Victoria Wood OTR/L, Author at The OT Toolbox

What is Polyvagal Theory?

January 22, 2026 by Victoria Wood OTR/L

polyvagal theory and vagus nerve exercises to support regulation

Polyvagal theory and vagus nerve exercises are common topics occupational therapists get questions on related to treatment related to regulation. For those of us working with children or parents of kids, we know that emotional regulation, stress, anxiety, and worries seem to be at an all time high. We can support these needs, and the ideas in this article are one tool in our toolbox.

In this guide, you’ll learn:

What polyvagal theory means in everyday language
How the vagus nerve affects behavior and emotions
The three nervous system states in children
Practical regulation strategies you can use right away

Upset, emotionally charged child with calm child regulation strategies using polyvagal theory

Polyvagal Theory Explained: A Practical Guide for Supporting Regulation in Kids

Polyvagal theory helps explain why children react the way they do under stress, and how we can support regulation before behavior escalates. If you work with kids or support them at home, understanding this framework can change how you respond to meltdowns, shutdowns, anxiety, and emotional overload.

This guide breaks polyvagal theory down into simple language, with practical strategies you can actually use.

What Is Polyvagal Theory? (In Simple Terms)

Polyvagal theory explains how the nervous system responds to safety and threat. Instead of choosing behaviors on purpose, children’s bodies often react automatically based on what their nervous system detects.

The theory was developed by Stephen Porges, and it emphasizes one key idea:

Regulation comes before reasoning.

When a child feels safe, learning and connection happen naturally. When they don’t, their nervous system shifts into survival mode.

The vagus nerve is a major communication pathway between the brain and the body. It helps regulate:

Heart rate
Breathing
Digestion
Emotional regulation

Polyvagal (meaning “many branches”) theory explains how different pathways of the vagus nerve influence connection, fight-or-flight responses, and shutdown.

Clinical therapists, in their efforts to understand the “why” of certain behaviors, have been asking about Polyvagal Theory. You probably know more than you think about this, but have not put all the pieces together. This is something we as pediatric occupational therapy providers need to be able to answer questions when our occupational therapy clients ask!

According to the Polyvagal Institute, “Polyvagal Theory is a way of understanding how our nervous system responds to different situations, like stress, danger, or safety. It was developed by Dr. Stephen Porges, a neuroscientist and psychologist, in 1994. In simple terms, Polyvagal Theory helps us understand how our body and brain work together to respond to stressors that are a part of everyday life as well as experiences that are more significant, such as trauma.”

A lot of the information presented on this topic is hard to decipher from a clinical perspective. While I find medicine fascinating, it is difficult to understand all the scientific terminology related to Polyvagal theory.

At first glance, this article popped up: “The Polyvagal theory describes an autonomic nervous system that is influenced by the central nervous system, sensitive to afferent influences, characterized by an adaptive reactivity dependent on the phylogeny of the neural circuits, and interactive with source nuclei in the brainstem regulating the striated muscles of the face and head”.

In this post we will learn the nuts and bolts of this theory, but more importantly, how it correlates to the learners we work with. When I read descriptions like the ones above, I try and imagine talking to a teacher or new parent using this definition. While I, as an experienced pediatric occupational therapist, might sound smart, I am not likely to have others “buy in” to therapy if they can not understand what we are doing.

POLYVAGAL THEORY and what we see

Now that you have clinical definitions in your toolbox, what does Polyvagal theory actually mean? Polyvagal theory breaks down the function of the vagus nerve and its’ connection with the rest of the body.

The Three Polyvagal States (With Kid-Friendly Examples)

The vagus nerve is a large nerve that goes from the base of the brain to the gut, connecting the brain to the body. The vagus nerve plays a key role in regulating our heart rate, breathing, and digestion, as well as our emotional state.

The theory suggests that the central nervous system (made up of the brain and spinal cord) has three branches:

Ventral Vagal State: Safe & Connected
Sympathetic State: (Fight or Flight)

Ventral Vagal State- Feeling safe and connected

This is the regulated state.

Calm body
Able to communicate
Ready to learn and engage

This response state is the “social engagement” response (termed ‘ventral vagal’ in the Theory), which is activated when we feel safe and connected to others. This is when we are relaxed and open to social interaction, and is communicated in our eyes, facial expressions, and tone of voice. This branch is referred to as the “relaxed” state.

What it looks like: relaxed posture, eye contact, flexible thinking

Sympathetic State: Fight or Flight

This state activates when a child perceives danger or stress.

Increased energy
Big emotions
Fast reactions

Fight or flight is the next branch. This is activated when we are in a threatening or dangerous situation. In polyvagal theory this is termed “mobilization,” and is the body’s way of preparing to fight a threat, or run away from it.

What it looks like: meltdowns, aggression, anxiety, restlessness

Dorsal Vagal State: Shutdown

This is a protective response to overwhelming stress.

Low energy
Withdrawal
Disconnection

What it looks like: zoning out, refusal, fatigue, “freeze” responses

This branch is the “collapse” response. Our body feels powerless to respond and will often shut down, or become unresponsive to stimuli in the surroundings. In Polyvagal theory this is called “immobilization.” You might have referred to it as shut down or freeze state.

Understanding these states helps adults respond with support instead of punishment.

All three of these branches are controlled by different parts of our nervous system, but are managed by the vagus nerve. Polyvagal theory suggests that by being able to understand these different branches or response states, we can better manage our own health and wellness, and understand the behavior of others (including empathy).

What Is Polyvagal Therapy?

Polyvagal therapy is not a single technique. Instead, it’s an approach used by trained professionals to help individuals:

Feel safe in their bodies
Improve emotional regulation
Build nervous system flexibility

For children, everyday caregivers can support polyvagal principles through co-regulation, movement, sensory input, and connection—without providing therapy.

NEUROCEPTION AND POLYVAGAL THEORY

Here is where things get tricky. If our systems worked correctly 100% of the time, we would not be over or under-responding to stimuli.

The autonomic nervous system has a build in monitoring system that interprets information about risk through sensors in the body (neuroception). These sensors determine danger, without involving the thinking parts of our brain. Autonomic can be thought of as “automatic”. Neuroception scans people, our body, and the environment for cues of safety or danger. The nervous system reflexively shifts to manage the situation for a survival response.

A neurotypical system with a great sense of resilience will have greater cues detecting safety, whereas a less resilient person’s system will lean toward detecting threat.
When in a calm state, the nervous system is less likely to activate the fight or flight response.
If our neuroception or feedback monitoring system is faulty, it sends a signal of danger when we are actually safe, or signals safety when we are in danger.
Some people find themselves in a constant state of hypervigilance, just waiting for a threat.
Hypervigilant people may seek out risky behaviors to keep their body in this state of arousal.

Polyvagal theory and sensory processing

Polyvagal theory sounds a lot like regulation, arousal level, and sensory processing. When we understand the polyvagal theory, it is easier to see that sensory processing is a function (or dysfunction) of the vagus nerve.

What kind of people come to mind when you think about polyvagal theory and sensory processing?

People with anxiety disorders – often in a constant state of high alert, easily triggered, sensitive, and “jumpy.” I think I gasp 50 times a day.
Autism spectrum – classically linked to arousal level difficulties, behavioral responses, and over/under reactions to stimuli.
Depression – sometimes people with depression miss signals around them, or may exaggerate their responses.
Sensory seekers – the risk takers often do not have the same feedback mechanism to alert them to possible danger.
Sensory avoiders – these people are often overly fearful of stimuli or events around them.

Each of these challenges have some aspect of sensory dysregulation.

Polyvagal Theory in Everyday Life With Kids

Polyvagal theory explains why:

Talking doesn’t work during meltdowns
“Calm down” isn’t effective
Movement helps more than lectures
Connection restores regulation faster than consequences

Before asking for compliance or problem-solving, the nervous system must feel safe.

HOW CAN I APPLY POLYVAGAL THEORY TO EVERYDAY LIFE?

Recognize your response to stress and anxiety. Even if we do not realize that our brain has detected danger, there is an automatic reaction. A lot of it is self reflection skills. Pay attention to your nervous system activation and what that looks/feels like, or interoception skills (increased heart rate, breathing, blood pressure, sweating, flushing). Learn to recognize these responses in the people you work with. I have many children whose pupils dilate, or ears turn bright red when overstimulated.
Practice or teach self-regulation. This is the ability to manage your response to stressors. We often teach this through deep breathing, deep pressure, gentle touch, quiet words, yoga, meditation, or other calming activities.
Build social connections – according to Polyvagal theory, building social connections can help us feel safe and secure. This can help reduce stress responses.
Identify triggers – learn what makes you (or your clients) feel unsafe or in danger. Learn to work through or avoid certain triggers. We do a lot of work on this with sensory therapy. My book, Seeing your Home and Community with Sensory Eyes is full of chapters that describe typical daily triggers and responses.
Seek professional support. If you feel you are struggling with your mental or emotional health, or your responses to stimuli are not typical, an occupational therapist or mental health professional that understands the vagus nerve and self-regulation can help.

Basically, having an understanding of the tools available can be used along with a stop and think strategy to help us interact in the environment and stressors around us.

HOW CAN I USE POLYVAGAL THEORY IN HEALTHCARE OR SCHOOLS?

The most efficient treatment aims at uncovering the cause or “why” our learners do certain things. We do not just put band aids over a gaping wound. This is a temporary fix, that does not lead to long term results.

