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Specific Learning Disabilities: An Occupational Therapy Perspective

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 An Occupational Therapy
Perspective
Prof. Vaithi M Perumal
Prof & Head, Occupational Therapy
SAIMS Medical College & Post Graduate Institute,
Indore
 This Presentation
• Introduction – SLD
• Occupational Therapy Role in Dysgraphia
Brain Functions
 Learning

Transmit nerve signals to the brain at 200 mph

Brain and Learning Disabilities
 Brain and Learning Disabilities
• Genetics
• Birth factors
• Nutrition
• Developmental disruptions
 Brain and Learning Disabilities

• Lack of Hemisphere specialization

• Inadequate interhemispheric communication
• Left Hemispheric Lag or damage
 Brain and Learning Disabilities

• Abnormal Persistence of primitive reflexes

 Brain and Learning Disabilities
• Sensory processing issues
 Brain and Learning Disabilities
• Auditory Processing difficulties
– difficulty in distinguishing the difference between
similar sounds
• Sound Recognition
• Sound Localization
• Sound Differentiation
 Brain and Learning Disabilities
• Visual Processing difficulties

Object {form} perception Spatial perception

Form constancy Position in space

Visual closure Depth perception

Figure ground Topographical

orientation
 Brain and Learning Disabilities
• Tactile Defensiveness
 Brain and Learning Disabilities
• Proprioception / Kinesthesia difficulties
 Brain and Learning Disabilities
• Vestibular difficulties
 Learning Disabilities
• Any disability that affects / inhibits a child’s
ability to acquire and apply knowledge
– Traumatic brain disorder
– Autism Spectrum Disorder
– Intellectual impairment
– Specific Learning Disability
 Reading
Math Composition
Academic
Writing
Mechanical
Spelling
SPECIFIC
LEARNING Perceptual
DISABILITY Problem Visual
Memory Memory
Problem Auditory
Non Language Memory
Academic Problem
Visual Motor Fine
Problem
Gross
Phonological
Processing problem
Specific Learning Disability -
Associated problems
Receptive
and Auditory/
Expressive Phonological
Social Skills Language Processing

Visual Study and

Processing Organizational
Learning Skills
Disability
Visual-
Motor Metacognitive
Processing

Memory Attention
 SLD - Inclusion Criteria
Difficulty in . . .
• Oral Expression
• Listening comprehension
• Written expression
• Basic reading skills
• Reading comprehension skill
• Mathematics reasoning
• Mathematics calculation
 SLD - Exclusion Criteria
If difficulty is the result of . . .
• Visual, hearing & motor impairment
• Intellectual Impairment
• Emotional Disturbances
• Environmental, Cultural or economical
disadvantage
 Dyslexia
• Difficulty in reading
Dyscalculia - Math
Dyspraxia
 Dysgraphia
Written Expression
 Dysgraphia
• Dys = impairment
• Graphia = producing letter forms by hand
• ia = refers to having a condition

• Impaired handwriting can interfere with learning

to spell words in writing
• often but not always, associated with ‘Dyslexia’
or Attention Deficit and Hyper Activity
 THE PROCESS – DYSGRAPHIA
Encoding of auditory and visual Expression of written words or
information into symbols for graphemes is articulated
letters and written words

Linguistic Motor
stage stage

Mediated through the angular Mediated by Exner’s writing area

gyrus, which provides the
of the frontal lobe
linguistic rules which guide
writing
Dysgraphia is different from ‘agraphia’ in which writing
ability is lost due to brain injury
 Dysgraphia

