Putting it All Together: The Foundation

OK friends, I know this is a long one.  Deep breath, and take movement breaks as needed :)

With the warm weather and laid back schedule of the summer, sometimes it can be more difficult to set aside time for things that are not beach, pool, or cookout-related.  We get it too.  Enrollment was too low to make it feasible to run tonight’s workshop, so rather than do all the scrambling prep work I usually find myself doing the Sunday before a workshop, I got to spend some time in the pool yesterday myself. 

I got some nice relaxation in, as I floated around in a tube with my eyes closed listening to the radio.  I have been reading a book called The Universal Sense: How Hearing Shapes the Mind (Seth Horowitz, Ph.D, 2012), which inspired the following game I made up on the spot.  I guessed where I was in the pool based on how I was hearing the sound of the radio.  I opened my eyes to check.  I was a little off.  I closed them again.  I brought attention to what each ear was hearing individually.  I guessed.  I opened them.  I thought about how the vestibular structures in the inner ear (which detect movement) were also giving me information about how I was moving around.  I guessed where I was.  I opened my eyes.  I got more and more accurate over time.

As an OT, even a relaxing moment for me sometimes includes turning a challenge into a game to promote growth.  It's what comes naturally, but it certainly occurs to me that most people don’t spend a lot of time thinking about all of these things.  That’s cool though, because I’m going to give you a peek into that rich tapestry today.  Many questions I get from parents or teachers can be answered by sitting down and doing a little activity analysis.  Here is how I think about it, broken into steps:

1.    What are the demands of the task?  What skills does the individual require in order to approach this activity?  To grow in skill with this activity?  To master the activity?

2.    How does the child’s natural approach to learning fit with this activity?  What parts will feel easy?  Challenging?  Motivating?  Stressful?

3.    How can I grade or modify those components of this activity to make certain components easier?  More challenging?  More motivating?  Less stressful? 

4.    Take time to observe the child’s approach and how it changes or if it gets stuck (sometimes the hardest part is observing without interfering).  Respond as needed by asking questions (both to yourself and to the child).

5.    Modify the activity on the fly as needed to reduce actual giving of directions and promote self-discovery, while giving just enough challenge to facilitate growth without becoming too stressful.

6.    Notice and celebrate growth and learning!  A high-five, a hug, a pat on the back, an encouraging statement...whatever works for you!

Now lets talk about some possible demands where a child might get “stuck”.  We’re going to focus on what many therapists consider the foundation or core of quality movement.  Many of these skills should be addressed before moving on to more precise skills like fine motor development and other higher-level skills.  As we know, taking time to build a solid foundation will pave the way for easier learning in a global way, vs. having to start fresh with each new task as you do when the foundation isn't steady.  Some definitions:

·      Biomechanical

o   Range of Motion- Is the muscle flexible enough to move through the full range?

o   Strength- Does the muscle contraction produce enough force to overcome resistance?  In general, it is ideal to have stability in the trunk before moving on to limb strength.

o   Endurance- Can the muscles maintain strength for the task over the amount of time or repetitions required?

·      Sensory

o   What information is the vestibular system (inner ear) giving about posture and movement?

o   What information are the muscles and joints (proprioceptive/kinesthetic systems) giving about joint position and muscle status (stretched, flexed, neutral)?

o   What information are we getting from the tactile receptors about what is touching our body, and what we are holding or manipulating?

o   The above 3 give us the most information pertaining to our bodies in space, which is why I tend to start there, but I am also thinking about other visual, auditory, smell, or taste cues that may be giving us hints about the task and/or our environment.

·      Coordination

o   Reflex Integration- What involuntary movements or muscle tension are contributing to this movement?  Are they providing support or hindering progress?

o   Sensory Feedback- Are we using sensory information efficiently to do what needs to be done, or is that sensory information still contributing to a reflex loop?  Is some information too intense/distracting?  Is some information being lost?

I tend to think of the development of coordination as a constant cycle between the terms discussed above.  Babies begin by orienting to some type of stimulation- movement, touch, sound, etc.  Orienting is the process of initiating a response to this information and turning the body, eyes, and ears towards it in order to identify it.  The spinal cord and lower levels of the brain take this (sound, sight, movement, etc.) information, many times before we consciously notice it, and produce an involuntary movement, generally referred to a primitive reflex.  Each type of reflex has a little lesson to teach about keeping our bodies safe, bonding with our loved ones, understanding our senses, and moving efficiently through the world.  In the absence of medical conditions or trauma, these reflexes are hard wired in all infants.

As the baby keeps experiencing these involuntary movements, they begin to do them on their own (I’m sure you’ve all seen babies begin to rock back and forth rhythmically as they learn to crawl, bounce up and down as they learn about their legs, and even begin to deal with startles with greater and greater ease!). 

Muscles and neurological pathways become stronger and more efficient the more the baby practices on their own.  Once the movement pattern can be performed independently without involuntary accessory movements or emotional reactions, the reflex is said to be integrated. 

