If you want ideas for toys that will support your child’s sensory and motor development and like to be intentional with your purchases, this guide is for you.
By and large I am ever striving for a minimalist lifestyle. I have anxiety and lots of extra stuff makes that worse. However, I also am a sucker for a great toy that I think will get a lot of mileage and/or uniquely suites a child’s needs or interests.
Overall, I stay far away from toys with lights and music because I truly believe kids need opportunities to create their own magic in play. (I have exceptions. Such as for kids with significant motor delays I think technology, lights and music [barring those susceptible to seizures!] give kids lots of bang for their buck when they have to work so hard to get their bodies moving!
Benefits to Being Intentional with Toys
Play is slowly making a comeback, and everyone will benefit from that! In play, children develop….
Attention skills
Self regulation and emotional regulation
Executive functioning
Language
Relationships
Imagination
Problem solving
You get it. Play is awesome. But being intentional about which toys you select helps you set the stage to promote your child’s sensory and motor development and lots of fun without tons of unused things gathering dust.
Below you’ll find my recommendations by age. For ease I created separate links for 0-12 months, 12 months through 2 years, 2-4 years old and 5-8 year olds. Click on the image for the list you want to be brought to that post. When possible, I included links for items that I recommended that I found on Etsy, in an effort to support small businesses. I cannot attest to the experience you’ll have with sellers or stores. I’m just showing you what toys I think will be awesome for your kids! There are also affiliate links from which I will receive a portion of sales.
This week on my Instagram account, I’ve been talking all about the benefits of gardening for kids. I grew up with a mom who loved to garden, so I have lots of fond memories of picking strawberries off of the bush, making snapdragons talk and walking barefoot in the dirt.
When lockdowns and stay at home orders hit this past year, what did we see filling our newsfeeds? For my part, I saw a lot of sourdough bread starters and a lot of people talking about starting to garden! People were seeking out or returning to former occupations, which we know can help our ability to self regulate. Whether is was because we had more time than we knew what to do with at home or because we inherently knew that working with our hands has a host of benefits to our mental health, I think there was a large uptick in interest in gardening this past year.
This study was interesting because it looked at how students participating in a “healing garden” class improved in markers of vocational readiness.
Journal Journal of People, Plants and Environment
Article Title: The Effects of a Healing Garden Program based on Vocational Adaptation on Career Attitude for College Students with Developmental Disabilities
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
Methods Twenty five college students with developmental disabilities participated in a Healing Garden class which incorporated principles of vocational adaptation to promote skills required for vocation participation. Thirty students in the control group took general courses that were based on the theory of vocational adaptation.
Students in both groups completed the Career Attitude Measurement Tool before and after the study. The study author used this as a measure for the students’ current attitudes toward careers.
Findings
Students in both the control and experimental group demonstrated significant increases for the areas of confidence and independence.
Only students in the healing garden group demonstrated significantly increased measures of finality, preparation, and determination.
Reference
Kim, S.Y. (2020). The Effects of a Healing Garden Program based on Vocational Adaptation on Career Attitude for College Students with Developmental Disabilities. Journal of People, Plants and Environment, Vol. 23 No. 1: 77-85. https://doi.org/10.11628/ksppe.2020.23.1.77
Sleep is a very popular topic amongst parents of infants and toddlers. Those little guys have lots of energy during the day, so if you’re not getting a lot of sleep at night, keeping up with them can be even more taxing.
While a number of factors affect anything in our physiological processing, sensory processing seems to have its own role in many of our daily activities. Based on the finding of this study, it seems sleep may be amongst those things. The authors interestingly looked at data on sleep and sensory processing, comparing a relationship both at an isolated point of time as well as a predictive relationship between the two.
Read on to see what sensory systems they found impacted sleep habits as well as what a child’s sleep habits as a 6 month old had to do with their sensory processing as a 2.5 year old.
Journal American Journal of Occupational Therapy (SNIP 1.121)
Article Title: Sleep and Sensory Processing in Infants and Toddlers: A Cross-Sectional and Longitudinal Study
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
MethodsChild were recruited from a sample of children participating in a larger randomized control trial. That study investigated the difference between families receiving additional education on a variety of topics and how it might impact weight gain for children birth to 5.
Families of 160 children participated in the study.
Questionnaires Parents completed questionnaires on their children’s sleep habits at 6 months, 1 year, 2 years and 2.5 years old. They also completed a questionnaire to provide information about their children’s sensory processing characteristics only at 2.5 years old.
Sleep questionnaires asked about:
Overnight sleep duration
Number of times a child woke up during the night
How long their child takes to fall asleep
If mothers’ characterized their children’s sleep habits as problematic
Parents completed the Sensory Processing Measure-Preschool home form. This assesses:
Vision
Hearing
Touch
Body awareness
Balance and motion
Praxis (planning and ideas)
Balance and motion
Findings
Comparing Sleep & Sensory Scores at the 2.5 Year Mark
Researchers analyzed the data on sensory processing and sleep that parents completed at the 2.5 year mark for their children to assess potential relationship between the two factors. They found that if children took 10 additional minutes to fall asleep, their sensory scores in the area of vision and touch indicated more sensitivity (Appleyard, K., Schaughency, E., Taylor, B., Sayers, R., Haszard, J., Lawrence, J., . . . Galland, B. 2020, p. 5).