Dyslexic Motor Spatial

Dysgraphia Dysgraphia Dysgraphia
 Dysgraphia - Classification
Dyslexic Dysgraphia:
• Ability to copy letters
• Difficulty in spelling it
• May have good fine motor skills, but have
illegible written work.
 Dysgraphia - Classification
• Motor Dysgraphia: Deficient fine motor skills,
poor muscle tone, poor fine coordination and
clumsy, May require unreasonable amount of
time and effort for writing May have poor
drawing skills and copying ability. They may
have normal oral spelling ability. Writing is
often affected due to poor pencil or pen
holding
 Dysgraphia - Classification
• Spatial Dysgraphia: difficulty in the
understanding of space. They may have
normal spelling ability and normal fine motor
ability but may have illegible spontaneous
writing work, illegible copy work, and problem
in drawing.
Common Signs and symptom include
but not limited to …

• Generally illegible writing (despite appropriate

time and attention given the task)
• Inconsistencies : mixtures of print and cursive,
upper and lower case, or irregular sizes, shapes,
or slant of letters
 Common Signs and symptom include
but not limited to …

• Inconsistent position on page with respect to

lines and margins
• Inconsistent spaces between words and letters
• Unfinished words or letters, omitted words
Common Signs and symptom include
but not limited to …

• Holding the writing instrument very close to

the paper, or
• Holding thumb over two fingers and writing
from the wrist
 Common Signs and symptom include
but not limited to …

• Talking to self while writing, or carefully

watching the hand that is writing
• Slow or labored copying or writing - even if it
is neat and legible
• Strange wrist, body, or paper position
 Dysgraphia - Team Approach
• Psychologist
• Occupational Therapist
• Remedial Teachers
• Special Educators
 Occupational Therapy
• Branch of Modern Medicine: Allied Health
• Degree – BOT – 4 ½ Yrs UGC recognized Program
– Clinical Subjects
• I- Anatomy, Physiology, Sociology, Psychology,
Pharmacology, Bio Chemistry, Pathology
• II – Gen Medicine, Gen.Surgery, Psychiatry, Applied
Psychology, Bio Mechanics
• III – Pediatrics, Orthopedics, Neurology, Bio Engineering
• IV – Community Medicine, Research Methodology &
Statistics, Rehabilitation
– Professional Subjects
• OT in Pediatrics, OT in Neurology, OT in Orthopedics, OT in
Medical conditions, OT in Surgical conditions, OT in
Psychiatry, OT in rehabilitation, Community Based
rehabilitation & Physical Diagnosis
 Occupational Therapy
• Master’s Program – 2yrs – 3 yrs
• Specialty – Pediatrics, Neurology, Orthopedics,
Psychiatry, Geriatrics, Cardio – Pulmonary Rehab,
Physical Rehab, Industrial Rehab & Community Based
Rehab
• PhD Programs
 OCCUPATIONAL THERAPY IN
DYSGRAPHIA
• Children are frequently referred by teachers to
school-based occupational therapists for
handwriting difficulties in the classroom
• Occupational Therapists is responsible for
identifying underlying motor, sensory,
cognitive, or psychosocial deficits that may
interfere with the development of legible
handwriting and for selecting intervention
strategies to overcome those deficits
 OCCUPATIONAL THERAPY IN
DYSGRAPHIA
• Occupational therapists work to reduce the
deficits in sensory motor performance
components such as eye hand coordination,
visuomotor integration and in hand
manipulation that are significantly correlated
with poor hand writings
Development of handwriting skills.
• Handwriting is a complex skill which requires
the maturation and integration of cognitive,
visual perceptual, and fine motor skills
• The small muscles of the hand follow a
developmental progression of prehension and
grasp through infancy, toddlerhood, and the
preschool years to prepare a child to grasp
and manipulate a writing instrument
Development of handwriting skills.
• A child’s early experiences with scribbling
pave the way for imitating and copying lines
and circles in the preschool years
• Eye-hand coordination, visual perception,
auditory perception, directionality,
sequencing, and memory also develop with
maturation and experience in the early years
and are thought to be the underlying
components required for handwriting
 Development of Prewriting and handwriting in young
children (Bayley, 1993)
Scribbles on paper 10-12 months
Imitates horizontal, vertical, and circular
2 years
marks on paper
Copies a vertical line, horizontal line, and
3 years
circle
Copies a cross, right oblique line, square,
left diagonal line, left oblique cross, some
4-5 years
letters and numerals, and may be able to
write own name