Understanding that the responses we see are an autonomic or uncontrolled response to stimuli, can help you accept your learner’s responses differently. This can lead to better informed quality of care. Example: understanding that you were hit or bitten because your kiddo was responding to something we were asking them to do, rather than being naughty, goes a long way.
Trauma informed care – learning about Polyvagal theory helps with trauma informed care building trust, safety, and empowerment. A child (or adult) who feels safe around you is more likely to step out of their comfort zone and keep trying.
Mind body interventions – teach relaxation techniques as part of your treatment plan. Words are often not enough to calm an overactive state. Empower your learners to take control of their body and nervous system
Pain management- understanding the role of the vagus nerve can help understand the response (or over/under response) to pain to treat your patients more effectively.
Caregiver/client relationship – when you show that you understand what a person is going through, it builds trust and a willingness to go through the healing treatment process.

Polyvagal therapy

Polyvagal therapy can be talk-based therapy, or sensory based therapy to help reprogram the central and autonomic nervous systems. It can involve yoga, meditation, and mindfulness.

Immersion therapy aims to slowly surround the person with the stimuli that is triggering, helping their body have a more appropriate response to it. Slowly working with sounds, smells, or textures, can help desensitize the ANS response. The key is to do this slowly, while watching for bodily responses.

Desensitization is similar to immersion – the body is slowly desensitized or accustomed to certain stimuli. This may be through slowly working from something easy to tolerate, to more difficult input. Example: when working with textures you may start at dry beans, then dry noodles, rice, sand, playdough, putty, all the way to shaving cream.

Dialectical Behavioral Therapy (DBT) is a type of talk therapy. “Dialectical” means combining opposite ideas. DBT focuses on helping people accept the reality of their lives and their behaviors, as well as helping them learn to change their lives, including their unhelpful behaviors.

Journaling can help understand and manage emotions. The OT Toolbox has many resources to get you started journaling and self-monitoring.

Vagus Nerve Exercises That Support Regulation

Vagus nerve exercises are another tool in your therapy toolbox to support self regulation and co-regulation. There are specific exercises you can do that target the vagus nerve to get out of that fight/flight/fright/freeze zone. I like to use these vagus nerve exercises in Simon Says games, brain breaks, and other activities in OT sessions. Check out our relaxation breathing post for why breathing helps.

1. Movement & Heavy Work

Heavy work provides proprioceptive input, which helps calm the nervous system.

Examples:

Wall push-ups
Carrying books or groceries
Animal walks
Pulling resistance bands

How Heavy Work Supports the Polyvagal System

Heavy work helps shift the nervous system out of survival mode and toward regulation by:

Grounding the body
Increasing body awareness
Reducing stress hormones
Supporting co-regulation

This is why structured, visual supports can be so effective for kids who struggle with transitions, emotional regulation, or sensory processing.

One tool we’ve created are our Heavy Work Movement Cards. These printable cards offer ideas and movement based activities to provide proprioceptive input, vestibular input, and heavy work that is calming and regulating to move the body to a calm and ready state.

2. Breathing & Oral Motor Input

Slow breathing with extended exhales
Blowing bubbles or pinwheels
Humming or singing

3. Sensory & Connection-Based Strategies

Deep pressure hugs (when welcomed)
Rhythmic rocking
Safe eye contact and calm voice

Deep breathing- Breathe in through your nose with short breaths for four counts. Then Hold your breath for 7 seconds. Then slowly breathe out for 8 seconds. Repeat this a few times.
Arm hugs- Wrap your arms around your upper arms and place them just below the deltoids. Gently give yourself a hug and breathe in and out.
Tap your collar bones with both hands. Place your right hand on your left collarbone and your left hand on your right collar bone. Tap your fingers one at a time.
Place one hand on your chest and the other on the back of your neck. Breathe in and out deeply.
Arm taps– Place the palm of your hand on the opposite shoulder with both hands. Gently pat up and down both arms at the same time.
Neck turn and look– Sit with your shoulders back. Gently look over your right shoulder and look as far to the right as you can with both eyes. Hold that position and gently breathe in and out. You will feel a release of pressure in your chest and a sigh. Then repeat on the opposite side.
Eye gaze up– Bend your neck to one side by placing your left ear toward your left shoulder. Look up toward the ceiling with your eyes. Hold that position as you breathe in gently. You will feel a slight release of pressure in your chest and a sigh of breath. Then repeat on the other side. Hold that position until you feel the sigh.
Hum! This is a simple way to focus on breath work. I also saw a meme recently that said you can’t think about ruminating thoughts at the same time as you are humming. This is a good way to stop stressing or anxiety thoughts.
Gargle– This is another simple way to stimulate the vagus nerve. Bonus is that it’s a life skill that some of our kids need too.
Meditation and mindfulness– This is another life skill that kids and adults need throughout life, so now is a good time to work on this with kids and teens.

During my career as a pediatric occupational therapist, I have found the best treatment has been understanding my learners. Once I take a step back and show them that I understand their fears, pain, and objections, I can create a bond of trust that begins the healing process. While I do not like getting hit/bitten/slapped, or chasing a kid down the hallway, I do not get angry about it. I understand their response is often out of their control, and they usually do not have the language to be able to express themselves.

This has taught me much patience in working with people who struggle. As a highly sensitive person myself, polyvagal theory gives me grace to understand that I am a work in progress. Sometimes my body has a mind of its’ own, and I have to practice what I preach.

Frequently Asked Questions About Polyvagal Theory

Is polyvagal theory evidence-based?
It’s a widely used framework in trauma-informed and nervous-system-based approaches, especially for understanding regulation and safety.

Is polyvagal therapy the same as occupational therapy?
No. OTs may use polyvagal-informed strategies, but therapy requires professional training.

Can parents use polyvagal strategies at home?
Yes—through movement, connection, sensory input, and co-regulation.

Are vagus nerve exercises safe for kids?
Gentle movement, breathing, and sensory activities are generally safe and supportive when developmentally appropriate.

heavy work activity cards for occupational therapy

Our Heavy Work Activity Cards support movement, proprioceptive input, and vestibular input through heavy work activities designed to calm and regulate the body. Get your copy here. These cards and many other heavy work tools are available inside The OT Toolbox membership.

Victoria Wood, OTR/L is a contributor to The OT Toolbox and has been providing Occupational Therapy treatment in pediatrics for more than 25 years. She has practiced in hospital settings (inpatient, outpatient, NICU, PICU), school systems, and outpatient clinics in several states. She has treated hundreds of children with various sensory processing dysfunction in the areas of behavior, gross/fine motor skills, social skills and self-care. Ms. Wood has also been a featured speaker at seminars, webinars, and school staff development training. She is the author of Seeing your Home and Community with Sensory Eyes.

How Long Should OT’s Address Handwriting?

November 25, 2025November 24, 2025 by Victoria Wood OTR/L

How many times during this school year alone did you get a referral for a middle schooler for handwriting difficulties? Too many, I bet. In school based occupational therapy, handwriting referrals come in every day. Referrals like this beg the question, “how long should OT’s address handwriting?” In this post we will explore some of the evidenced based research, clinical observations, and standardized measurements involved in assessing and addressing handwriting skills.

HOW LONG SHOULD OT’S ADDRESS HANDWRITING SKILLS?

In theory, a person could change their handwriting legibility and skills at any point in their lifetime. It is never too late to learn or improve a skill. That’s the neuroplasticity that we always talk about. If school-based therapy and handwriting were this cut and dry, the answer to: how long should OT’s address handwriting skills, would be; forever.

Unfortunately, handwriting and school-based therapy are not as simple as someone wanting to improve a student’s handwriting.

Let us look at some of the factors that go into deciding whether to take on handwriting or continue addressing it:

Handwriting motivation…this is the big factor. An older student who sees nothing wrong with their handwriting, or is not motivated to change it, will be a difficult sell.
Habit – it takes three days to create a habit and more than three months to undo it. Imagine a habit that has been in place for five years! You can work with a student for months on correct letter formation and they revert right back to their old way as soon as your session is finished
Child is less than 8 years of age – Benbow (2006) says that any grip once it has been used over time, becomes kinesthetically “locked in” and is difficult to change without motivation. Once a child is about 8 years of age, their grasp is more difficult to change.
Function – at some point (usually late elementary) function over neatness wins out. Typing skills begin to take over long written essays, and a paper that is mostly legible is considered acceptable. This goes for functional writing as well as a functional pencil grasp.
Efficiency – is their handwriting fluent and efficient? Your student’s writing or grasping pattern might not look pretty, but if they can complete work within a reasonable time frame, this is functional. This breaks down the components of handwriting to make it fluent and efficient.
Time – do you have the time as a therapist to dedicate to improving handwriting? Six weeks of intervention (about 15 hours) may be sufficient to improve legibility with carryover of learned skills throughout their day.

WHAT IS THE EFFECTIVENESS OF HANDWRITING THERAPY?

Before jumping in and committing to a year of handwriting therapy, consider the effectiveness of treatment. The American Journal of Occupational Therapy recently published a systemic review of curriculum-based handwriting programs for students in preschool through second grade. Challenges with handwriting in school can have a negative impact on academic performance. The study focused on the youngest group of learners. Their research on the effectiveness of handwriting therapy resulted in the following:

curriculum-based handwriting interventions resulted in small- to medium-sized improvements in legibility
mixed evidence for improvements in handwriting speed
insufficient evidence for improved fluency
after review of 9 handwriting curriculums, no clear support was found for one handwriting program over another

WHAT ARE THE IMPLICATIONS OF POOR HANDWRITING/GRASPING SKILLS?