They also found that if children’s parents rated their child’s sleep habits as more “problematic” by one point on rating, these children also had higher scores in the social participation area, indicating more trouble with social participation.
Assessing the Impact of Sleep Habits at 6 Months & Sensory Scores by 2.5 Year
Children who slept for shorter amounts of time as a 6 month old demonstrated poorer scores in the Social Participation area of the Sensory Processing Measure as 2.5 year olds (Appleyard, K. et al 2020, p. 5).
Those children who took longer to fall asleep as 6 months old had sensory scores that indicated higher sensitivity in the area of hearing as 2.5 year olds.
Things to Consider
Researchers listed limitations to include that only parent report served as the data to assess these patterns. Additionally, data was only collected for sleep at night. The investigators mentioned that sleep during the day may also need to be considered when assessing a child’s sleep patterns. Also of note is that it is possible that at some time during the study period of 2.5 years, children may have had an underlying neuropsychological condition although the study was labeled as “typically developing children.” Finally, the sample from which the authors drew was largely of European descent who were healthy and had a good socioeconomic standing.
References
Appleyard, K., Schaughency, E., Taylor, B., Sayers, R., Haszard, J., Lawrence, J., . . . Galland, B. (2020). Sleep and sensory processing in infants and toddlers: A cross-sectional and longitudinal study. American Journal of Occupational Therapy, 74, 7406205010. https://doi.org/10.5014/ajot.2020.038182
The newer kid to the more mainstream discussions in pediatric OT is interoception. The term cropped up I’d say about 2-3 years ago. It speaks to how we experience the internal signals of our body and the effects those have on regulation and awareness. I think it is definitely crucial to consider when working with children with Sensory Processing issues.
One thing the study authors emphasized in this study and approach is the idea of teaching children to be curious about what their bodies are telling them. I take this as the idea being to not stigmatize the feelings. I think this is very insightful and helpful from an acceptance based approach! I think that often children who have more sensitive sensory systems are often also anxious and/or struggle with more intense feelings. For these children they may compound their negative feelings when trying to please others if made to feel badly about their feelings. I think the authors are on a very good path by reframing the children’s sensory sensitivities in a positive light.
Journal Behaviour Research and Therapy (SNIP 2.086)
Article Title Acceptance-based interoceptive exposure for young children with functional abdominal pain
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
Methods Child were screened and recruited from a pediatrician’s office. Inclusion criteria included:
Age between 5 years and 9 years 11 months at time of screening
A guardian who was fluent in English
At home access to a device with video chat function
Positive Screen for FAP on the Questionnaire on Pediatric Gastrointestinal Symptoms Rome III Version (Meaning 2 or more stomachaches with impairment or 8 or more stomachaches with or without impairment over 2 months time (Zucker et al. 2017, p. 202)
Children who had an IQ of <70 or pervasive developmental delay were excluded.
Intervention
Parents completed a semi-structured interview, and both parents and child completed 2 weeks worth of a pain-diary. Both parents and child also completed multiple self-report questions. These provided information on the mental health of the parents and child, emotional regulation and pain symptoms. Parents completed ratings of their children’s pain before treatment and two weeks after treatment.
What was in the pain diary?
A parent and child rating on a pain thermometer that indicated the intensity of the child’s pain
A parent report with insight on their child’s distress about the pain
The child’s report of their affect
Treatment
Children participated in 10 weeks of therapy during which they participated in cognitive and physical activities to promote becoming, “Feeling and Body Investigators.” Both parents and children received positive reframing education on how their sensitivity can be beneficial and an advantage.
The children’s parents traced them on a piece of paper to create a body map that was then used throughout treatment. Researchers then introduced children to specific body sensations. They also completed exercises that illustrated interoceptive feelings (Zucker et al., p. 203).
See the infographic for more details on the treatment intervention.
Findings
Investigators found that parents’ ratings of their child’s pain were significantly reduced following intervention. Similarly, the children’s ratings of their own pain decreased significantly.
Parents’ ratings of the distress their child’s pain caused them were also significantly decreased following intervention. The authors suggest this supports the study’s aim of reducing a child’s fear of their own bodily sensations.
Parents also rated how their child’s pain interfered with their day pre and post treatment. After treatment, parents’ ratings improved significantly.
Both children and their parents reported decreased negative affect (such as sadness and nervousness) for children following treatment.
Things to Consider
The demographics of this study were mainly caucasian (75%) females (66%) (Zucker et al. 2017, p. 206). One may consider how easily the findings can generalize to the general public who presents with FAP. The study authors also mentioned that the sample size was small and there was no control group.
References
Zucker, N., et al. (2017). Acceptance-based interoceptive exposure for young children with functional abdominal pain. Behaviour Research and Therapy, 97, 200-212.
Sensory processing is so central to what peds OT’s do these days, but there remains a lot of difference in opinions. From “whether it exists,” to what’s the most effective way to treat it. One often leaves OT school feeling like there’s still a lot of new learning to be done.