Because the sensory input and motor responses are linked, poor sensory processing can negatively impact movement development, and challenges with reflex integration can contribute to poor sensory processing.  This is one of the reasons why you frequently see coordination and strength challenges in children with sensory processing differences and vice versa.  Development of this independent, integrated movement will pave the way for the next reflex, where the cycle continues as another lesson is learned. 

In this way, reflex integration, biomechanical components, and sensory processing are all intertwined in the development of coordination.  Even as adults, sometimes these reflexes can activate, particularly when we are under stress or learning something new. 

I know that was a lot.  Think of it this way:

1.    Something happens.

2.    We give it attention.

3.    We may have a “knee jerk reaction” or automatic response.

4.    We play around with that automatic response for a little bit.

5.    We get more proficient and we begin to feel comfortable.  We can do it and breathe simultaneously!

6.    We relax what we can, and movement gets smoother.

7.    Then something else happens and the cycle continues!

I have a story about what this feels like as an adult.  One Christmas, I crocheted an afghan for my sister using a simple striped pattern.  Part of the gift was for me to teach her how to crochet so that she could do the last stripe herself.  Here is what happened to her, using the above steps as a format.

1.    We scheduled a lunch date where I demonstrated and described how to do the basic crochet stitch.

2.    She listened and watched.

3.    She tried it out.  She was putting the hook in the right place, gathering the yarn, and pulling it out correctly. 


Her right shoulder was hiked way up, her elbow was poking out like a chicken wing, her left arm was firmly curled up to her chest holding the afghan, her tongue was poking out of the side of her pursed lips, and I very much doubt she was breathing.  

4.    We had a long laugh as she realized what her body was doing and proceeded to comically ham it up in this manner for several minutes.

5.    Her movements naturally sped up and the extra stuff got smaller, as she began to understand what needed to happen with the yarn in a more global sense.  She found she could do it while carrying on a conversation (with her tongue inside her mouth).

6.    She relaxed the muscles she no longer needed for support, and assumed a much more natural arm position.

7.    She decided she wanted to make a baby blanket on her own for a friend’s baby shower (she was very successful, even through the planning, pattern reading, and learning a new stitch)!

You can see how motivation and low stress levels can have a lot to do with the speed of progress through this loop.  Occupational therapists use these factors to their advantage.  Many OT's create engaging activities to promote self-discovery for children who are “stuck” in certain places, without contributing to stress or other blocks to learning.  Any time you are working with a child (or adult), and they are learning something new, step one is to create a low stress, fun, learning environment with enough challenge to keep them engaged.  In this way, they are free to move through those steps at their own pace.  Start with what they are interested in, and add components to challenge target areas bit by bit within their tolerance.  It can be tricky at first to stay engaged with a child who is having difficulty, but I have to say, my best games have been invented out of necessity with a "stuck" child where my initial plan wasn't quite the best fit.  Sometimes you have to let go of your own agenda (even after all that activity analysis and grading).  A helpful mantra from Sheila Frick, OT: "If it works, it's treatment.  If it doesn't work, it's assessment."  If something doesn't go well, that just tells you that there's still a piece missing, and it gives valuable information for future attempts.

I’m going to finish by giving you some basic activities that promote improved overall skill at this foundational level.  An easy way to do this is to incorporate developmental movement patterns into play.  Think of things that babies or small children do as they learn to move: they roll over, they crawl (on their tummies or up on all 4’s), they rock back and forth on their hands and knees, they somersault, they hug their knees and roll head to feet or side to side on their backs. 

Think about how different animals walk, and incorporate them into play as well- bear, crab, lizard, elephant, snake, donkey kicks, etc.  These are the best types of movement to practice using vestibular, proprioceptive, and tactile information in order to develop a sense of timing and coordination with movement. 

Move back and forth between two yoga poses like cat and cow, child and cobra, or downward dog and upward dog.  Don’t forget about the importance of the breath.  Breath-holding means the movement isn’t effortless yet.

You can use these activities obstacle course style, in addition to whatever challenging activity you are trying to promote (or conversely, if these are the challenging activities, add preferred activities to the obstacle course).  You can also use these as regrouping breaks.  Next time you or your child is feeling “stuck” in a task, invite them to take a step back and take some time to breathe deeply through their nose to take the stress level down a notch.  Maybe even choose from a couple of the above activities- choose and do them together!  Go back to the initial activity after a bit, and notice any changes.  You may be surprised at what you notice.  Even if it’s still a challenge, you may notice improved breathing, greater efficiency of movement, or just improved focus and attention.  Sometimes, as an adult, moving helps you come up with an alternate way to approach the task as well!  Celebrate those victories!

The next installments will discuss some of the mid-level task demands, as well as provide examples of activity analysis and modification ideas for some common games and activities.  Have a question or thought?  Specific game your child is having difficulty with?  Leave it in the comments below.

I’m off to do some more “relaxing” in the pool!  Visit our new Pinterest page for some activity ideas that target different aspects of coordination!