If the following symptoms are present when doing writing assignments, you may have more of a case to continue or add handwriting services:

Causes discomfort – the child may complain of hand or arm pain, or may be observed shaking the hand out excessively, or rubbing the hand or arm
Causes fatigue – the child fails to complete a writing task because the hand is tired
Blocks the movement of the fingers and causes the child to control the pencil with wrist or arm movements, which are more tiring and less effective
Contributes to untidy work owing to any of the above factors.
Decreased output may be present
Decreased speed of writing

CAUSES OF POOR HANDWRITING/GRASPING SKILLS

How long should OT’s address handwriting skills, depends on the cause and implications. A student who has messy handwriting along with the following difficulties may be a good candidate for handwriting and fine motor therqpy:

Weak hand muscles
Poor fine motor skills
Early exposure to writing/child is too young for writing
Lack of exposure to fine motor activities
Poor sensory feedback
Low muscle tone
Hypermobility of joints
Decreased motor coordination, dexterity, and fine motor precision

In the above scenario, there is a physiological reason for poor handwriting skills.

What about orthographic coding?

Orthographic coding plays a critical role in the development of efficient handwriting skills. It refers to the brain’s ability to form, store, and retrieve the visual images of letters and words, which supports the automaticity of letter formation. When children experience orthographic coding difficulties, they may struggle to recall how to form letters without visual or verbal cues, impacting writing fluency and overall legibility. These students often rely on slow, conscious motor planning for each letter, making writing laborious and inefficient, especially in academic settings where speed and accuracy are needed.

Motor planning and automaticity are key components in overcoming orthographic coding challenges. Developing a consistent motor plan, or knowing where and how to start each letter and using the same movement pattern every time, builds neural pathways that allow for smoother and more efficient handwriting.

Over time, repeated multisensory practice using consistent cues and structured approaches can help these motor patterns become automatic. This frees up cognitive resources for higher-level writing tasks like content generation, spelling, and punctuation.

To support students with these challenges, occupational therapy interventions often focus on multi-sensory strategies that reinforce the motor patterns of letter formation. This might include using air writing, tracing with tactile materials, or incorporating rhythm and movement to enhance retention. For further reading and practical strategies, you can explore related posts on motor planning, handwriting automaticity, and letter formation.

ASSESSMENTS ARE IMPORTANT TO DETERMINE HOW LONG OT’S SHOULD ADDRESS HANDWRITING SKILLS

Over the years I have become more reliant on standardized testing measures to determine outcomes. While I am a big fan of clinical observation, actual measurements go a long way to helping determine the cause of the problems and solutions. I do use handwriting assessments but they are more subjective in measuring skills. The following handwriting assessments are available to assess writing skills:

ETCH: Evaluation tool of Children’s Handwriting
Test of Handwriting Skills (THS)
Here’s How I Write
Learning Without Tears – Screener of Handwriting Proficiency

ASSESSMENTS FOR FINE MOTOR SKILLS:

In addition to handwriting assessments, there are some great fine motor tests that will give you more information on fine motor skills:

Beery Test of Visual Motor Integration – VMI tests drawing, motor coordination, and perception
Bruininks Oseretsky Test of Motor Proficiency – specifically the motor precision and manual dexterity subsections are great for measuring finem motor skills.
Peabody Developmental Motor Scales – this test from birth to age six will give a general overview of fine motor skills.
Miller functional assessment Miller Function and Participation Scales (M-FUN) assesses a child’s functional performance related to school participation.

VISUAL PERCEPTION

When assessing for fine motor and handwriting skills, it is important to rule out visual perceptual difficulties. Sometimes visual perceptual problems are subtle, but are the foundation of handwriting delays. I find that the perceptual test on the Beery VMI is not sufficient for truly assessing visual perception. The following tests are more comprehensive, and have perceptual skills broken down into subsections like memory, figure ground, form constancy, visual closure and more:

DTVP: Developmental Test of Visual Perception- used to rule out (or in) visual perceptual difficulties
MVPT: Motor Free Visual Perception Test
TVPS: Test of Visual Perceptual Skills

TREATMENT FOR HANDWRITING/GRASPING SKILL DELAYS:

Once you have determined that your learner meets certain criteria for handwriting therapy (age, motivation, habit, fine motor function, carryover), you can provide a treatment plan to move forward.

My recommendation is therapeutic interventions to address the core difficulties (fine motor, visual perception, sensory processing, weakness) first, or at the same time.

There are numerous handwriting programs out there to teach and remediate handwriting skills. Each on has its’ pros and cons. Use what is right for your specific learners, or develop a hybrid program. Below are just a few of the more common ones:

Handwriting Without Tears (learning without tears) – teaches letters in groups and order of difficulty. Uses a narrative for learners to remember. It does not necessarily translate into the classroom as teachers do not usually use it.
TV Teacher – it is motivating and has songs to remember the letters. The kids like Ms. Marnie. Con: do you want to be incorporating another electronic program into treatment?
Fundations: this combines writing and literacy. It has a good progression (although somewhat confusing at times). The paper has a lot of lines and can get confusing for those with perceptual difficulties
Size Matters: this is based on the belief that if the size is correct, the other pieces will fall into place
First Strokes program incorporates detailed fine motor elements along with handwriting teaching. This program strongly supports addressing utensil grasp as part of handwriting development. It offers materials for early writers in preschool through learning cursive skills. Focus is placed on stroke sequence, legibility, and touch point accuracy.
Handwriting Heroes: fully downloadable program, containing videos and printables to teach letter forms by groups that are based on the first stroke of the letter. This program emphasizes the importance of teaching lowercase letters first since they are 98% of what students read and is claimed to be even easier to learn.
Read this Handwriting article.
Check out our Overview of Handwriting for how to support these areas.
We also have Essential Components of Handwriting which breaks down the components.

The bottom line on how long should OT’s address handwriting:

It depends. There is not a 100% steadfast cut off point or rule regarding teaching or remediating handwriting. Use the information you gathered above to determine if this is a worthwhile cause to pursue. Ask yourself if the 12-year-old you are assessing meets the criteria. Are they motivated, do they want to change, is there an underlying issue, is their writing functional, and is there going to be enough carryover to make progress?

I am making headway in my cause to dismiss OT services, or not provide them, when I am assessing students who do not meet any of the criteria. This does not mean there is no hope for these students, but they do not need the skilled intervention from a therapist. If motivated enough, students can remediate handwriting skills on their own at home though workbooks and practice.

Better yet, create early intervention strategies that schools can use from preschool onward with all their students. Have in-services to review handwriting programs, introduce fine motor skills, and develop good grasping patterns. An ounce of prevention is better than a pound of cure.

Manual Dexterity Goals

September 19, 2025September 19, 2025 by Victoria Wood OTR/L

In today’s blog post, we’re talking all things manual dexterity goals. Fine motor IEP goals, or goals designed to target manual dexterity needs can be identified based on dexterity weaknesses that impact participation in the educational environment. You’ll also find many manual dexterity activities in this blog post, including this dexterity activity.

Be sure to read about IEP and 504 plans for information on where to begin with these processes. Another resource you’ll want to check out is our self regulation IEP goals and identifying student strengths for IEP writing.

Goals, goals, and more goals! It seems all therapists do is create, work on, and document about goals. Occupational therapy is about play. Where is the fun in that? Unfortunately, therapists are driven by measurable data and reimbursement.

what are manual dexterity skills?

Manual dexterity refers to the ability to use your hands in a skillful, coordinated way to grasp and manipulate objects and demonstrate small, precise movements. Manual dexterity is one of the components of fine motor skills.

Other fine motor skills include: speed and precision, visual motor skills, and strength. These skills allow for manual dexterity, or coordinated precision, to happen. Those skills listed out are:

separation of the sides of the hand
open thumb web space
neat pincer grasp
arch strength and development
bilateral coordination
finger isolation
hand strength
finger strength
in hand manipulation, including translation, shift, and rotation

There are tons of articles and ideas in the OT Toolbox Archives under “manual dexterity” to help gather ideas of what to be watching for when evaluating a student for fine motor skills.

In occupational therapy, manual dexterity is a key area of focus, particularly for children who struggle with fine motor control. Strengthening these skills supports independence in self-care, academics, and play. Understanding what manual dexterity means helps caregivers and professionals identify delays and build effective goals.

That being noted, the focus on progress and goals will continue. Writing goals and measuring them can feel overwhelming at times. Today we will focus just on manual dexterity goals.

Manual dexterity or precision in fine motor skills, has many underlying factors that impacts graded coordination in functional tasks.

What Is Manual Dexterity?

Manual dexterity refers to the ability to skillfully use the hands and fingers to complete precise movements, tasks, or manipulations. This includes actions like buttoning a shirt, writing with a pencil, tying shoes, or manipulating small objects like coins or beads.

Manual Dexterity Skills and Examples

Some common manual dexterity skills include:

Turning pages of a book
Zipping a jacket
Using scissors accurately
Stringing beads or building with small blocks
Picking up small objects like Cheerios or coins
Handwriting and coloring within lines

These examples can help inform targeted fine motor goals in occupational therapy, especially when writing IEP goals or designing home exercise programs.

Manual Dexterity Activities for Therapy

When planning manual dexterity activities, it’s important to select tasks that match a child’s developmental level and gradually increase the precision or coordination required. Effective manual coordination activities may include:

Tweezers games for grasp precision
Pegboards or lacing cards
Bead stringing or bracelet making
Using a hole punch or stapler
Squeeze toys or clothespins
Drawing mazes or tracing lines with resistance

These activities can be used during direct services, at home, or embedded into classroom routines for additional practice.

Why Manual Dexterity Matters in Pediatric OT

In pediatric occupational therapy, manual dexterity is one of the foundational skill areas that supports overall development, academic success, and independence in everyday life. Weakness in these areas may lead to challenges in writing, drawing, using tools, self-care tasks, and participation in age-appropriate play.

By embedding manual dexterity goals into treatment, therapists support fine motor coordination, hand dominance, bilateral integration, and task sequencing, all of which improve fine motor skills needed for success in school and at home.