Learning curves for new grads can be steep. I will say that I personally have shifted my thinking dramatically as an OT since the time I graduated. I have gone from being verydetail oriented, goal focused, everything must look like typical to much more practical, holistic and functional.
This journey has led me to be interested in developmental approaches like the DIR/Floortime model. From what I’ve read, it is a collaborative approach between parents and professionals, in which parents are key players. It also emphasizes emotional development and engagement. These are also two elements that have become largely more important to me as I’ve learned to see the forest instead of focusing only on the trees.
I plan to research more into DIR and similar approaches, but this was a basic starting point on an article that reviewed DIR’s impact on communication and self-regulation.
Journal Journal of Occupational Therapy, Schools, & Early Intervention (SNIP 0.535)
Article Title Intervention effects on communication skills and sensory regulation on children with ASD
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
Methods Professionals recruited 25 children aged 3-6 years old with ASD and their families to participate in this study.
Intervention
A multi-disciplinary team developed focused individualized intervention plans for each child that were completed for a 10 month period. The programs included 1-2 elements that were included in the approach: Floortime, sensory integration and speech therapy (Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida p. 349, 2018). Important aspects of the intervention process included:
A team of multi-disciplinary professionals who worked as a team with families
Identifying children’s strengths, preferences and interests
Focusing on developmental areas that emphasis connection, engagement and social skills to promote learning in a child’s natural environments
Every member of the team of professionals was trained in DIR/Floortime and OT’s additionally were trained in Ayres Sensory Integration (Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida p. 350, 2018). All team members had also worked for more than 5 years in the Early Intervention System with children with ASD.
Sessions were as follows…
Floortime A psychologist led parents in 30 minute Floortime sessions, in which psychologists coached parents in promoting joint attention from their child. The psychologist also observed and provided feedback to the parent utilizing these skills following the time spent working together.
Sensory Integration OT’s led sessions for 30 minutes if the child participated in multiple therapies from the three options (SI, Floortime and Speech therapy). The children who only participated in SI therapy participated in 45 minute sessions. OT sessions aimed to promote joint attention, social skills, perceptual skills and motor planning through eliciting increased integration of sensory input.
OT’s also provided education to parents as to the connection between sensory integration abilities and difficult behaviors children sometimes display. In this education, OT’s included information on how to adapt the child’s every day routine with modifications to promote regulation.
Speech Therapy Speech therapists used augmentative and alternative communication systems in sessions to promote natural gestures and symbolic communicative forms during their 30 minute sessions (Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida p. 352, 2018).
Measures Parents completed the Assessment Scale of Children with ASD, which gathers information on Social Communication, Repetitive Behaviors and Restricted Interests, and Sensory Processing.
Findings
Children demonstrated statistically significant improved scores for the areas of Social Communication and Sensory Processing. The area of Repetitive Behaviors and Restricted Interests did not yield a statistically significant in the change in parents’ ratings.
Things to Consider
The authors note that the study had no control group, so the results cannot be compared to a lack of treatment, alternative treatment, nor control for development by maturation alone. They also noted that they did not compare or categorize children based upon the severity of their symptoms of each area included.
A limiting element in applying this study to a wide array of OT’s is that the OT’s in this study were trained in both Ayres Sensory Integration and Floortime. I definitely believe I do Sensory Integration Therapy based on the principles in the infographic above, but I’m not officially trained. What I do take away from this article is evidence that developmental models such as DIR/Floortime are a valuable tool to enhance the occupational therapy one is already providing.
References
Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida (2018). Intervention effects on communication skills and sensory regulation on children with ASD, Journal of Occupational Therapy, Schools, & Early Intervention, 11:3, 346-359, DOI: 10.1080/19411243.2018.1455552
Watling, R., & Hauer, S. (2015). Effectiveness of Ayres Sensory Integration® and sensory-based interventions for people with autism spectrum disorder: A systematic review. American Journal of Occupational Therapy, 69, 6905180030.
Mindfulness has been a buzz word for I would say the past four years or so in education. Maybe in society at large also, but it seems it’s really made itself known in how it might help the young minds we help to educate. Kids have always needed adults to model and teach how to process the sometimes overwhelming world. However, in today’s society where technology is king, one has to be more and more intentional to be truly connected to what is going on in your life.
I really loved this article because I think it highlights the importance and connection of mindfulness on self-regulation. As an OT I often approach self-regulation by addressing sensory processing deficits with sensory input or modifications to the environment. However, I also love bringing children’s awareness to situations, triggers and reactions and teaching them tools they can use to help in those situations.
Also…I’m really interested in one of the assessment measures they used. It’s called the Head-Toes-Knees-Shoulders and is used to assess controlling and directing actions, inhibitory control, paying attention and remembering instructions! If I were working right now, especially in the schools, I would definitely be looking into this.
