Occupational Therapists: What Do They Do?

Karla was worried. Her 11-month-old baby girl, adopted from South Korea a month earlier, wouldn’t transition from the bottle to rice cereal, depriving her of the calories and nutrients she needed. So the new mom and her husband, Chris, took their infant to be evaluated at the adoption agency’s clinic. There, they received an immediate referral to Early Intervention, which provides services for infants and toddlers who are delayed in developing the basic skills babies typically master in their first 3 years.

Clinicians said “Little Miss,” as Karla calls her in her blog Beyond the Dryer Vent, was suffering from the stress of adoption; her parents felt there was a larger problem. But there was one thing on which everyone agreed: While there was no formal diagnosis, the baby had feeding issues due to oral sensitivity, along with other developmental delays. This finding led to occupational therapy.

Occupational therapy, known as OT, is designed to help children and adults acquire (or regain) the skills needed to perform the activities—or “occupations”—of daily life. “It’s a huge field,” says Lindsey Biel, an OT specializing in pediatrics and coauthor with Nancy Peske of Raising a Sensory Smart Child. When a child shows delays in mastering typical activities, or displays unusual or disruptive behavior, the OT is often the first professional to work with her.

OTs are found in many settings. Children up to age 3 may receive home-based therapy under EI. Some OTs, like Biel, are private service providers, visiting their young clients at home or in school. Others offer therapy in private sensory gyms. But, Biel says, the majority of OTs are found in schools, both pushing into classes to work with kids and pulling them out for one-on-one work on fine and gross motor skills, along with sensory gym time.

These master’s level health-care professionals take a holistic approach to a client’s physical well-being, explains the American Occupational Therapy Association, by also considering psychological, social and environmental factors that may affect functioning.

Biel explains that during an evaluation, the therapist uses a task analysis to figure out just what’s going on. Say a 5-year-old girl isn’t putting on her shoes. Is the issue sensory-based? Fine motor? Or maybe she just likes all the attention she gets from Mommy? What about a kindergartner who is still in pull-ups? “Is it because the potty’s scary?” Biel asks. “Do dangling feet make him feel like he’s falling, or is his tush uncomfortable? We also look at what muscle groups need to be recruited effectively to go to the bathroom.”

Biel breaks down a litany of issues OTs address on her site Sensory Smarts: attention span and arousal level; sensory and processing skills; fine and gross motor skills; activities of daily living (ADLs), also known as self-help skills, such as brushing teeth, dressing and toilet training; visual-perceptual skills; handwriting; and assistive technology.

When it comes to attention, arousal level, and sensory and processing skills, the work OTs do is based on theories presented by occupational therapist A. Jean Ayres, PhD, back in the 1970s. She posited that children and adults with sensory processing issues can’t synthesize all the information streaming in from the traditional five senses­­—touch, hearing, taste, smell and sight—as well as two “internal” senses, body awareness (proprioception) and movement (vestibular). Proprioception allows for motor control and posture, while vestibular receptors tell the brain where the body is in space, which links directly to balance and coordination. (Peske has made a short, fun video that introduces these seven senses.)

Children who have trouble modulating sensory input may experience over-sensitivity (hypersensitivity), under-sensitivity (hyposensitivity) or both to an impairing or overwhelming degree, at school, at home and in the world at large.

An extremely hypersensitive child tends to be withdrawn; because she’s easily overwhelmed by auditory and visual stimuli, she may want to avoid gym, recess and lunch. The buzz of fluorescent lights and anxiety about the loud fire alarm going off may distract her, making it difficult to pay attention and participate in class.

Meanwhile, those who are under-sensitive crave input. In the classroom, that translates into “disruptive” sensory seekers, since they want to keep moving, touching everything, and even tripping or crashing into other kids. It’s easy to see why this type of behavior leads to a diagnosis of ADHD, which the child may or may not have.

For hyper-sensitive children, OTs may suggest things like special seating and testing in a separate room, which will help avoid sensory overload. To help sensory seekers achieve an optimal level of arousal and regulation, OTs working in sensory gyms provide movement activities like swinging, crashing onto huge bean bags, and jumping on trampolines. They may also build sensory breaks into the day, allowing the child to walk around, stretch and even do jumping jacks at regular intervals. A wide variety of products including fidgets and chewable pencil tops and jewelry may provide calming input that helps children sit and focus.