Fine Motor Goals for IEPs and OT Documentation

Manual Dexterity Goals in Occupational Therapy

Here are examples of manual dexterity goals that can be used in occupational therapy documentation or individualized education plans (IEPs):

The student will improve manual coordination by manipulating small classroom tools (pencil, scissors, glue) with appropriate grasp and control in 4/5 trials.
The child will demonstrate fine motor precision by placing 10 small pegs into a pegboard within 1 minute with minimal assistance.
Given visual and verbal prompts, the student will use fine motor skills to complete a 3-step self-care task (e.g., buttoning, zippering) independently on 3 out of 5 opportunities.
The child will increase manual dexterity by stringing 15 beads with a pincer grasp in under 2 minutes across 3 consecutive sessions.

These fine motor goals reflect functional tasks and can be adjusted to support classroom performance or daily routines.

Setting effective fine motor goals is essential when developing an IEP or occupational therapy treatment plan. Consider the child’s current performance, strengths, and areas of need.

Some fine motor IEP goals may include:

Improve pencil grasp and in-hand manipulation to write first and last name legibly in 3 out of 5 opportunities.
Increase speed and accuracy of cutting along a line using scissors independently during art or classroom tasks.
Demonstrate improved hand strength and dexterity to open containers in lunchbox without assistance in 4/5 school days.

These goals can also align with manual dexterity activities and classroom expectations.

manual dexterity goals

Before churning out a dozen goals, it is important to review the basic framework and structure of excellent goals. A

s much as I dislike all of the documentation involved in providing therapy, having great measurable goals makes it a little easier. When goals are SMART, they are specific, measurable, attainable, relevant, and timebound.

The key to successful goal writing is to incorporate all five of these elements into each goal. Check out this post on Breaking Down Goals for more information.

Manual Dexterity Examples

Manual dexterity goals are going to be related to manipulating objects with the hands, rather than the visual motor goals of copying shapes, writing letters, coloring, and cutting.

Examples of these from the Bruininks-Oseretsky Test of Motor Proficiency Second Edition (BOT^™-2) include the following five items measured in fifteen second intervals:

transferring pennies (total pennies into box after fifteen seconds)
sorting cards
making dots in circles
placing pegs into a pegboard
and stringing blocks

Other manual dexterity measurements might include; the Purdue Peg Board, 9 Hole Peg Test, Jebson Hand Function Test, Functional Dexterity Test, and the Box and Block Test.

It’s important to know about fine motor milestones when assessing these results in order to create fine motor goals.

Specific examples of fine motor, manual dexterity activities include many components of every day activities. There are many fine motor skills required in the school environment. At home there are just as many!

It would be hard to list out every single manual dexterity example, but here are some listed below. Some of these are related to the school environment and may be incorporated into IEP goals based on manual dexterity needs in the school-based OT environment. Others are more ADL or IADL based and do not impact education. These dexterity goals may be covered in outpatient or medical model of occupational therapy.

Typing on a keyboard
Handwriting, holding a pencil
Coloring in lines
Writing in a given space
Buttoning clothes
Zipping a zipper
Snapping a clothing snap
Tying shoelaces
Threading a needle
Cutting with scissors
Using chopsticks
Turning a key in a lock
Playing a musical instrument
Operating small tools (e.g., screwdrivers)
Applying makeup
Drawing and coloring
Pressing buttons on a device
Sculpting with clay or manipulating play dough
Braiding hair
Flipping a coin
Manage money
Stringing beads
Assembling puzzles
Crafts
Tearing paper
Playing board games
Painting miniatures or models
Using a combination lock
Applying nail polish
Playing jigsaw puzzles
Building with LEGO bricks
Weaving paper crafts
Operating a computer mouse
Folding origami
Stacking small items like Jenga game pieces
Cutting food with a knife
Putting on jewelry
Playing cards
Folding paper
Flipping a light switch
Opening a door handle
Turning a faucet
Opening containers like a toothpaste lid
Sealing plastic sandwich bags
Using a spoof and Fork
Pouring liquid from a container
Applying lotion or cream
Turning the pages of a book
Using a stapler
Playing with building blocks
Playing with small toys
Using tweezers
Using fingernail clippers
Flossing teeth
Turn a pencil sharpener
Turn a watch dial
Put on a watch

not so great manual dexterity goals

How do you translate the data you gathered in a standardized assessment into SMART goals? One strategy is not to be to vague. This is one of the first goals I pulled up when searching for “manual dexterity goals”:

The student will improve fine motor dexterity skills to manipulate small objects, use tools, or engage in activities that require precise hand movements.

This goal is missing several components. It is not specific, measurable, attainable (how will you know when the student has improved?), or timebound. While it IS relevant to therapy, it is missing all of the other components that make it a usable goal.

How about this one?

In six months, the student will improve manual dexterity skills by improving score on the BOT2 test from 11 to 18 points in 3 of 4 trials.

There is a big part of me that likes this goal. It has all of the components of a SMART goal. The drawback is you will be constantly teaching and reviewing the specific items on the test, which will nullify the results the next time you retest. Also, school based therapists can not use standardized assessments each time they measure and report on goals.

Another thing to consider about writing fine motor goals based on the results of standardized testing; This goal is a “no no” in the school system (I found out the hard way this year). Maybe there is a way to tweak it in a long term goal, while having several different short term goals. After all, your ultimate measurement for progress and discharge may be those results from updated standardized testing!

manual dexterity goals – framework

The goals I tend to write have several similar components (as dictated by the school district or governing body):

In TIME FRAME (one, three, six, 12 months)
student will improve manual dexterity skills
by…
as measured by clinical observation and data collection by occupational therapist
3 of 4 trials, 8 of 10 opportunities, 4 of 5 sessions. I prefer this to percentages because it feels more specific than “75% of opportunities”.

measurable manual dexterity goals

The following is a list of goal ideas to get you started. It is by no means an all inclusive list, because students are as different as snowflakes.

To use an activity in goals, you can add time frames, percentages, number of seconds, assistance, or whatever modifications you need.

For example, to write a fine motor goal based on a specific fine motor task, follow this format:

In 12 months (specify date), the student will demonstrate improved manual dexterity skills by:

stringing 3 half inch beads on a lace within 15 seconds, stringing one at a time
place 9, 1/4 inch pegs into a 5 inch pegboard using dominant hand within 30 seconds
pick up and hold 10 pennies without dropping any, using dominant hand only, and a pincer grasp to pick up
find 10 quarter inch beads in medium green theraputty using a pincer grasp (this can include picking off the extra strings of dough)
independently button/unbutton 4/4 one inch buttons on a standard button strip
rotate a pencil in hand from the lead side to use the eraser using one hand only
rip one inch pieces of construction paper using finger tips
crumple pieces of tissue paper using one hand to reduce to 1/4 the original size
independently open screw top containers and replace
roll 10 one inch balls of playdough and place them in one inch circles
pick up 10 pennies and place into a vertical slotted container in 30 seconds
place 15 clothespins accurately on the edge of a plastic container, using dominant hand to squeeze clothespins
flip 10 quarters on a horizontal surface using in hand manipulation, without sliding quarters off of table
lace a shoe lace through holes x6 holes (does not have to be in correct order)

Manual Dexterity Activities

Remember when writing and using goals, these are just the items you are measuring for documentation. This does not mean these are the only manual dexterity activities you do during your treatment sessions. It would be next to impossible to list all of the possible activities you will be measuring in your goals.

You may end up with 27 goals this way! I often add 3-4 challenges within the goal, as I feel that one item might not be enough to accurately represent my student.

Manual dexterity intervention strategies can (and will!) include the list of 50 examples of dexterity that we shared above. After all, occupational therapy is all about functional tasks as a tool and a goal. However, some more manual dexterity examples can be rooted in play and the interests of the individual.

Some dexterity activities to try include:

String beads
Play with play dough
Copy designs on a geoboard
Make strings of paper clips
Deal and play games with playing cards
Play with tangrams
Build puzzles
Play with LEGO
Stack craft sticks
Tearing paper crafts
Play with water droppers
Use tweezers to pick up and manipulate small items
Use a pickle picker to pick up small items
Cut food with a knife
Use toothpicks to create art
Finger painting
Cross stitch or making plastic sheeting art
Lacing cards
Cut out shapes
Work on typing speed
Work on clothing fasteners
Practice flossing teeth
Crumble paper art
Pushpin art
Use the activities in our Fine Motor Kits

Working on fine motor skills, visual perception, visual motor skills, sensory tolerance, handwriting, or scissor skills? Our Fine Motor Kits cover all of these areas and more.

Check out the seasonal Fine Motor Kits that kids love:

Letters Fine Motor Kit — Summer Fine Motor Kit

Kit de motricidad fina de verano — Summer Fine Motor Kit

Or, grab one of our themed Fine Motor Kits to target skills with fun themes:

Want access to all of these kits…and more being added each month? Join The OT Toolbox Member’s Club!

Handwriting Without Tears Letter Order

September 17, 2025September 17, 2025 by Victoria Wood OTR/L

In this blog post, we’re covering Handwriting Without Tears letter order, or the specific order to teach letter formation based on the handwriting curriculum, Handwriting Without Tears (Learning Without Tears). We’ve previously covered the cursive HWT order so this is a nice resource to have on hand.

Have you noticed most teachers teach letters in alphabetical order? The first thing they teach is name writing, then writing the alphabet. This seems like a logical progression, but is not the most effective or efficient method. There are several different handwriting programs out there to address this important skill. Many of them do not teach letters in order.