Journal Journal of Child and Family Studies (SNIP 1.061)
Article Title Effects of a Mindfulness-Based Program on Young Children’s Self-Regulation, Prosocial Behavior and Hyperactivity
4 Case series (and low-quality cohort and case control study) [This study was a cross-sectional study]
5 Expert opinion without explicit critical appraisal
MethodsInvestigators assigned 127 children aged 4-6 in eight kindergarten classrooms from Toronto public schools to either a control or intervention group. The primary researcher implemented the training program for all classrooms as she was trained in the specific program used in this study. It is the Mindful Schools program.
Intervention
Children in the intervention group participated three times a week in twenty minute lessons for a period of six weeks. Some components of this particular mindfulness program included children practicing external and internal mindful awareness practices and lessons in “heartfulness”(Viglas, M. & Perlman, M. p. 1153, 2018). To conclude the session, children wrote or drew about the new practice they learned in their “Mindfulness Journal.” In addition, investigators encouraged children to practice these skills and teach them to their family. Children were invited to share about those experiences at the start of the subsequent session.
Measures To measure controlling and directing actions, inhibitory control, paying attention and remembering instructions, researchers assessed children with the Head-Toes-Knees-Shoulders (HTKS).
Teachers filled out the Strengths and Difficulties Questionnaire as a means to assess children’s prosocial and hyperactive behaviors. The five subscales are Prosocial Behavior, Hyperactivity, Conduct Problems, Emotional Symptoms and Peer Problems.
These items were measured before the intervention began and once the six week program had finished.
Findings
After the intervention was complete, students who participated in the Mindful Schools program showed better self-regulation skills than those in the control group per results of the HTKS.
Children in the mindfulness group also demonstrated significantly better scores in the Prosocial and Hyperactivity subcales on the Strengths and Difficulties Questionnaire when compared to peers in the control group. Researchers detected no significant difference between groups for the subscales for Conduct Problems, Emotional Symptoms and Peer Problems.
When researchers compared children’s scores from the first to second assessment using the HTKS, they found those who had lower self-regulation at the start had significantly more gains and benefited to a higher degree from the mindfulness interventions than those with higher scores on the HTKS during the first data collection.
Similarly, change in scores from before to after intervention of the teacher completed questionnaire indicated that those with higher scores for hyperactivity and lower scores for prosocial subscales before treatment benefited significantly more from mindfulness training than peers with opposite scores (higher prosocial and lower hyperactivity) before the program began.
Things to Consider
When I select articles, I make an effort to look into interventions that are relevant to OT practice. A limitation as an OT in applying this research is that this study assessed a specific program. In order to be truly confident of generalizing the findings here, you would have to use this same program.
Also, the program is structured in a way that seems to provide treatment on a group level. In this study, the same interventionist visited classrooms three times a week. I know that isn’t possible for you and your school caseload.
However, I’m taking this information as evidence that a structured program/curriculum on mindfulness can demonstrate significant and positive results for self-regulation. I’ll continue to research into mindfulness programs and will definitely share if I find one geared more toward a one on one approach to increase its generalizability to OT sessions.
Reference
Viglas, M. & Perlman, M. (2018). Effects of a Mindfulness-Based Program on Young Children’s Self-Regulation, Prosocial Behavior and Hyperactivity. Journal of Child and Family Studies (27)1150–1161. https://doi.org/10.1007/s10826-017-0971-6
Hand skills and how they develop in infants are so intricate and fascinating. I worked only a brief stint in early intervention, so my exposure to working with infants has been limited. I love babies, but I have always thought I would have to be more seasoned to be a therapist to infants. My fresh out of the gate, type A, overachieving new grad self struggled with the fact that one can hardly make babies do what you want them to do! Now that I’ve had some time to learn how to finesse and scaffolding activities for older kids, I think I would have a better go with babies too.
This article was interesting to me because I loved the idea of constraint induced movement therapy when I learned about it. Not because I love restricting a child’s movement, but the concept just makes good sense to me.
What I love even more about this article, though, is that they were detail oriented. They don’t argue that CIMT and mCIMT don’t benefit children with cerebral palsy. However, they specifically wanted to know how it might impact outcomes for infants with CP.
Journal American Journal of Occupational Therapy (SNIP score 1.121)
Article Title Effectiveness of Modified Constraint-Induced Movement Therapy Compared with Bimanual Therapy Home Programs for Infants with Hemiplegia: A Randomized Controlled Trial
4 Case series (and low-quality cohort and case control study) [This study was a cross-sectional study]
5 Expert opinion without explicit critical appraisal
Methods Health professionals recruited parents through public health services. Children could be included if…
They had a formal diagnosis of spastic hemiplegic CP from a physician
They were 8-16 months old (no older than 18 months at the end of treatment)
Could follow simple and age-appropriate instructions
Researchers excluded children with additional medical issues and those who demonstrated no difference in the function between their two hands. Study authors randomly assigned children to either a modified Constraint Induced Movement treatment group or a Bimanual Therapy group. Thirty three infants and their families participated in 8 weeks of individualized daily one-hour play sessions 7 days per week. Occupational therapists visited the families once per week and guided parents on ways to promote the child using his/her affected hand during play.
Intervention
Children in the mCIMT group wore a soft, custom-made mitt and participated in activities to promote unilateral hand use. The children in the BIM group completed activities to encourage symmetrical and asymmetrical hand use. All children had sufficient head control, and treatments were done with the child sitting (floor or high chair) and given trunk support if needed.
