzzles
• Playdough
• Posting Box
• Lacing/Threading
• Paper Planes

 
Whilst we may use a variety of activities in  therapy sessions, we are always working towards specific goals! If you are not sure the benefits of the activities your therapist is using, just ask them! I do understand parents who are concerned when goals are not being addressed or the play appears extended and unrelated to the reason for intervention.

Parents and teachers should speak up.  Ask therapists when your child is doing worksheets for a whole session or playing UNO for an hour or being tested on something they haven't done before.  Ask therapists when your child looks uncomfortable.  Ask therapists when the play seems repetitive.  Speak to therapists when the play does not seem age-appropriate. There may be a therapeutic purpose or maybe the therapist needs the feedback; that they are not working towards the goals in an appropriate way. 
 
Play as a goal itself.
As described earlier, play is a childhood occupation and as OTs we are concerned about how children play.  How are they holding, grasping, releasing objects?  How are they moving their arms and legs ... intentionally, individually, together? How are children interacting with objects... exploring, manipulating, imagining? How are children interacting with other children... social skills, parallel, collaboratively?  How does the environment facilitate play?
 
How can we help kids learn through play?
It is the role of an OT to find the “just right” challenge to match activities with your child’s goals.
 
At home, you can help your child learn through play too!

• Set up “invitations to play” – This might include a few sticks and stones in a bucket to foster imaginative play in the backyard (read more here) or some selected items to play with kinetic sand (read more here).

• Rotate toys – Children find novelty with toys that they haven’t played with for a while.  Put some away in a box and then swap them with toys they have been playing with recently.

• Try new things – Encourage your children to have a go with play they may not naturally choose.  Every child has toys that they naturally gravitate too, so use these to encourage different play.  Mr 5 has always enjoyed blocks, cars and trains. Using trains we (over different play sessions) added some imaginary play like “snow” with packaging foam, cutting up strips of green paper to make trees, drew on paper plates to make stations and telling stories with the trains.

 
This article is part of “Functional Skills for Kids: 12 month series by Paediatric Occupational and Physical Therapists”.  You can read all of the childhood functions HERE.  Read all Your Kids OT’s monthly posts HERE.

Find more information about “Play”! stop by to see what other Occupational and Physical Therapists participating in the “Functional Skills for Kids series” have written: 

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Cindy is a registered Occupational Therapist practising in Sydney Australia.  She has two young children who are a constant source of inspiration and learning.  Cindy loves working creatively to help children to reach their potential, finding opportunities in everyday living and making learning fun. Cindy is the author of the Occupational Therapy blog Your Kids OT.

The information on this site is general in nature. The activities are safe for most children, however, you should consult an Occupational Therapist or health professional to address specific movement, sensory or other medical conditions.  

This article does not contain affiliate links.

References:
Alesandrini, N. A. (1949). Play – A child’s world. American Journal of Occupational Therapy, 3, 9-12.

Bundy, A.C. and Lane, S.J. (2012). Kids can be Kids: A Childhood Occupations Approach.

Cornelli Sanderson, R. (2010). Towards a New Measure of Playfulness: The Capacity to Fully and Freely Engage in Play . Dissertations. Paper 232. http://ecommons.luc.edu/luc_diss/232

Parham, D. (2008). Play and Occupational Therapy in L.D. Parham & L.S.Fazio (eds) Play in occupational therapy for children (2nd edition).St Louis: Mosby pp 3- 39

Occupational Therapists work in a variety of settings.  We see children in their home, a clinic setting, hospital or educational settings.  We might work closely with medical staff, parents and educators.  It can be confusing for people who have never met (or even heard of occupational therapists) to understand what we actually do! How do we differ from other professionals working with your child?  You may also be wondering if an elderly relative who has had a stroke just saw an OT, how can we possibly help your child?!

To understand what we are looking for when we see your child for an assessment takes me back to university and the models of practise we studied. Depending on our training (from all over the world) we might take slightly different approaches.  Having studied at Sydney University, the main theoretical model taught was the Occupational Performance Model (Australia) [OPM(A)].  Read more about the model here or for OTs interested in publications related to this model, find them here.

But what does this mean when my child has an assessment???

This model of practice helps an OT to consider the whole child ... their roles, activities, where their performance may need help, areas of strength and the context they are in (family, cultural, social, etc).  We may not consider every area in great detail depending on the reason for contacting us, however it gives us a framework to look at your child. 

Here is a typical scenario from my current OT practise to help you see what we consider when assessing your child .