One program specifically is; Handwriting without Tears (now called Learning without Tears). The Handwriting without Tears letter order is vastly different than writing letters in sequential order.

handwriting without tears letter order

The Handwriting without Tears program is popular among therapists for good reasons:

It’s a research-backed curriculum
The program is designed to be easy to teach and easy to learn
Developmentally appropriate sequence
It uses explicit instruction combined with guided practice
Promotes handwriting automaticity
Multisensory learning to support a variety of learning styles, including kinesthetic learners, visual learners, and auditory learners
Uses hands-on tools and activities in handwriting lessons
Uses intuitive lesson booklets to promote learning

According to the folks at Learning without Tears, “Pre-K–5 students move through a developmentally appropriate teaching order from capital, to lowercase, and cursive letters. This design helps children master handwriting skills in the easiest, most efficient way. Instead of teaching 52 letter symbols with a mishmash of different sizes, positions, and confusing starting places, we divide and conquer.”

what is handwriting without tears letter order?

If you have used the HWT program, you may have noticed the letters are not in sequential order. In other words, the Handwriting Without Tears program does not teach letter formation in order from A-Z.

This sounds counter intuitive, as students are generally taught letters in order. Child development skills, as found in the Peabody Developmental Motor Scales, demonstrates the visual motor progression of fine motor skills. We cover some of this in our post on drawing milestones.

When developing writing skills, pre-writing lines emerge. This begins when the stages start at scribbling, vertical and horizontal lines, then circular forms. After these are mastered, more difficult designs such as a cross, square, and triangle are developed.

Learners who are still mastering the basics of writing lines, do not have the necessary skills to form more complex designs such as the letter A which relies on diagonal lines, or B which requires semicircles. Students often get stuck at this stage if they are unable to form these letters.

The Handwriting without Tears letter order promotes success, focusing on letters that use the preliminary pre-writing strokes. This is why letters with straight lines are taught first and in a group, known as letter families.

HWT Letter Order Groups

The Handwriting Without Tears letter order progresses like this:

L, F, E, H, T, I
U, C, O, Q, G, S, J, D, P, B, R
K, A, N, M, V, W, X, Y, Z

Handwriting Without Tears Straight Line Letters

The first letters are L, F, E, H, T, I. Notice all of these letters require only vertical and horizontal lines.

This is the first developmental skill mastered. Imagine the success of learning six letters right away, rather than struggling on A and B!

handwriting without tears Circular Letters

The second set of letters are circular: U, C, O, Q, G, S, J, D, P, B, R. The letters within each section progress in level of difficulty from U to R.

Notice that letter B is 16th on the list! This is vastly different than the traditional method of teaching it as letter number two.

While R, is a circular letter, it also contains a diagonal, which segues into the third uppercase letter formation group.

Grab our Letter B Worksheet for sensory motor practice to form the semicircles that make up this circular letter.

We also have a Letter C Worksheet for improving the circular motion of the pencil which carries over to other letters (Also known as magic c and is helpful for forming the lowercase letter counterparts).

Further down the list is letter D, and you can use our Letter D Worksheet to work on the straight line followed by a rotated semicircular motion that then carries over to the remaining letters with the same motor pattern: P, B, and R.

handwriting without tears Diagonal Letters

The third and final set of letters are the diagonals. Copying a triangle is one of the last basic shapes to learn as a developmental progression.

Forming diagonals is tricky. Not only are students crossing midline, they are doing so in a top to bottom fashion.

The letters in this series are: K, A, N, M, V, W, X, Y, Z. A is number 18 on the list. Now you can see why students struggle to learn the very first letters of the alphabet. They are not developmentally ready for this skill at the time we are insisting on teaching it.

Try using our Letter A Worksheet for sensory motor practice to form the diagonals and starting the letter in the middle.

Starting Position for handwriting without tears letters

An additional method HWT uses to group uppercase letters is their starting position. This is not my personal method of teaching, as I prefer the developmental sequence.

When focusing on the starting point for letters, Handwriting Without Tears groups the upper case letters into three catagories, depending on where the pencil starts:

Frog Jump Capital Letters – F, E, D, P, B, R, N, M
Corner Starting Capital Letters – H, K, L, U, V, W, X, Y, Z
Center Starting Capital Letters – C, O, Q, G, S, A, I, T, J

Take a look at the Frog Jump Capitals that start at the left corner (F, E, D, P, B, R, N, M). Notice several of these letters are more complex with diagonal lines. This can be a challenge for some students that struggle with the pre-writing lines, specifically diagonals. Additionally, this grouping of letters includes several different pencil stroke patterns, which can also be a challenge for some students.

Their second grouping is the starting corner capitals (H, K, L, U, V, W, X, Y, Z). This grouping of letters also includes a mix of straight line letters, diagonals, and curves.

Lastly, the center starters (C, O, Q, G, S, A, I, T, J) are addressed. Again, this group of letters includes more curved lines, but again, a mix of straight lines, curved lines, and diagonals. Notice how many of the last letters are commonly used letters. This is another reason why this particular HWT letter order might be a challenge for some.

uppercase or lowercase letter order first?

There has been some discussion on whether it is better to teach upper or lowercase letter formation first. We cover the developmental reasons in our linked blog post.

The research has been inconclusive, as there are benefits to both.

While lowercase letters are everywhere, capital letters are the first introduced in toddler books and puzzles.
Lowercase letters will be used much more than capital, but uppercase letters are much easier to form due to the simple straight lines.
There is no retracing or letters that sit below the line in uppercase letters
B/D are not as confusing as lowercase b and d when writing capital letters
When reading, many agree that teaching letter sounds is more important than their names, therefore teaching lowercase letter sounds first, may be more beneficial than teaching the letter names
Consider the age of your learners – preschooler should write uppercase first, as that is their developmental progression stage. Kindergarten and later students may be able to start in alphabetical order, however for delayed students, this can cause frustration

handwriting without tears lowercase letter order

For the same reason we teach uppercase letters in a progressive order, Handwriting without Tears lowercase letter order is important also. These letters are formed in developmental progression as with the uppercase.

Just like their capital letters – c, o, s, v, w, t (just like uppercase only lower cross)
Magic C – these high frequency letters (a, g, d) start with a magic “c”. This helps differentiate between b and d. While “q” is a “magic c” letter, it is taught later to avoid confusion with g
The rest of the vowels – u, i, e
Familiar from capitals – l, k, y, j
Diving letters – these letters dive down (p, r, n, m, h, b)
Tricky leftovers – f has a tricky start, letter q is taught here to avoid confusion with g, x and z are familiar but infrequently used
Once these are learned, I add another group: the drop down letters. These are the most difficult to write correctly as all of the other letters sit on the line. When I am teaching correct letter formation, j, g, p, q, y are stressed as their own group, after the others have been learned

cursive handwriting letter order

As with upper and lowercase letter formation, cursive letters are formed in groups. While HWT has their way of presenting the cursive letters, I prefer (Amazon affiliate link) “Loops and other Groups“.

This system groups the letters into the way they are formed. There are the clock climbers, kite strings, loop groups, then hills and valleys. Capital letters are taught last, as they are tricky and not used as frequently.

Here is an interesting post from the OT Toolbox about teaching cursive writing.

How to Teach Cursive Writing is another great resource.

Handwriting Without Tears Letter Order: Why It Matters for Young Writers

When teaching young children how to write, the Handwriting Without Tears letter order offers a thoughtful, developmental teaching order that sets students up for success. Instead of following the traditional A-Z sequence, this method begins with letters that are easiest to form (like L, F, E, H), and builds confidence with correct formation from the very beginning. This intentional capital teaching order is backed by research and clinical observation, helping kids avoid common challenges like reversals and handwriting fatigue.

As an occupational therapist, I’ve seen how this method supports literacy skills and improves alphabet knowledge in a way that’s functional and developmentally appropriate. The progression of letters aligns with how children gain motor control and visual-motor integration skills. This gives kids a way to learn with success and confidence.

Why the Handwriting Without Tears Letter Order Works

The beauty of this approach is that it focuses on multi-sensory writing experiences using hands-on materials like wood pieces, chalkboards, and the ever-popular mat. These tools offer multisensory activities that integrate touch, sight, and movement. This helps with creating a motor plan for developing both muscle memory and motor planning. By breaking letters into meaningful categories (such as “Frog Jump Capitals” or “Starting Corner Capitals”), the method helps children internalize consistent patterns of movement.

The result? Better posture, improved pencil grasp, and fewer instances of letter formation confusion or reversals. Kids develop strong muscle memory for correct formation, which leads to more automatic writing and fluent sentence construction down the road.

Letter Formation Strategies that Support Real Learning

Handwriting Without Tears activities also include rich vocabulary support, songs, and movement-based games. These reinforce learning while making it fun and meaningful. Using visual cues, auditory repetition, and tactile feedback all at once gives young writers multiple ways to engage with each letter. These letter formation strategies aren’t just good for OT sessions—they’re practical for classroom teachers, homeschoolers, and parents too.

The curriculum’s commitment to hands-on materials like magnetic boards, wooden letter pieces, and roll-a-dough letters ensures that instruction is rooted in movement and exploration, not just pencil-and-paper tasks. When we combine these tools with consistent routines, movement breaks, and guided support, we empower young writers to feel successful and build foundational literacy skills that last.

Frequently Asked Questions about Handwriting Without Tears

Why Handwriting Without Tears?
Handwriting Without Tears is a developmentally appropriate approach that breaks down handwriting into manageable, multisensory steps. It supports young children with letter formation strategies that are backed by research in motor development and learning. This program uses a developmental teaching order, hands-on materials, and movement-based learning to reduce frustration, avoid reversals, and build strong alphabet knowledge and literacy skills from the start.

What are corner starter letters?
Corner starter letters are capital letters that begin at the top left corner of the writing space or chalkboard. Examples include F, E, D, P, and B. These letters follow a consistent movement pattern, helping children learn correct formation with fewer motor planning challenges. Teaching these letters first reinforces a top-to-bottom, left-to-right writing habit, which is essential for fluent writing.