During weekly visits, the OT’s ensured that parents knew to provide positive reinforcement for desired actions when performed. The professionals also guided parents on the activities they should complete the following week. The researchers required parents to complete a daily log with details of the play sessions.
Measures
Researchers used the Mini-AHA, which is an infant version of the Assisting Hand Assessment. This assessment uses criterion reference to measure the effectiveness of 8-18 month olds with hemiplegia’s use of their affected hand (Chamudot, R. et al, 2018, p. 2). Evaluators observe infants playing with specific toys which promote the use of bilateral hands. The scores on the Mini-AHA are not influenced by age.
Researchers also developed a Functional Inventory as a means to measure the results the treatment program had on gross motor and hand function for infants 7-18 months old. The FI has 31 items and is divided into Gross Motor Skills, Unilateral Hand Use and Bilateral Hand Use (Chamudot, R. et al, 2018, p. 3). The authors found high internal consistency for the initial total FI score, post-treatment total FI score and the three categories.
Parent Completed Measures
Parents completed the Dimensions of Mastery Questionnaire which measures infants’ mastery of motivation (Chamudot, R. et al, 2018, p. 4). Parents also provided information about pregnancy and labor in addition to demographic information.
Findings
Parents in the mCIMT group completed an average of 48.4 hours (out of 60 total for the intervention), and parents in the BIM group completed 45.0 hours on average.
Investigators found there was a significant main effect with large effect sizes of time on all of the outcome measures (Chamudot, R. et al, 2018, p. 6). Children in both groups demonstrated higher scores after treatment. When investigators assessed the interaction of time with treatment and effects of treatment, the results were insignificant. Researchers found significant and equal improvement gross motor function from analysis of the FI.
Authors investigated the interaction between motivation (from the parent reported scores on the DMQ motivation questionnaire) and performance. They did find one significant interaction with a medium effect size. Children in the mCIMT group (though not those in BIM) who scored low on the Object Oriented Persistence subscale of the DMQ at baseline, showed significantly greater improvements.
Authors posited that perhaps children with lower motivation to engage in tasks with their hands may benefit more from mCIMT than children with similar physical presentation but high motivation to engage objects with their hands prior to treatment.
Things to Consider
The authors mentioned that there was no control group that did not receive treatment to compare to the interventions. However they also mentioned that this practice could be viewed negatively because early intervention can have such a large impact on children’s development. To deny them treatment in this crucial window intentionally could reap long lasting detriment.
Important to note is that this article specifically sought to determine what difference, if any, investigators would find in comparing two treatment interventions for infants with spastic hemiplegia. There is evidence indicating the benefits of CIMT and mCIMT for children older than two years. So, it is important to differentiate and consider the differences between infants and older children when selecting treatment interventions.
References
Chamudot, R., Parush, S. Rigbi, A. Horovitz, R., & Gross-Tsur, V. (2018). Effectiveness of Modified Constraint-Induced Movement Therapy Compared with Bimanual Therapy Home Programs for Infants with Hemiplegia: A Randomized Controlled Trial. American Journal of Occupational Therapy 72 (6): 7206205010. https://doi.org/10.5014/ajot.2018.025981
Feeding therapy. I always say it’s a love-hate relationship for me. It’s love because I myself love food and eating. My Italian side of the family is big into cooking, so food definitely is a large part of our culture, and many cultures.
I love seeing kids become more confident and enjoy the process of exploring new foods and flavors. I think it’s fun to be silly with them and talk about taking shark bites vs. mouse bites, seeing who can crunch a carrot the loudest, etc.
The hate side of things isn’t so much a hate as it is a frustration that stems from my impatience. I am through and through a bottom up thinker. I have a hard time not getting to the root of an issue because I feel any progress we’ll see otherwise is likely a temporary bandaid. The struggle I have with feeding therapy is that a child can make lots of progress in the clinic, but seems to have a stand still at home.
As time has gone on, I firmly see that feeding therapy is whole family therapy. That’s not a bad thing, and really every therapy should be that way! However, there are so many emotional dynamics that go into mealtime that unlike learning to cut with scissors, if you don’t somewhat address the bigger emotional dynamic, you’ll likely see very limited progress.
This week’s article is to highlight the connection between family dynamics and feeding outcomes. So while the article doesn’t tell you what to directly do, (although I did write a review that covers that subject) I wanted to review it as a means to support the idea that addressing family dynamics is crucial in feeding therapy.
Journal Eating Behaviors (SNIP score 1.106)
Article Title Mindful Feeding: A Pathway Between Parenting Style and Child Eating Behaviors
4 Case series (and low-quality cohort and case control study) [This study was a cross-sectional study]
5 Expert opinion without explicit critical appraisal
Methods Researchers recruited 496 parents from a sample of a larger study on the topic of feeding. Parents completed an online survey.
Measures
Mindful Feeding Study authors used the Present Centered Awareness subscale of the Mindful Feeding Questionnaire to determine parents’ mindful attention during the process of feeding their children.