Controversy continues as to whether two widely used practices, joint compressions and a brushing of the skin, actually “rewire” the brain so that kids can appropriately integrate and respond to sensory input, allowing them to feel more comfortable and secure as they negotiate their environment. Even Biel admits that she isn’t always sure these practices have merit but “just when I have my doubts, there’s this great intervention. I had a child making almost no eye contact who was constantly in motion. I put him on cushions and gave him a good brushing. I got eye contact through the whole session; his parents were gasping. Is he cured? No. Was it organizing? Yes.”

Because there are so many different signs that may indicate sensory issues, Biel and Peske have devised a sensory checklist for parents to help them determine if processing difficulties may explain their children’s atypical behavior. Another tip for parents, educators and clinicians: If the child does much better in one setting over another, i.e. more hyperactivity is noted in a classroom versus home, sensory issues may be at play.

When gross motor skills involving the major muscle groups are at issue, the child will struggle with things like balance, coordination, strength and endurance, all of which will have a direct impact on everything from walking and climbing stairs to hopping, jumping and catching and throwing a ball. Such deficits can keep kids from participating in recess and sports, which can in turn affect socializing and self-esteem.

Throwing and catching balls of various sizes and weights and obstacle courses help with things like balance and coordination, while riding a trike builds strength and endurance. OTs will often work on gross motor skills in tandem with physical therapists, since some of their goals are so much aligned.

Additionally, low muscle tone and core body strength impedes kids’ ability to sit erect and alert, important for class participation and fine motor skills like handwriting. Crab walking, curls and rolling and bouncing on a therapy ball help address this deficit.

Fine motor skills involve the small hand muscles. When there’s a lack of strength, motor control and dexterity, kids will have difficulty drawing, using scissors and stringing beads. Such delays, if not addressed, will make academics—turning pages, writing, using a computer—that much harder. They also come into play with regard to self-help skills including buttoning, zipping and using utensils (see below).

OTs employ many fun techniques to help develop fine motor skills. For instance, a dot dot paint activity helps develop control, dexterity and the thumb-and-finger hold, aka the pincer grasp, key to using a pencil or fork. Popping bubble-wrap also develops the pincer grasp, along with dexterity and eye-hand coordination. Simple activities like picking up coins with one hand require manipulating small objects. Lacing helps develop fine motor coordination and also provides a visual focus. Preschoolers who play pickup games with larger tweezers graduate to Operation. Varying resistant consistencies of Theraputty increase both hand and finger strength and dexterity.

To become proficient in self-help skills, children may need to work on fine motor skills for things like dressing and undressing (buttoning, zipping, tying shoes), grooming (brushing hair and teeth, using the toilet) and eating (holding and using utensils.) OTs will model and practice these skills with clients, using many of the techniques noted above. Sensory issues present a different challenge: For instance, a child who can’t stand getting her face wet, wearing anything that feels scratchy or tight, or putting anything in her mouth is also going to have trouble with ADLs. Biel and Peske offer many tips to help children through challenging experiences including teeth brushing (desensitize gums; switch toothpastes), bathing (cover the face to avoid splashing) and shopping (avoid peak hours; let your child push the cart to get deep input).

Karla believes feeding therapy has helped Little Miss enormously. Three years after she began, she has not only transitioned from the bottle, “she has a much wider diet, including crackers, fresh fruits, non-chewy meats like hot dogs, and pasta—no sauce, please!” Karla says. “Pudding was exceptionally difficult because she hated the idea of the pudding-laden spoon touching her lips,” Karla says. “The funny part was, once there was something on her face—you know that pudding mouth kids get—Little Miss never knew it was there, at least until she saw me coming at her to wipe it off!”

She still shies away from mixed textures like yogurt with granola and has a bite size so small, Karla says: “She’s the only one I know who can take four bites from a Cheerio.” And like many kids on the autism spectrum (she was diagnosed with ASD in April), she self-limits her diet: “We eat a lot of Goldfish and pretzels around here.”