What are center starter letters?
Center starter letters begin in the middle of the top line or writing space. Examples include C, O, Q, and G. These letters often involve curves and circular movements, making them slightly more complex. Teaching these after corner starters allows children to develop the control and coordination needed for more advanced motor tasks.

Why teach letters in groups?
Teaching letters in developmentally appropriate groups (instead of alphabetical order) allows children to master foundational strokes and patterns before moving on to more complex shapes. We call these letter families. This strategy promotes correct formation, reinforces muscle memory, and supports multi-sensory writing by allowing for repetition and confidence-building. Grouped teaching also reduces the likelihood of reversals and helps build smoother transitions into writing words and sentences.

resources to support handwriting without tears letter order

Learning Without Tears letter strategies uses a multisensory approach to learning letters, which includes creating letters out of clay or wooden blocks, singing songs about letters, to drawing on tiny chalkboards.
Cursive writing letter order teaches more specifics about writing in letter groups

Everyone is different, as are their learning styles. Ultimately the goal is success. Whether that means using the Handwriting Without Tears Letter Order, or another teaching method, whatever helps and motivates your student is the correct choice. Nothing we teach is one size fits all. That is what makes our job so exciting and dynamic!

The Letters Fine Motor Kit is a supplement to any handwriting curriculum and uses hands-on, multisensory strategies to support letter formation.

Want printable handwriting and sensory motor activities to target the visual motor skills needed for letter writing? Grab a copy of our Letters! Fine Motor Kit. The printable PDF contains 100 pages of hands-on letter writing practice for multisensory handwriting!

Inside the Letters Fine Motor Kit, you’ll find:

A-Z Multisensory Writing Pages: Roll a ball of dough letters, ASL sign language letters, gross motor movement, small-scale letter box writing task, finger isolation letter trace, and writing practice area
Alphabet Fine Motor Clip Cards– Clip clothespins or paper clips to match letters with various fonts to strengthen the hands and focusing on eye-hand coordination, bilateral coordination, visual processing skills, and more.
Cut and place Fine Motor Mazes– Cut out the letter pieces and trace the maze with a finger to work on eye-hand coordination and finger isolation. Place a small letter on the letter spots to address in-hand manipulation and dexterity skills.
A-Z Cotton Swab Cards– Includes upper case and lower case letters. Dot the cards using a cotton swab or laminate the cards and use them over and over again.
A-Z Pattern Block Cards– These cards include a section for tracing with a finger tip for separation of the sides of the hand, eye-hand coordination, and finger isolation during letter formation. There is also a space to “finger write” the letter using the fingertip. This multisensory letter formation activity can be a great brain break during handwriting or literacy tasks. Learners can then form the letter using parquetry blocks.
Fine Motor Letter Geo-Cards– These geo board cards include A-Z in upper case forms. Users can copy the letter forms in a variety of multi-sensory strategies.
A-Z Color and Cut Letter Memory Cards– These upper case and lower case letter cards can be used to color for letter formation. Then use them in fine motor matching tasks or in sensory bins.
Color By Size Sheets– Help learners discriminate between tall letters, small letters, and tail letters. This visual perception activity invites learners to color small areas, using hand muscles for strengthening and handwriting endurance.
A-Z Building Block Cards– These LEGO block cards invite users to copy the cards to form letters using small building blocks. Users can place the blocks on the cards or copy the letter to address visual shift and visual memory. This activity set comes in upper case and lowercase letter forms.
A-Z Play Dough Letter Formation Cards– Print off these cards and laminate them to create play dough mats. Learners can form the letters using the arrows to correctly form letters with play dough while strengthening their hands and visual motor skills. Each card includes a space for practicing the letter formation, using a dry erase marker if the cards are laminated.
Graded Lines Box Writing Sheets– Users can trace and form letters in boxes to work on formation of letters, line awareness, starting points, and letter size.
Alphabet Roll and Write Sheets– Roll a dice and form the letter associated with the number of dots on the dice. This is a great way to work on letter formation skills using motivation. Which letter will reach the top first? This activity is easily integrated with a rainbow writing task to increase number or repetitions for letter practice.
Pencil Control Letter Scan– Use the letter bubble tracks to scan for letters. Users can fill in the letters of the alphabet to work on pencil control skills.
Color and Cut Puzzles– Color the pictures to work on hand strength and letter formation skills. Then cut out the puzzles and build visual perceptual skills.

Get your copy of the Letters Fine Motor Kit today!

Weighted Vests and Compression Garments

September 16, 2025September 16, 2025 by Victoria Wood OTR/L

What does a weighted vest do for kids? Picture of a weighted vest

Weighted vests, weighted clothing, and compression garments are used to offer proprioceptive input to elicit a calm and focused response. They tend to be used as a sensory intervention for children with diagnoses like sensory processing disorder, autism (ASD) and attention deficit hyperactivity disorder (ADHD), with the purpose of calming the body for functional activities.

Weighted vests are a hot topic in the therapy world, as they have been used in practice for decades. Sensory strategies are difficult to research, gather data, or prove their efficacy. Want to learn more about sensory processing disorder? Use this checklist to guide you!

Weighted Vests for Kids and Deep Pressure Tools

Weighted compression vests are one type of sensory input tool used to support children with sensory issues, including those with special needs. These vests are designed to offer consistent deep pressure input, a calming and organizing force that comes from engaging the muscles, joints, and connective tissue. This proprioceptive input helps a child become more aware of their body in space, which can improve focus, emotional regulation, and overall function throughout the day.

Many vests are made from neoprene material, offering gentle stretch and comfort while providing compression. Some models even include built-in ventilation to increase breathability during extended wear. Others feature interior weight pockets, allowing for adjustable weight and easier customization for different year old age ranges or teens who may need less weight or a vest that matches their child’s clothing more discreetly.

What Does a Weighted Vest Do for Kids?

A weighted vest works by offering steady deep pressure across the torso, especially around the waist and top of the shoulder, areas that support postural stability and body awareness. This input can have powerful effects on a child’s ability to:

Stay focused during learning tasks
Reduce sensory-seeking behaviors like fidgeting, jumping, or crashing
Manage emotional responses during transitions or overwhelming activities
Experience the sensory integration therapy benefits often sought through OT sessions

When paired with adult supervision and used properly, these vests can be a perfect addition to a child’s home routine or even integrated into their child’s school supplies for classroom use.

For children with sensory processing disorder or those with autism, this type of sensory input tool can offer a quiet and supportive way to regulate. Some children even prefer it over other forms of input because it doesn’t draw as much attention from peers, especially when vests are designed to look like athletic wear.

When to Use a Weighted Vest for Kids

It’s important to work with an occupational therapist to decide when and how to use a weighted compression vest. Use should be purposeful, short-term, and part of a comprehensive sensory diet. Ideal times might include:

Homework time
Classroom focus work
Transitions that often trigger dysregulation
Emotional regulation practice or calming routines
Circle time or gross motor tasks that require attention to the body

Wearing the vest should be limited to around 15–20 minutes at a time, followed by breaks. Keep in mind that categories of vests differ in design and weight, so proper fit and width (especially across the chest and shoulders) matters. Many options come with adjustable closures like a hook system for a snug but flexible fit.

Other Deep Pressure Tools and Proprioceptive Strategies

In addition to vests, there are other tools and activities that can provide proprioceptive input and support sensory integration:

Click to see examples of compression clothing or snug-fitting neoprene wraps
Weighted lap pads or shoulder wraps
Wall pushes, towel wringing, or resistance-based exercises
Carrying heavy items, like books or laundry baskets
Animal walks, bear crawls, or wheelbarrow walks
Jumping, pushing, pulling: activities that engage multiple muscle groups

What do weighted blankets do and research vs. clinical experience

Weighted clothing Research review versus clinical observation

This article will dive into the research versus clinical observation, on the use of weighted vests and compression clothing. Here at The OT Toolbox team, we’re lucky to have therapists with a variety of experiences, and years in the field. This blog post on weighted clothing, weighted blankets, and other weighted sensory tools explores both clinical experience and evidence for a combined viewpoint.

We’re covering both here: what the research says about weighted clothing and what clinical experience and data says about these weighted tools.

The first author, Sydney Thorson OTR/L is a school based therapist who bases her practice on research and evidence based practice. The second author, Victoria Wood OTR/L is an occupational therapist with 30 years of clinical experience, who bases her treatment on clinical observation, data collection, and real life experience.

Research on weighted vests and compression clothing

Research on weighted vests and Compression Vests

(Research review by Sydney Thorson OTR/L)

Weighted vests have been used in clinical practice for many years, without strong research evidence they actually work. In my opinion, this is a big deal for our field, as we should not be implementing such tools without good reason. If you’ve ever had questions about best practice and research on weighted vests, compression clothing, and weighted compression vests, read on.

A note about Research on Weighted Clothing, Weighted Vests and Compression Garments

If you are looking to purchase a vest or implement it into therapy, there is not much data available online, or in popular pediatric therapy books. Some features of the vests may be noted in research articles. Important factors such as the amount of weight to be used, the length of time it should be donned, or the frequency of use is never suggested. Why? Because we simply do not have any data to support this yet.

Most importantly, occupational therapists are often providing treatment under the Individuals With Disabilities Education Act, which mandates therapeutic and instructional strategies must be research-based whenever possible.

How Do I Know Which Research to Trust?

One of the most difficult parts of a literature review is understanding how likely it is that the study results are actually “true”, and therefore, clinically significant. In my review below, I have noted how strong the level of evidence, so that you can decide how best to use the information moving forward.

What does it mean to be clinically significant?

Statistical significance is what tells researchers if their chosen effect really happened or not. A researcher may determine that a weighted vest has a statistically significant effect based on their data from a research environment. In real-life practice, it may not have the same results.