Child Eating Behavior Study authors used subscales from the Child Eating Behavior Questionnaire as a means to measure children’s emotional over-eating and food fussiness per parent report.
Problematic Mealtime Behaviors The Problematic Child Mealtime Behaviors subscale of the Meals in Our Household questionnaire served as a tool to gather parent report on mealtime behaviors.
Parenting Style Investigators used the Parenting Practice Questionnaire to serve as a tool to classify parents’ parenting style as authoritative, authoritarian or permissive.
Findings
In general, the parents who self-reported more authoritative parenting reported higher levels of mindful feeding, while those reporting more authoritarian and permissive parenting reported less mindful feeding (Goodman, L.C., Roberts, L.T. & Musher-Eizenman, D.R., 2020, p. 3). Those parents who used mindful feeding strategies more often had children who they reported were less likely to be fussy, less likely to eat in response to emotions and less likely to have problematic mealtime behaviors ((Goodman, L.C., Roberts, L.T. & Musher-Eizenman, D.R., 2020, p. 4).
Authoritative Parenting Per parents’ self-reports, authoritative parenting had a direct and indirect negative impact on children’s emotional over-eating and food fussiness. Meaning, those with an authoritative parenting style had children who were less likely to be fussy and to eat as a reaction to their emotions. This style of parenting did not demonstrate a negative direct impact on problematic mealtime behaviors.
However, when authors assessed how authoritative parenting impacted mindful feeding and how that in turn impacted problematic mealtime behaviors, they did find a significant effect. So, having an authoritative parenting style doesn’t directly impact mealtime behaviors. However, an authoritative style impacts a parents’ mindful feeding habits, which in turn impacts the problematic mealtime behaviors.
Authoritarian Parenting Per parents’ self-reports, authoritarian parenting had a direct and positive impact on children’s emotional over-eating. That is, parents with an authoritarian parenting style reported their children as more likely to eat in reaction to emotions. This result was not seen for food fussiness and problematic mealtime behaviors. As authors assessed how authoritarian parenting impacted mindful feeding and how that in turn impacted problematic mealtime behaviors, food fussiness, and emotional over-eating, they did find a significant effect.
Permissive Parenting Parents who self-reported permissive parenting style had both a direct and indirect positive impact on problematic mealtime behaviors, food fussiness, and emotional over-eating. This means, parents reporting this style also reported their children as presenting with more mealtime behaviors, food fussiness and emotional over-eating.
Things to Consider
The authors mention that it would be beneficial to the research to complete a longitudinal study in which they could assess these outcomes for the same group of parents and children at multiple points in time. This would allow drawing stronger conclusions about the connection between parenting style, parents’ mindful feeding habits and children’s eating behaviors.
Of note is that the sample in this study had a majority demographic of white families (79%), which may impact the ability to generalize findings to the picky eating population. I was not able to find the race demographics for picky eaters, so I can’t conclusively say one way or another.
The study authors also mention that it would be valuable to explore the bidirectional relationship between parents’ mindful eating habits and children’s challenging behaviors, as the children’s challenging behaviors may also impact the parents’ strategies. Finally, they include that exploring other factors, such as other life stressors, that may impact this relationship between parent and child dynamics during feeding would be useful.
What does this all mean for a feeding therapist?
While this data is preliminary and low level evidence, I think it is very important to acknowledge and include families in feeding therapy intervention. I think we are doing a disservice to children and their families if we expect the child’s progress in the comfort of a therapeutic feeding session to transfer over to home without directly also educating parents and caregivers on how to interact with food, respond to their children and shift a mindset of learning to learn about food.
References
Goodman, L.C., Roberts, L.T., & Musher-Eizenman, D.R. (2020). Mindful feeding: A pathway between parenting style and child eating behaviors. Eating Behaviors 36. http://doi.org/10.1016/j.eatbeh.2019.101335
4 Case series (and low quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
* This was a systematic review which included mostly RCT’s and Level II studies. As this type of systematic review doesn’t fall into either 1A nor 2B, I chose to categorize it into a level 2A study. The evidence reviewed was higher than case studies but lower than cohort studies.
Methods
The authors of this systematic review included studies that investigated the effect of interventions that are not Ayres Sensory Integration specifically. They included studies published between 2007 and May 2015. Authors included studies on sensory-based techniques as well as sensory environmental modifications. Interventions targeted clients between 2-21 years old with sensory integration difficulties. Authors ensured that articles investigated specific sensory techniques or sensory environmental modifications.
Findings
Qi-jong massage The authors concluded there is strong evidence for young children with ASD with Qi-jong massage (Bodison, S.C. & Parham, L.D. 2017, p. 5).
Three Level I and and 1 Level II studies demonstrated improvements in self-regulation, parenting stress, tactile differences and ASD symptoms. Children were 2-7 years old and had ASD. Their parents, after being trained by occupational therapists, provided 15 minute daily massage. The studies lasted 4 and 5 months.
Important to note is that the OT’s had at least 50 hours of training in Qi-jong before training parents on its implementation. This may make it a challenge intervention for most OT’s to implement.