Copies a triangle, print own name, copies

5-6 years
most lower – and upper case letters
Pencil Grasp Development
 Factors contributing to handwriting difficulties

• Handwriting difficulties can be a result of

problems intrinsic to the child or as a result of
external factors, such as poor teaching methods
• If a child does not receive sufficient instruction
and feedback when s/he is learning letter
formation, errors can become habitual and result
in poor legibility
• Trying to teach printing before the child is
developmentally ready can also result in poor
writing skills
 Factors contributing to handwriting difficulties

• Intrinsic factors that cause handwriting

difficulty include: kinesthesis, fine motor skills,
eye-hand coordination, orthographic coding,
visual perceptual skills, and visual motor
integration.
 Handwriting Assessment
• Observation
• Hand Dominance
• Pencil Holding, Paper position, Sitting Posture
• Components of legibility include letter formation,
alignment, spacing, slant, and size
• Speed of writing
• Checklists and standardized assessment tools
components of legibility, such as slant, size,
and alignment
 Handwriting Assessment
• Criterion-referenced assessment, such as the
Evaluation Tool of Children’s Handwriting
• This measurement tool assesses children’s
legibility and speed of handwriting.
• Total percentage scores for word legibility, letter
legibility, and number legibility are derived from a
variety of writing tasks, which include writing the
alphabet from memory, near-point copying, far-
point copying, dictation, and sentence
composition.
 OCCUPATIONAL THERAPY
INTERVENTION - DYSGRAPHIA
• Usually Occupational Therapists use
Remediation, Accommodation & Modification
strategies for managing dysgraphia.
Commonly used occupational therapy
treatment strategies include Perceptual Motor
training, motor learning, Cognitive training,
Sensory Integrative Therapy training,
Biomechanical & neurodevelopmental
training..
 MULTISENSORY APPROACH
• Handwriting intervention incorporating a
sensory integrative approach employs a
variety of sensory experiences, including
proprioceptive, tactile, visual, auditory and
olfactory input. This multisensory approach is
thought to encourage sensory integration and
affect the quality of motor output, such as
improving legibility of written letters
 MULTISENSORY APPROACH
• chalk and chalkboard
• magic markers or felt pens
• verbal description while student writes
• finger writing in viscous substances
• copying and tracing on regular lined paper
• colored or embossed lined paper
• Forming letters in a tray of rice or sand with a finger
• Letter forming with a finger or dowel in clay
• Tracing or copying letters over a rough surface
• “Sky writing” letters in the air
 MULTISENSORY APPROACH
• Block design
• Bead stringing
• “Rainbow writing” using different colors to copy the
same letter
• Dried glue for writing lines
• Parquetry
• Wrist weights
• Paper folding
• Design copying on paper strips and masking tape on
the floor
 MULTISENSORY APPROACH
• Shape tracing behind a masking box with
vision occluded
• Tracing letters with a magic marker over
cellophane
• Black construction paper covered with salt
and Bags of hair gel for finger tracing
 Cognitive handwriting interventions
• Cognitive interventions use metacognitive
skills to guide handwriting performance rather
than sensory input. A variety of approaches
are employed to improve handwriting, such as
self-instruction, modeling and imitation,
guided practice, and self-evaluation.
 FRAME OF REFERENCE USED BY
OCCUPATIONAL THERAPISTS IN HAND
WRITING TRAINING
• Neurodevelopmental:-
• This is based on neuromaturation principles
and the typical sequence of neuro motor
development. Modulating muscle tone,
promoting proximal joint stability, and
improving hand function are goals of this
approach.
 OT - Handwriting
• Acquisitional:-
• Handwriting, a complex motor skill and , like
other acquisitional skills, can be improved
through practice, repetition, feedback, and
reinforcement.
• Sensory Integration:-
• This includes controlling sensory input through
selected activities to enhance the integration of
sensory systems at the subcortical level.
 OT - Handwriting
• Biomechanical:-
• This addresses occupational performance in
terms of range of motion, strength, and
endurance. Various ergonomic factors are also
considered in this approach to be improved.
Sitting Posture
Paper Position:
• Position of the paper
should be slanted on the
desktop so that it is
parallel to the forearm
of the writing hand.
• Right handed - slant -
25 to 30 degrees to the
left with the paper just
right of the body’s
midline.
• Similarly, a slant of 30
to 35 degrees to the
right and paper
placement to the left
midline for left handers
Pencil Grasp
• Dynamic
tripod with an
open web
space is the
ideal grasp for
writing
 Writing Instrument:
• Pencil
• Writing Board / Slanting Board
• Pen / sketch of child’s choice
• Different size , texture grip
 Type of Paper:
• Unlined paper or lined paper that has a
dashed middle guideline between the lower
baseline and upper line is commonly used in
elementary grades.
• Most of the researches confirm that lined
paper improves legibility than unlined papers.
Children usually start out using wide-spaced (1
– inch) guidelines, and, as hand proficiency
improves , transition to narrow-spaced (3/8 -
inch) lines notebook are used by grade 3-4.
 BEHAVIOURAL
• Occupational therapists use reinforcing
environment to improve adaptive behaviour
and child’s social competence.
 ACCOMMODATION
• This approach reduces the impact that writing
has on learning or expressing knowledge
without substantially changing the process or
the product.
Accommodation
 Accommodation
Change the tools: use paper or writing instruments of
different colors
use paper with the raised lines to
keep writing on the line
use the writing instrument that is
most comfortable
use of fun grips on the writing
instrument
Use of software if needed
Change the format Typing instead of writing
of the product Allow for oral presentation / visual
presentation
ASSISTIVE TECHNOLOGY FOR DYSGRAPHIA