REASON FOR REFERRAL -
A six year old child has difficulty with handwriting and producing legible work.  The child is in year one at school and the teacher reports that they have difficulty paying attention in class and is constantly breaking pencils. 

ASSESSMENT PROCESS - 

Occupational Roles:
OTs consider the child's role as a student and friend in the classroom.  What is preventing them from participating fully in those roles?  We would also consider any impact this has on the child as a "player", "self-carer" or "son/daughter". 

Occupational Performance Areas:
​Then we consider the areas of self-maintenance, rest, leisure/play and productivity/school occupations. Based on the referral, emphasis would be on school tasks (ie. productivity) - What school tasks and functions are they having difficulty completing? This might include writing activities, mathematics, sitting on the floor, listening to instructions, transitioning between tasks, completing work in a timely manner, etc.

Occupational Performance Components:
What components may need to be address that may explain underlying difficulties? 

* Biomechanical - This may include muscle tone, range of motion, strength, manipulation,  joint stability, coordination, bilateral coordination, fine motor and gross motor skills.

​For this case study we may look at how the child holds the pencil, how they produce written work, how they move their hand/arm/shoulder, posture of head/body, ​what the written work looks like. 

* Sensory motor - This may include a child's under or over responsiveness to touch, movement, sight, sound, taste and smell as well as theirvisual perceptual skills and body awareness. 

For this case study we may consider how much pressure the child is applying to the pencil, do they have sensory seeking behaviour, what are they doing when they have difficulty paying attention, what is the classroom environment like ?

* Cognitive - This may include perceiving, planning, sequencing, problem solving, understanding concepts, learning, short term/long term and working memory.

For this case study we may consider the child's familiarity with the alphabet and letter formation,  We may also consider how they structure sentences.

* Intra personal - This may include self regulation, self esteem, inner drive and motivation to participate in activities.

For this case study we may consider the child's behaviour and motivation in the classroom.  Does this differ in different environments? What does the child find motivating?  Do have difficulty controlling their emotions?

* Inter personal - The ability to relate to other children and adults. This may include communication, following instructions, asking for help, taking turns and waiting.

For this case study we may consider how the child relates in a 1:1 context compared with a classroom environment? Who are they seated near and what impact does that have on the child? What is their proximity to the teacher's desk from their own desk?

OTs use a variety of standardised and non-standardised assessments as well as observations of your child in their natural environments.  OT reports can be quite daunting for parents and teachers as we are looking at such a range of things for your child.  I hope this article helps to explain the background behind your child's assessment and report.

​As OTs we may use a model like the Occupational Performance Model (Australia) with people throughout their lifespan. OTs work in aged care, mental health, rehabilitation, disability, return to work programs and increasingly diverse populations.  They may also consider some of the same things we consider in your child to help them to maximise function and independence.  

If you would like your own copy of this application of the OPM (Australia), you can download your FREE copy here! Please redirect your friends, family and colleagues to this page so they can download their own copy as well!

​Has this article helped you to understand occupational therapy assessment?
What model of practice underpins your work as an OT?
​

Mr 5 is starting big school in 2 weeks time.  He has his uniform, hat, shoes, lunch box....He is ready (even though I may be a bit emotional)!

Parents I speak with are often worried about how their child will cope with being at BIG SCHOOL!  Their main concerns are usually social "Will they have anyone to play with?" "Will they sit by themselves at lunch time?" or sometimes about self care "Will they know when to go to the toilet?"

Kindy teachers are fantastic at helping children settle into big school.  They will take them for walks around the school so they are familiar with the buildings, they will introduce class mates to each other (repeatedly), they will schedule regular toilet visits and give lots of reminders about how to sit, raise their hand and interact with other children. 

As a parent there are a few things you can practise with your child in these few weeks before school starts to help the transition go smoothly. 

(1) Practise getting dressed - Let your child "dress up"  and play in their uniforms at home.  Don't worry about getting them "dirty" - that's what the washing machine is for! In fact after a few washes a brand new uniform will be less stiff and more comfortable for the first day.  

Encourage your child to practise fastenings such as zippers, clips, buckles and buttons. If they are struggling, show them patiently how to grasp and manipulate the fastenings. Sometimes children struggle with the fine motor coordination or using both hands together to manage fastenings.  Practise now before the pressure of time hits on a school day!  

Choose fastenings where possible which promote success.  If your child is not confident with tying shoe laces, don't worry they will get it! Buy the velcro shoes and save everyone unnecessary stress!