Weighted Vests The authors concluded there is limited evidence for the use of weighted vests for children with ADHD (Bodison, S.C. & Parham, L.D. 2017, p. 5).
A level I study did show improved attention and in-seat behavior when a group of 6-9 year olds wore vests with 10% of their body weight. The authors mention that limitations in the design of the study impacted its internal validity. This in turn caused them to interpret these findings with caution.
Study authors also noted that the evidence they found for the use of weighted vests with children with ASD had low levels of evidence, so these studies were not formally included in the review. The authors conclude the evidence for the effectiveness of weighted vests for children with ASD is insufficient at this time.
Slow Linear Swinging The authors concluded there is insufficient evidence to support the use of slow linear swinging to improve attention for children with ASD.
A level I study investigated the impact of being on-task following slow, linear swinging in a group of children with ASD. The study demonstrated no significant difference between children who swung and those in the control group (Bodison, S.C. & Parham, L.D. 2017, p. 6).
Study authors did note a limitation of this study is that the arousal level of children was not assessed prior to their participation in swinging. They posited, therefore, that if a child was in a low arousal state prior to a calming activity, this may have demonstrated no positive impact on the child’s on-task behaviors.
Sensory Enrichment in Preschool The authors concluded there is insufficient evidence supporting sensory enrichment in a preschool classroom.
This level I study investigated the impact of embedding tactile, proprioceptive and vestibular activities for 12 weeks in a preschool classroom’s daily routine. All children in the classroom participated in these activities, but one group of children also received ASI through OT sessions.
Both groups improved in their play skills, but no difference was noted between them. Study authors of this review mention that design limitations, including a very small sample size of 8, limit the implications of the study findings.
Sensory Environmental Modifications The authors concluded there is moderate evidence supporting sensory adaptations of a dental environment to assist participation for children with ASD in their routine dental cleanings (Bodison, S.C. & Parham, L.D. 2017, p. 6).
Children reported improved measures of pain intensity and sensory discomfort as well as improved participation in dental cleaning for typically developing children and those with ASD. Children received deep pressure from a decorative wrap and the auditory and visual aspects of the the dental environment (Bodison, S.C. & Parham, L.D. 2017, p. 7).
Most interesting to me is that investigators measured children’s electrodermal responses as a means to quantify impact on stress and anxiety. They found a moderate to large effect size for children with ASD after they received the intervention!
So What Do You Think?
I appreciate when studies have high standards for the research they include in their reviews. However, due to the nature of the current evidence in OT, that sometimes means there is limited information on the interventions we use most.
I’m interested in the idea of Qi-jong massage, but I will say that the skeptic in me thinks, “Well, if anyone received a 15 minute massage to start their day, I would definitely expect them to show improvements in their behaviors.” I also am curious to see if the massage was compared to other interventions such as a tailored sensory diet. If families really followed up with those every day with good fidelity, I hypothesize that we would similarly see as good if not better results in the developmental gains for children.
Reference
Bodison, S.C., and Parham, L.D. (2017). Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth with Sensory Integration Difficulties: A Systematic Review. American Journal of Occupational Therapy72 (1). https://doi.org/10.5014/ajot.2018.029413
“You’re the physical therapist, right?” “Oh, here comes the handwriting teacher.” “Can you get me a weighted vest for him? He can’t sit still.”
All school based OT’s have heard one of these statements at some point in their career. While it sometimes takes a couple of years for teachers to recognize and understand who you are and what your role is, I love school OT. It is my jam. What appealed to me most about the school setting as a new grad was built in teammates. I was blessed with an enthusiastic and encouraging special education teacher. She planted the first seeds of teaching me to appreciate small gains and to realize I can’t control everything.
Backing Up Our Recommendations with Evidence
So what does the evidence say about the interventions OT’s use and the ones that many of our coworkers request? This systematic review will give you insight to just that–stability balls, handwriting interventions and weighted vests, to name a few favorites. Check it out below and see what areas you may want to reassess in your own practice.
Journal American Journal of Occupational Therapy (SNIP score 1.121)
Article Title Interventions Within the Scope of Occupational Therapy to Improve Children’s Academic Participation: A Systematic Review
4 Case series (and low quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
* This was a systematic review which included a wide array of evidence from RCT to Level III studies. As this type of systematic review doesn’t fall into either 2A nor 3A, I chose to categorize it into a level 2B study. The evidence reviewed was higher than case studies but lower than cohort studies.
Methods
The authors of this systematic review included studies that were peer-reviewed, in English and published between January 2000 through March 2017. They included only level I-III studies that fell within the scope of occupational therapy. Although many studies were not completed by OT’s, the authors did require that school practitioners or researchers conducted the studies. The study authors grouped articles into three categories:
Educational Participation
Literacy Participation
Handwriting
Findings
Educational Participation
Weighted Vests The authors of the review concluded there islow evidence to support the use of weighted vests as a means to increase participation as from the evidence below.
In a Level II study, students with ASD served as their own controls in three conditions when they did not wear a vest, wore a vest with weight and wore a vest without weight. The targeted outcomes of time sitting, attention to task and seated behavior did not significantly improve.