• Note taking software

• Audio Notetaker by Sonocent
(www.audionotetaker.com) – This desktop
product allows digital audio recordings to be
imported and converted to typed print for
playback, review, and editing. .
• The Pulse Smartpen by LiveScribe
(www.livescribe.com). This pen contains an
infrared camera that records what is drawn or
written, and links it to audio that is recorded
simultaneously.
ASSISTIVE TECHNOLOGY FOR DYSGRAPHIA

• Speech-to-Text Dictation Programs

• Dragon Naturally Speaking by Nuance
(www.nuance.com/naturallyspeaking). This
widely-used program converts dictated speech
to text for documents, email, and
spreadsheets.
• Windows OS – Microsoft Windows operating
system also contains built-in speech
recognition software.
ASSISTIVE TECHNOLOGY FOR DYSGRAPHIA

• Proofing Written Work: Text-to-Speech

Products
• An array of text-to-speech products can help
students with dyslexia to proof their written
work. Popular products include ClaroRead,
Kurzweil 3000, and Texthelp Read & Write.
 Transition into Adulthood

Transition planning requirements:

– Vocational training
– Preparation for post secondary education
– Employment possibilities
– Independent living
– Social skills
– Self-determination skills
 Adults with Learning Disabilities

• Supports and modifications needed for college

success
• Time management issues
• Organizational skills
• Self-discipline
 Conclusion
• Specific Learning Disability
• Understood – Supported – Rehabilitated
Scientifically
• Dysgraphia – Rehabilitation Team
• Occupational Therapy – Approaches –
Independent in Learning Occupation and
functional performance
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 An Occupational Therapy
Perspective
Prof. Vaithi M Perumal
Prof & Head, Occupational Therapy
SAIMS Medical College & Post Graduate Institute,
Indore
vaithirehab@gmail.com Ph: 9303223584

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