Submitted by Amanda Hart, Occupational Therapist
| Before | After |
|---|---|
| Could not copy or imitate basic pre-writing strokes or letters | Able to write all uppercase letters with fair to good legibility when provided a visual model |
| Wrote using a fisted grasp | Started to use a tripod grasp for about half of a writing worksheet |
| Difficulty writing with one hand throughout an entire worksheet; would switch hands at the midline of paper | Began to demonstrate a more consistent hand preference (right-hand) |
| Slow gait | Walking at a more typical speed |
| Poor balance and gross-motor skills | Can now kick a moving ball |
| Often drooled to the point where his shirt will be soaking wet | Mealtime drooling and the amount of food his would spill out of his mouth decreased by about half |
| Could not sit with an upright posture for a prolonged period of time | More able to sit with an upright posture for the entirety of a tabletop activity |
| Easily fatigued | Demonstrates increased endurance during gross-motor activities |
Adam is a six and a half year old boy who is about to go into first grade. He has a diagnosis of Developmental Delay and 17q12 chromosomal deletion. He also wears glasses for nearsightedness and uses an occlusion patch. I see him twice a week for OT and he also sees a PT and SLP twice a week. When I first started to work with him at the beginning of Kindergarten, Adam presented with difficulty writing with one hand throughout an entire worksheet, and would often switch hands once he got to the midline of his paper. When he held any type of writing utensil he demonstrated a fisted grasp instead of an emerging tripod grasp we would expect. Adam can be described as unsafe in the hallways due to poor balance (as he is frequently tripping and falling), though his gait could also be described as slow. Adam has low tone and it is difficult for him to sit with an upright posture for a prolonged period of time. He also did not demonstrate enough fine motor control or visual perceptual skills to copy or imitate basic pre-writing strokes or letters. Adam is often drooling to the point where his shirt will be soaking wet. Reflex testing indicated a present ATNR [Asymmetrical Tonic Neck Reflex], TLR [Tonic Labyrinthine Reflex], Moro [reflex], STNR [Symmetrical Tonic Neck Reflex], and Spinal Galant [reflex]. He inconsistently demonstrated unintegrated hand reflexes bilaterally.
His PT and I started to work on integrating his reflexes 4 months ago, both together and in our one-on-one sessions with him. We begin each session completing the [Brain Tune up] activities. All of us notice an increased level of attention when we start our sessions with these activities. In the first few sessions we focused just on rhythmic movements [from the Brain and Sensory Foundations course]. This was to get information about what type of movement felt best for him and how he responded to touch. It was also a way to introduce working on his unintegrated reflexes. We completed the four rhythmic movements for the first 6 sessions (or three weeks). In the beginning, Adam could get very silly and say that our facilitating the movements “tickled him” making it difficult to complete the movements for a full song or even seven seconds. By the end of the 3 weeks of rhythmic movements he was able to complete the windshield wipers with the movement coming from his hips independently and he started to be able to nod his head with they rhythm of the movement for several seconds at a time.
Adam’s ATNR most impacts his performance, however we choose to work on his TLR first as this is also not integrated. We worked on integrating his TLR through continuing the rhythmic movements each session, the isometric activities, and floor games in prone [from the Brain and Sensory Foundations course]. These floor games would take place in the PT/OT co-treatment and for the entirety of the PT session. The floor games took place for 10-15 minutes of each OT session. We decided to use the play-based games due to his age.
Following the integration activities we completed repatterning in stand with facilitation. We found that completing the isometric activities accurately required both of us to assist Adam and this was done once a week during our co-treatment time. Improvements we began to see within two months of focusing on this reflex included decreased fatigue, increased safety when navigating the hallways, improved walking up and down stairs, a better understanding of his body positioning and limbs, and an increased ability to follow motor based instructions. During this time we were also focusing on his ATNR through developmental movements and play games [from the Brain and Sensory Foundations course]. These activities happened in his PT, OT, and SLP sessions. His OT sessions also included 3-5minutes of working on integrating his hand reflexes through the isometric activities. His ability to recognize and label letters and sounds drastically increased during this time. He was able to write all uppercase letters with fair to good legibility provided a visual model by the end of those first months. He also started to use a tripod grasp for about half of a writing worksheet. He began to demonstrate a more consistent hand dominance of his right hand, though I may classify it as a hand preference compared to a true hand dominance. His walk became a more typical speed and started to be able to kick a moving ball. His drooling during mealtimes and the amount of food his would spill out of his mouth decreased by about half.
This past month we began to also focus on integrating Adam’s Moro reflex. Though his unintegrated ATNR most affects his performance we were so pleased with how some of his major issues were supported through working on his TLR we wanted to see if working on his Moro reflex would have the same effect. These isometric activities required one of us to help facilitate the leg movements and one of us to facilitate the arm movements. Due to his age and language being more mature we decided to incorporate the 5-step balance process [from the Brain and Sensory Foundations course] into each session we completed integration activities.
Over the past month we have noticed that he is less tired and more able to sit with an upright posture for the entirety of a tabletop activity, and demonstrates increased endurance during gross motor activities. During this time his PT continued to work on integrating his ATNR through play based activities during his individual sessions. We are hopeful to see how else Adam can be helped as we continue to integrate his reflexes.
Edited, emphasis added