The Evidence Points Toward…Insufficient Data to Say
A systematic review investigated 13 studies that were group or single-case studies with children with ASD. Eight studies indicated weighted vests are an ineffective tool to increase seated behaviors and engagement. Five studies did show strong support. Small sample sizes and a limited geographic area represented in the samples limit the external validity.
Stability Balls The authors of the review concluded that there is low evidence for the use of stability balls to improve educational participation.
In an RCT in a gen ed second grade classroom, students who sat on standard chairs were on task more often when working with peers and independently than those seated on stability balls.
In a level III study, investigators observed students in a second-grade classroom while using standard classroom chairs and then twice using stability balls. They found a significant increase in students being on task while the students used stability balls.
A second level III study found eight students with ADHD in 3rd-5th grade showed a significant increase in the average time they remained in their seat and the time they spent on task.
Yoga Authors of this systematic review concluded there is moderate evidence that supports the use of yoga as a tool to increase school participation.
A level III study assessed the Yoga4 Classroom program for second grade students and showed significantly increased attention and on-task for academic tasks.
Students in the intervention group of an RCT for a manualized yoga program geared toward social-emotional wellness in sixth to ninth graders showed significantly higher levels of school engagement than the control group.
A systematic review found children with learning disabilities, emotional and behavioral problems showed significant improvements in their communication and classroom contribution compared to control groups. However, the authors deemed the evidence inconclusive due to a high risk of bias.
Literary Participation
Full disclosure-I’ve excluded some findings in my reporting. Not to skew the findings, but to include the elements that seem most realistic for an OT to include in their session.
Strong evidence from four studies showed that children who participated in embedded creative and engaging literacy activities in small groups had significant increases in their positive attitude toward reading. They also showed an improved self-concept as a reader. An intervention mentioned that OT’s could definitely include is to have students create a story with the use of drawings and interactive discussions (Grajo, Candler, & Sarafian, 2020, page 6).
Handwriting The authors broke down the data on handwriting interventions into the domains listed in the headings below
Approaches to Address Component Skills
Authors reviewed four RCT’s to determine how addressing the underlying components of motor skills, kinesthesia and visual perception impact legibility. The study on kinesthesia did not demonstrate improvement. The remaining RCT’s showed moderate evidence that addressing underlying components of visual perception and motor skill training improved handwriting speed. These methods did not impact handwriting legibility.
Sensorimotor vs. Therapeutic Practice
Seven studies investigated the difference between sensorimotor activities and therapeutic practice.
Sensorimotor activities addressed visual perception, kinesthesia, visual-motor integration, in-hand manipulation, and the biomechanical features of handwriting. Therapeutic practice included paper and pencil activities that implement cognitive aspects of feedback on the child’s performance as well as self-evaluation (Grajo, Candler, & Sarafian, 2020, page 8).
Strong evidence from 1 Level II and 3 Level I studies showed therapeutic practice was more effective than sensorimotor methods to improve handwriting legibility for children with handwriting challenges,.
Interventions in Addition to Usual Classroom Activities
The evidence for students receiving additional instruction outside of the standard instruction within their classroom was low and with mixed results. An RCT and Level II study found for typically developing children there was a significant positive result with the use of additional instruction. Two different studies assessed differences between children receiving additional intervention and those who did not. These studies did not yield a significant difference between the groups’ performance.
Interventions in Place of Usual Classroom Activities
The review found results from six studies (4 Level II and 2 Level III) that combined programs (often the teacher and an OT working together to teach handwriting) has low evidence to support these over a teacher’s instruction alone. Of note is that there were insufficient details provided on the “typical classroom curriculum” that these combined programs replaced. Thus, one is limited in drawing a conclusion on the effectiveness of combined programs over a standard classroom curriculum.
A Level II study compared a manualized combined program to a manualized program of therapeutic practice found no differences between the two. Finally, a Level II study found a teacher’s designed instruction was more effective than a combined program that was manualized.
Of Note
The authors mention that limitations of this systematic review include some studies having no control group nor random sampling in addition to small sample sizes. They also included that many studies were completed by practitioners outside of occupational therapy, such as school psychologists, reading interventionists, etc. However, the interventions were within the scope of OT practice. Therefore, they suggest that one may be limited in the ability to predict how these interventions and findings would generalize to pediatric OT’s practicing in schools and clinics.
What did you learn?
For me, it is always a little disheartening to read evidence that does not support sensorimotor approaches over therapeutic practice. Sensorimotor is fun and engaging, and I do believe children are learning when we teach them this way! However, if the evidence is pointing toward therapeutic practice to be more effective to improve legibility for handwriting, I think we have a duty to accept that and incorporate these strategies into our sessions.
By no means do I think we can’t use something if there is not an article to back it up. However, I think we need to consider the evidence and make sure evidence based treatments are taking up the majority of our treatment time!
References
Grajo, L. C., Candler, C., & Sarafian, A. (2020). Interventions Within the Scope of Occupational Therapy to Improve Children’s Academic Participation: A Systematic Review. American Journal of Occupational Therapy,74(2). doi:10.5014/ajot.2020.039016