The clinical significance is just another way to say, “does this treatment actually work for my patients in their normal environment?”

All good literature reviews start a question that needs to be answered:Do weighted or compression vests improve regulation in children with disabilities?

In my opinion, the simple answer is…probably not.

Best Evidence for Weighted Vests

A systematic review is generally the best way to learn about a research topic. Researchers thoughtfully and methodically take into account numerous studies, compiling the results into one article, for the reader to enjoy.

One of the more recent systematic reviews, titled, “Systematic Review on the Efficacy of Weight Vests and Blankets for People with ASD or ADHD” noted that earlier reviews found that these items did not have efficacy (Denny et al., 2018). Since then, data continues to show inconsistent effectiveness of weighted vests.

This review included 18 studies, four of which were also systematic reviews. The efficacy of each study in this review was noted and used to offer the following results;

Results (Denny et al., 2018)

In individuals with ASD or ADHD:
- Moderate evidence suggests that weighted items can increase attention and occupational performance.
- Mild evidence supports that weighted items can reduce maladaptive behaviors, like aggression, self-injurious behaviors, or off-task behaviors.
- No evidence supports the use of weighted items to increase adaptive behaviors, like seated, on-task behavior.
More rigorous studies are needed to determine if weighted items actually produce a clinically significant effect.
Use weighted items cautiously to determine if they will provide positive outcomes.

Should Occupational Therapists Use Weighted Vests?

In my opinion, with the inconsistent and insufficient available evidence of an intervention that is broadly used, OTs should turn to the leaders for guidance. This would include the American Occupational Therapy Association (AOTA). The American Journal of Occupation Therapy (AJOT) provided two systematic reviews on the topic of sensory interventions in 2020.

One review reported that weighted vests are not effective in increasing educational performance in children with ASD (Grajo, Candler & Sarafian, 2020).

The other systematic review from the AJOT went even further and stated that “weighted vests/items…received a red light designation…indicating that therapists should not use these approaches for children with sensory processing challenges” (Battin et al., 2020).

Best Evidence for Weighted Compression Vests

Compression vests are currently less likely to have specific data on their use, as they are often used a part of a treatment plan, either with weighted vests or other sensory items. Weighted vests are far more popularized in the research arena, but below you will find the best available evidence for compression vests.

A meta-analysis (including a systematic review) that complied recent data for deep pressure therapy items, including weighted and compression vests, squeeze machines, and brushing therapy, found that none were supported by evidence for any reason (Losinski, Sanders & Wiseman, 2017). Many of the studies reported on were low-quality for a number of reasons, and it is unknown how this could contribute to the results.

Weighted Vests and Autism

Occupational therapists often support individuals on the autism spectrum in the classroom, home, community, and clinic. OTs work closely in early intervention services with individuals diagnosed with autism.

While there are benefits for using weighted vests with individuals on the autism spectrum, in my opinion, it’s important to discern, through a research review, whether the specific needs of the individual are addressed.

A weighted vest, weighted clothing, compression clothing, compression bed sheets, or weighted blanket are just some of the tools used to support individuals with autism.

The benefit suggested of a weighted device or compression material refers to the regulation of the central nervous system, and the physical input through the proprioceptive system. This input can impact sleep, temperature regulation, to organize and calm the nervous system. It’s easy to see the connection between the nervous system, regulation of the individual, and functional performance of tasks.

Another great resource is the use of sensory clothing, or clothing that supports sensory needs, no matter the diagnoses or preference. In recent years, there are more options out there as well as greater availability to accessing sensory-friendly garments.

Should Occupational Therapists Use Compression Vests?

Unsurprisingly, there is limited guidance from our OT leaders at AOTA and AJOT that is specific to compression vests. This means that therapists can wait for guidance to come out, conduct their own research to add to the mix, or follow their next best available guidance. My gut tells me to follow the guidelines from AJOT for weighted vests, noted above.

This data trend is not exclusive to vests – some recent data does not support implementing any single-system sensory intervention in the school environment. Single-system sensory interventions, like swings, vests, and brushing, are becoming increasingly unsupported by leaders in occupational therapy (Grajo et al, 2020; Novak, 2019; Bodison, 2018; Wong et al, 2014; Watling, 2015).

This data does not make any statement towards other “sensory” experiences that are play-based, functional, or explorative in nature.

Research on the use of sensory-based interventions presented in the AJOT in 2018 suggested that many OTs “continued to use primarily clinical experiences and knowledge from their professional education programs rather than formal evaluations or scientific literature” (Carter & Glennon, 2018). The authors (and I) recommend a shift in our practice to utilize research evidence over personal experiences.

Clinical observation, data collection, real life experience on the benefit of weighted vests and compression tools

(Clinical experience by Victoria Wood, OTR/L)

The other side of the coin is a conflicting opinion, but one that therapists who have seen the benefits of weighted clothing and compression garments at work.

How a weighted vest works

Sensory seekers need to have their sensory “cup” filled in order to feel satiated. Have you ever wondered why a child with hyperactivity would be prescribed a stimulant?

The simple answer is; they will continue to seek input until their cup is full.

The stimulant, such as Ritalin, fills their cup faster than other sensory input. Once the cup is full, the person seeking input feels satiated, and can focus on work, functional tasks, or social skills. It is similar to needing to eat until you are full.

In a recent article on relaxation breathing, we covered how the autonomic nervous system responds to stimulation that is perceived as dangerous, over-simulating, or anxiety inducing via the commonly referred to signs of “fight, flight, freeze. It is through our limbic system that this occurs.

In response, heavy work activities support the calming or organization of this input. Other self-regulation activities such as proprioceptive input, visual input, and vestibular input can further support this sensory need. Just like the heavy work input of the proprioceptive system and vestibular system, this is organizing and regulating.

We shared more resources and tools to support this natural process in a blog post on using the benefits of a sensory burrito blanket as a sensory tool to offer heavy work input through compression.

A weighted vest, or compression garment, provides proprioceptive input similar to a deep hug. This deep pressure calms the central nervous system, thus calming, satiating, or organizing the body and brain.

What about research?

The reason there is not sufficient research and evidence on tools such as weighted/compression garments, vibration, therapeutic listening, sensory diets, etc. is the method by which it is collected.
Sensory data is collected through observation, interview, trial and error.
A person being interviewed about the behavior of their student/child may not paint a clear picture. Oftentimes, caregivers either over dramatize, or deny behaviors and outcomes.
Clinical observation may point to a reduction in maladaptive behaviors, or an improvement in attention while wearing a vest or using another sensory strategy, however, it is difficult to determine if the vest is making the difference versus sleep, diet, mood, exercise, weather, or 75 other variables.
It is difficult to trial a sensory strategy in a vacuum. Other variables are always present.
Behavior is difficult to measure.

Do sensory strategies such as a weighted vest work?

(In my opinion) weighted clothing works.

In my 30 years of experience I have seen countless patients show remarkable results from sensory strategies, especially compression and weight. The change in behavior is often instantaneous.

I have visibly seen a calm come over a child within minutes of donning a vest.

Some children are able to suddenly sit for 20 minutes at a table doing work while wearing a vest, where previously they were able to sit for barely three minutes.

Many patients I have worked with understand the value of their vest, and will begin to request it when needed.

The placebo effect of weighted garments:

The placebo effect is a beneficial health outcome resulting from a person’s anticipation that an intervention will help. How a health care provider interacts with a patient also may bring about a positive response that’s independent of any specific treatment.

If patients a,b,c, and d have a great outcome while wearing their “superman” vest or “police bullet proof garment”, it matters not if this is a placebo, or actual physical change happening to their central nervous system. If they feel better, have improved attention, and decreased maladaptive behaviors, the vest or strategy is working!

Dr. John Diamond, while reporting about the placebo effect, states; “What I am proposing is that rather than dismissing a cure as being “just a placebo effect,” we should try to do the very opposite. We should try to make all cures a result of the placebo effect.

If up to thirty-three percent of patients can improve with harmless distilled water, and only some sixty percent get the desired result with the pharmacologically active substance, we should be striving for all patients to be cured with a placebo. Then we would not have to administer a dangerous active substance.

Do no harm.

Health professionals follow an oath to do no harm. Under the correct supervision, weighted/compression vests do not harm a person. In my opinion, why not take a chance on trialing a simple strategy such as a compression vest, if it does no harm?

It might be the key to success you have been looking for, and might prevent more intrusive treatment strategies. Many times medical doctors prescribe simple medications in the hopes that symptoms will be alleviated, without actually having test results to confirm a diagnosis.

To me, this is much more harmful than trying a strategy such as a vest, or noise canceling headphones.

Trial and error with weighted clothing (or compression garments, weighted vests, etc.

Because of the nature of sensory based treatment strategies, much of what is done is trial and error.

What works for one may not work for another.

One child may need a combination of ten strategies to find the organization they need. The strategy used successfully for three months, may suddenly stop working. This is the exciting (and frustrating) element to treating sensory processing difficulties.

How to use compression garments and weighted blankets

How to safely use a weighted or compression vest/garment

The body responds well to an on/off wearing schedule. This is because the nervous system becomes satiated or “used to” the input after about 15-20 minutes. Similar to wearing a watch or a necklace. At first you are acutely aware it is on your wrist.

After about 20 minutes you no longer notice it.

If you take the object off for a period of time, then don it again, the stimulus becomes new and recognized.

A few tips for weighted clothing:

Wear the weighted clothing/use compression garment for 20 minutes.

Wearing a weighted/compression garment for more than the allotted 20 minutes is not necessarily harmful, it just stops working as effectively. Under the right supervision, a vest can be worn for longer periods if it is not possible to complete this type of rigorous wearing schedule. Watch for signs of shut down, overheating, or excessive fatigue.