(2) Practise getting food out (and not losing their lunch box)- There is nothing more stressful for a child than not being able to eat.  Choose a lunch box which they can open and close independently.  Check with your school if they need separate containers for fruit or morning tea.  Make sure your child can open and close every container you plan to send to school.  Label everything and help your child to identify their name and containers (especially if you have just bought them a new one).  Use your containers on a picnic with your family and ask your child to identify which container belongs to them. 

If you send it packaged food such as biscuits, sultanas or poppers, practise opening these as well.  Consider transferring things into zip lock bags or brown paper bags which are easy to open. 

Don't forget to practise opening and closing drink bottles as well if you want to prevent leakages through new school bags.

(3) Practise saying good bye to you - Keep it short and sweet. Don't linger and don't show your emotional response (a pair of sunnies is a good idea) to seeing your little boy (or girl) starting school. You could role play this at home. Set your child up at a little table to do some drawing and say "goodbye" and physically walk to another room.  You could even reverse this and your child could be the parent dropping off their child (you).  Remind your child that you will come back! You could even arrange a meeting spot if you know where they will be at the end of the day (eg. I'm going to come and pick you up from your classroom.)

(4) Practise social skills - Practise with people you meet at the park or friends you have visit. You could model for your child simple phrases such as "Hi, I'm Cindy, what's yours?" " Can I sit next to you?" "Do you want to play tip?" "I like your lunch box, I have Peppa Pig on mine". 

If possible arrange a play date with other kids from the same school either before school starts or in the first few weeks.  Avoid asking "Who did you play with? Did you make any friends today?".  Instead ask your child, "Can you remember who sat next to you in story time? Can you remember who was in front of you when you lined up to go into class?"  Even if they can't remember initially, as your child learns the names of other children in their class, they will be able to tell you.

(5) Practise sitting on the floor cross legged - Read books or play games at a low table with legs crossed.  If your child isn't used to this position then it would help to practise!  Help them not to lean on furniture or other children. Get bigger siblings involved with reading stories as the "teacher" to your child starting school.  If your child has difficulty sitting cross legged, they may have difficulty with postural tone, low muscle tone, core muscle strength or sensory processing difficulties.  

Start encouraging your child to sit with legs straight and stretch.  You could sit with your feet up against their with your legs straight too.  Work on core muscle strength activities such as sitting on a gym ball to watch tv, doing sit ups, wall sits and animal walks.   If they continue to have difficulty with sitting cross legged, you may need to seek advice from an occupational therapist or physiotherapist.

(6) Practise asking for help - Use opportunities when visiting friends or relatives to encourage your child to ask for help.  They could ask the grown up "Where is the bathroom?".  This helps your child to look beyond their own parents for help.  Sometimes we can anticipate the needs of our child but in a classroom setting, children need to know how to speak up especially when they need help.

(7) Practise going to the toilet - Encourage your child to lock the door when using the public toilet.  You might need to show them what the door looks like when it is vacant and when it is occupied.  Boys should be shown how to use the urinal or at least what a urinal is for.  I've heard cringe-worthy stories of Kindy boys washing their hands in the urinal!

Always pack a spare pair of underwear and socks into the school bag (with a plastic bag) even if it has been months since your child has had an accident.  School can be an intimidating environment for some.

I have been deliberate in not adding too many "academic" things to practise before school starts but have included these three (at the bottom of the list).

(8) Practise holding the pencil with a dynamic tripod grasp - Starting the writing journey with an efficient grasp will help your child to be confident with controlling their pencil. Read more about pencil grasps here!

(9) Practise writing their name with the correct directionality - This is something that is asked of Kindy kids repeatedly so if your child is aware of writing their own name or most of the letters, then they are off to a flying start.  Always encourage them to use a capital letter for the first letter and then lower case letters following. Not sure of the direction yourself? The rED Writing app is fantastic for Australian school age kids as it shows parents and kids the correct directionality.  Read more about the rED writing app here. 

(10) Practise one to one correspondence - Encourage your child to point to one item at a time when counting or one word at a time when reading. Try singing the alphabet with your child whilst asking them to point to each letter individually.  There are lots of kids who start school thinking "LMNO" is one letter.  Show them lower case as well as capital letters. Help your child with the visual tracking to point to each item/letter/word.  This an important skill for maths readiness as well as reading and writing.

Do you have a child starting BIG SCHOOL?  Are they ready? Are you?

