Tag: School OT

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Mindfulness Training & Its Impact on Self-Regulation

mindfulness
Image by truthseeker08 from Pixabay

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

  • 1A Systematic review of homogeneous RCTs
  • 1B Well-designed individual RCT
  • 2A Systematic review of cohort studies
  • 2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 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 Investigators 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

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Evidence Behind the Strategies: OT & Academics

Evidence in OT
Image by Sasin Tipchai from Pixabay

“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

  • 1A Systematic review of homogenous RCTs
  • 1B Well-designed individual RCT
  • 2A Systematic review of cohort studies
  • 2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies
  • 3A Systematic Review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 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 is low 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.

OT in academics

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

OT in academics

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,.

OT in academics

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

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Handwriting Program Performance Outcomes

Handwriting program
Image by metin seren from Pixabay

Ah, handwriting. The source and summit of our profession, right? (Just kidding.) However, while a lot of school OT’s like to remind people, “we are not handwriting teachers,” (I agree) it also makes sense as to why OT’s are called into action when a child’s handwriting is preventing them from participating in their school day. 

Where do we start? What program or method do we use? Personally, I started with what information was handed down to me on Handwriting Without Tears. I particularly like the idea of  developmental teaching order that they use. I think sometimes people think, “Oh, A is the first letter of the alphabet, let’s start with A.” There are diagonal lines in A, though, and children start forming those around 4 ½ years old. So, makes sense to me to start with the straight line letters first. 

In recent years, I’ve been intrigued by the Size Matters program. It was new to me and I like some of the concepts I picked up from learning about it. All this to say, which program should we use? 

Journal American Journal of Occupational Therapy  (SNIP score 1.121)

Article Title Curriculum-Based Handwriting Programs: A Systematic Review with Effect Sizes

  • 1A Systematic review of homogenous RCTs
  • 1 B Well-designed individual RCT
  • 2A Systematic review of cohort studies
  • 2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies*
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 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 many two-group non-randomized 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

A systematic review gathered articles from January 2006-December 2015 that included curriculum-based programs and handwriting intervention for students in preschool through 5th grade. 

The researchers included 13 studies total, with 10 Level II, 2 Level III and 1 Level II-III studies.

Findings

Handwriting Legibility

For legibility, the programs with the largest effect size was the Explicit Handwriting Program. Medium to large effects on legibility came with the Size Matters Handwriting Program and Write Start.

Programs with small or very small effect sizes on legibility included the Fine Motor and Early Writing Pre-K Curriculum, Handwriting Without Tears, Write Direction and Intensive Handwriting Practice.

Handwriting Speed

The Explicit Handwriting Program also the largest effect size on speed. The Write Start and Intensive Handwriting Practice programs had small to medium effect sizes. 

Size Matters Handwriting Program had small to medium effect size in the opposite direction, meaning kids wrote slower.

Fluency

Four studies assessed fluency, all investigating the Write Start program. There were significant differences for fluency in three of four studies. The authors noted that the studies being too similar and variations in post-test findings led them to determine there is insufficient evidence to speak to the effects of the program on fluency. 

Handwriting Program Characteristics

All interventions lasted a minimum of 6 weeks, with the majority lasting more than 12 weeks. However, the total number of hours of intervention did not show a relationship with the impact on legibility and speed of writing.

The only two programs to have a larger than small effect size on both legibility and speed were the Write Start program and Explicit Handwriting Program.

Choosing a Handwriting Curriculum Based on Your Needs

An interesting highlight of this review is that different curriculums had significant effects on different outcomes. The authors suggest that OT’s consider this when choosing a curriculum to use. It may be most effective to choose a curriculum that improves legibility if that’s what you’re most concerned with. 

So, the findings from this review may suggest that at this point in time, an OT may consider the following:

Legibility

The largest effect size on legibility came from students using the Explicit Handwriting Program. My initial thought was, “Okay! Let’s explore this. Seems like the best option!” Upon reading the program characteristics, it was very detailed. Intervention included dexterity exercises, discussions about context of writing with children, learning 2-3 letters in cursive per session given modeling, etc. (Kaiser, Albaret, & Doudin, 2011, p. 613, 614). That is to say, it was thorough, but is not a standardized program. The may be why the authors suggested the use of Size Matters Handwriting Program over Explicit Handwriting Program. On average, children using the Size Matters Handwriting Program and Write Start Program showed medium to large effects for improved legibility. For my part, I’m going to investigate Write Start in more detail.

Handwriting program

Speed

From their review, the authors suggest that Explicit Handwriting Program, Write Start or Intensive Handwriting Program may be the best choices for curriculum if your primary concern is speed.

Handwriting program

Things to Consider

The authors mention that they did not include level I studies in the review, as there were not any studies of that level of evidence that met inclusion criteria. Level I studies would give us more robust evidence to make our decisions on which program to use. The authors also mentioned that the way they measured their data on effect sizes did not take into consideration for repeated measures. They note that they intentionally did this to be conservative, but that this method may have produced effect sizes that were smaller than they really were.

What Do You Think?

What programs do you typically use with your students? Which programs mentioned here are new to you?

References

Engel, C., Lillie, K., Zurawski, S., & Travers, B. G. (2018). Curriculum-Based Handwriting Programs: A Systematic Review With Effect Sizes. American Journal of Occupational Therapy, 72(3). doi:10.5014/ajot.2018.027110

Kaiser, M., Albaret, J., & Doudin, P. (2011). Efficacy of an Explicit Handwriting Program. Perceptual and Motor Skills, 112(2), 610-618. doi:10.2466/11.25.pms.112.2.610-618