​

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Welcome to a new series called "Ask an OT"! Since starting this blog 18 months ago I have been asked lots of questions! Often these questions are repeated as parents are all grappling with issues related to raising kids.  The most common question is "What does an OT do?"  Well you can read about that in the "about me" section of this blog. 

As is the nature of this blog, all answers to "Ask an OT" are general in nature and do not replace an individual assessment and consultation with an Occupational Therapist. 

Today, I'm answering "Help! My child hates wearing socks and shoes!" 

This is a really common cry for help that I come across.  The answer will depend on several factors. 

(1) Age - How old is your child? If they are a toddler or preschooler, then they may be getting used to this new expectation! Are the socks and shoes chosen easy for them to put on themselves or do they have complicated fastenings? Have you taught them how to hold open the socks to wiggle in toes, then pull up? Have you tried "anklet" socks if they are having trouble with longer socks? Here is a helpful tip for those learning how to match shoes to the left and right feet. 

(2) Disability - Does your child have a cognitive delay or a diagnosed disability such as Autism Spectrum Disorder? They may benefit from visual aids or a social story to help them to understand the expectation of when socks and shoes are to be worn.  Avisual schedule may help your child to organised themselves to be "ready" with a daily routine. 

(3) Sensory Issues - Is this an issue about the feel of the socks/stockings/shoes on their feet?  If this is an isolated issue relating to sensation then keep reading as these strategies may help.  If your child is exhibiting other issues with sensory information (eg.  intolerant to food textures, having difficulty with certain noises, constantly seeking movement, etc), then seek help from an Occupational Therapist for a full sensory processing evaluation.

Our sense of touch is an important protective tool that we use to identify when something is sharp, hot, or may cause us harm. "Children with sensory over-responsivity (sometimes called "sensory defensiveness" respond to sensory messages more intensely, more quickly, and/or for a longer time than children with normal sensory responsivity". *  This means that a sensation (in this case socks, stockings or shoes) may be perceived as "painful" and the child may have a "fright, flight, fight" response. "An individual with hypersensitivity to touch ortactile defensiveness appears to overreact to sensation that most people don't particularly notice, or at least are not bothered by". ** 

So what can you do?

(a) Understand the problem and acknowledge your child's feelings.  
Your child will probably be exhibiting  an emotional response to this problem as it is a frustration between an external expectation placed on them and the perceived "pain" they may be experiencing. You as a parent may also be experiencing an emotional response...acknowledge your child (and your) feelings.  Reading this article will help you to understand the problem a bit further.

(b) Prepare your child and their legs/feet.  Often firm deep pressure can help to calm a child and override tactile irritation.  
> You could try a massaging (eg. with lotion) the legs and feet prior to wearing socks and shoes. 
> You could try "sandwiching" the child's legs between cushions or wrapping in a towel/blanket for a few minutes.
> You could try a "heavy weight" such as a bag of rice or cuddle from a pet (under 5% of the child's body weight).
> You could try "heavy work" such as jumping on a trampoline.

(c) Modify the environment (ie. the socks/stocking/shoes).
> You could try turning socks and stockings inside out so the seams are away from the legs and feet.  This simple change can often help children instantly.  Hidden underneath shoes, no one else needs to know!
> You may purchase "seamless" socks and stockings (underwear and other clothing too) from companies such as It Makes Sense.
>Does your child prefer certain material (eg. cotton rather than wool)? Do they prefer tight fitting or loose fitting socks? Are thicker stocking more tolerable than thinner stockings?  
> Does your child have a preference with shoes as some fastenings may irritate (eg. laces vs velcro vs buckle vs pull on shoes).
> Does your child dislike tight fitting shoes? You could try buying shoes half a size bigger so their toe does not touch the end of the shoe or slightly wider shoes.

(d) Provide opportunities when your child does not need to wear socks and shoes (eg. at home or on the weekends). This is NOT giving in to your child! It is listening to your child's sensory signals and allowing them to self-regulate.

(e) Seek an OT assessment. Your child may benefit from a comprehensive assessment and a sensory diet to address this issue. 

Do you have a question that you would like to "Ask an OT"?  Email me at [email protected] and your answer may be featured on the blog!

References:
*   Miller, LJ (2006)Sensational Kids: Hope and Help for Children with Sensory Processing Disorder (SPD) 
** Mailloux, Z (1993) Tactile Defensiveness: Some People are More Sensitive from Sensory Integration Quarterly.

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