2. Weighted vests or weighted blankets should be 5-10% of the body weight.

The weight should typically be 5-10% of the body weight, higher for a weighted blanket, as the weight is distributed differently. Adjust as needed for maximum effectiveness. Some people are more sensitive to input than others.

3. Collect data.

Trial and error with data collection, observations, and a checklist, are helpful when trying any new sensory strategy. Have caregivers fill out a form targeting certain behaviors, rather than “improved compliance”. What does that look like? Sit for 20 minutes without fleeing. Reduction in self injurious behaviors from X to Y. Recover from meltdown in 5 minutes versus 20. The NAPA center has a nice overview of weighted vests and their benefits.

Additionally, this resource offers a sensory checklist that can help with getting started on obtaining data and observations regarding sensory needs.

We hope that this discussion encourages you to further explore the quality of your practice, treatment methods and strategies, and recommendations for families – how will you move your practice forward?

Compression Vest Alternatives

We’ve covered a variety of options to use as a compression garment to offer sensory support through pressure. Compression vests are a common term, but the vest garment is not always feasible as a sensory compression tool.

Compression vests may not be preferred because of the fit of vests.

Alternatives to compression vests may include:

Compression blankets
Compression clothing like Under Armour
Weighted toys
Weighted blankets

Have you used any of these compression tools?

Frequently Asked Questions About Weighted Vests for Kids

How heavy should a weighted vest be for a child?
A common guideline is to start with a vest that is approximately 5% to 10% of the child’s body weight, distributed evenly across the vest. For example, a 50-pound child might wear a vest with 2.5 to 5 pounds of total weight. However, the exact amount can vary based on the child’s needs, age, and tolerance. Always consult with an occupational therapist to determine the safest and most effective weight range.

Do weighted vests help kids with ADHD?
Yes, weighted vests can help children with ADHD by providing deep pressure sensory input that supports focus and self-regulation. The consistent proprioceptive input from the vest can help calm the nervous system, which may reduce fidgeting and improve attention during classroom tasks or homework. While not a cure or standalone treatment, many children with ADHD benefit from using a weighted compression vest as part of a broader sensory or behavioral support plan.

How much weight for a weighted vest for kids?
The ideal weight is typically 5% to 10% of the child’s body weight, but the design and material of the vest also matter. Vests with interior weight pockets allow for gradual weight increases or reductions. Some models provide less weight but more compression, which may still be effective without added bulk. Work with an occupational therapist to assess your child’s individual needs.

Do calming vests work for ADHD children?
Yes, many calming vests, which include weighted or compression options, are reported to help children with ADHD manage sensory overload and improve their ability to concentrate. These vests provide consistent pressure, helping to organize the sensory systems and reduce internal “noise” that can make focus difficult. Results vary by child, but they are often a useful tool when paired with other supports.

Are weighted vests safe for children?
Weighted vests are generally safe when used under the guidance of an occupational therapist and with proper supervision. It’s essential to monitor the child’s comfort, posture, and response during and after wear. Look for features like built-in ventilation, adjustable fit, and less weight for younger children. Avoid using the vest for extended periods without breaks.

How long should a child wear a weighted vest for?
Weighted vests should typically be worn for 15 to 20 minutes at a time, followed by a break. They are not intended for all-day use. This short-term wear helps the nervous system process input without becoming overstimulated or desensitized. Timed use during transitions, learning tasks, or calming routines is ideal.

Are there any risks with weighted vests?
When used improperly, risks may include fatigue, overheating, discomfort, or changes in posture. Always ensure proper fit and weight distribution, particularly around the top of the shoulder and waist areas. Children should never wear a vest that’s too heavy or too long without supervision. Adult supervision and guidance from a professional are key to safe use.

AND

Sydney Thorson, OTR/L, is a new occupational therapist working in school-based therapy. Her
background is in Human Development and Family Studies, and she is passionate about
providing individualized and meaningful treatment for each child and their family. Sydney is also
a children’s author and illustrator and is always working on new and exciting projects.

Sensory Room Rules, Protocols, and Guidelines

September 15, 2025September 15, 2025 by Victoria Wood OTR/L

Today’s post on sensory rooms in schools is part of a series focusing on sensory rooms. We are going to explore the rules, protocols, and guidelines to using your sensory room. Other posts in the sensory room series highlight benefits, why have one, things to consider, cleaning materials, supervision, use by teachers and aides, building a sensory room on a budget, and sensory room equipment.

Sensory Room Ideas for the Classroom or School Setting

Sensory rooms don’t have to be large spaces or a whole classroom space. They simply need to meet the sensory regulation needs of the students who use them. Thoughtful sensory room ideas might include calming lighting (like string lights or dimmable lamps), soft textures (bean bags, floor cushions, or weighted blankets), and sensory tools (fidget bins, noise-canceling headphones, or resistance bands). Visual schedules or picture symbols help guide kids through activities like wall push-ups, deep breathing, or swinging, depending on what’s available in your space. Keep it flexible, what works for one student may not work for another.

Why do we need sensory room rules, protocols, and guidelines?

Did you know that a sensory room is considered a controlled and intentionally created space that provides multi-sensory resources to support a student’s sensory needs? This space is used in the school environment to help students with regulation and sensory needs to help them engage in learning.

Because of this, it’s important to have some sensory room rules and guidelines in place. The therapy providers reading this might be thinking, “Oh yes. We need to definitely regulate and maintain the integrity of the sensory room as a therapeutic tool”. It’s an option for supporting self-regulation.

Unfortunately, chaotic and unpredictable environments are sometimes created when a room is poorly designed, or personnel are not trained how to properly use the room. It is essential that the support personnel like teachers, teacher aides, and other staff understand how to use the room itself, not just the equipment inside it.

In the sensory rooms that I’ve seen in place, some of the issues that come up include:

Something that we often see is that the paraprofessional takes their student to the sensory room for scheduled sensory breaks throughout the school day.
Items in the room might be used incorrectly, or the student wandering around and trying a few things.
Items are broken
Materials are not put back into place, leaving the space a mess
Students might be taken into the sensory room as a reward
Students are taken into the room after they are in a state of dysregulation.
Students use equipment like sensory swings very aggressively or unsafely
Students might be in the room unsupervised
There might be too many students in the room at once.
Staff haven’t been trained on the “why” behind the sensory input.

This list is just the beginning of the iceberg! So many therapy providers have experienced different things when it comes to a calming space.

People who do not understand sensory processing difficulties, may see the sensory room as a playground or free-for-all space. While it is designed for some freedom of movement, your sensory room is best used with some direction and instruction.

The last thing you want to have happen in your sensory space, is for your student to feel/act worse than when they came in. Instructors who are given some rules, protocols, and guidelines, are better equipped to use the space to benefit each student’s unique needs.

It is more important how you use the space not what you have in it. One of the most common mistakes is to go into a sensory room and turn on every piece of sensory equipment. This can be very over stimulating for some. If used incorrectly students can exhibit self-injurious or aggressive behavior.

Remember the equipment is only as good as the person using it.

Creating a Calming Space for Kids

One of the most important things to remember is the goal of the space. A well-designed sensory room is more than just a break area where kids can go to chill out. The space should be a calming space for kids that teaches lifelong regulation strategies. This environment should support a child’s ability to reset and return to the classroom feeling focused, safe, and in control. Include elements that support proprioceptive input (like pushing, pulling, or heavy work), vestibular movement (like gentle rocking or swinging), and tactile experiences (such as bins filled with dry rice, fabric swatches, or play dough).

Keep the space quiet and predictable, with clear boundaries so kids know this is a place for self-regulation and not playtime.

What your sensory room should not be

There are many positives of having and using a sensory room in a school setting. It is important to use the space well, so it does not get a bad name. People might complain they sent their kids to the sensory room and they came back more out of control than before. You may have heard that Johnny acts out so he can get sent to the sensory room. Maybe teachers say their kids never “earn” their chance to use the sensory room.

These are common misconceptions and results of a poorly controlled space.

What to avoid when Setting up Sensory Room Guidelines

There are some things we’ve seen in the school settings that are actually counterproductive when it comes to setting up a sensory room. Some things that might be ineffective for students and staff include:

Don’t let the sensory room become a free for all space to send students to. The time needs to be planned and structured to work well.
Don’t make the sensory space a punishment for students. Getting the explosive student out of your classroom is important at times for the safety of the other students, going to the sensory room is not considered a punishment. It is a space to work on self-regulation and feel better so they can learn. Students who feel this is a punishment may avoid the sensory room when they can benefit from it, or may act out to get a change to go to the sensory room.
Don’t let the space be used incorrectly. When not used correctly, some students are demanding a sensory break every 20 minutes because it is fun to get out of class.
Don’t make the sensory room a reward or something that must be earned. While the sensory room space is usually a positive experience and a reward, students who are out of control are not going to be able to earn this sensory break. It needs to be recognized by the staff that your student needs a break, and explained that they need to work on their Zones of Regulation, or slow their engine down (Alert Program).
Don’t let the sensory room be a babysitter. We’ve all seen it; Teachers and staff need a break too. However, this space is not for students to be dropped off and left. It is a supervised space with direct coaching.
Sensory rooms must not be used for the purpose of separating students from their peers, either during class or break times.
This space is not an alternative curriculum or alternative to formal education.
Sensory rooms are not alternative play spaces for students who prefer not to play outside.
A school sensory rooms must only be used for students who have been assessed by an occupational therapist as having sensory needs, and in accordance with the occupational therapist’s recommendations.

Knowing what NOT to make from a sensory room can help to define the guidelines that allow us to use the space effectively…

Sensory Room Rules

Each space is going to be unique and have a different set of rules, however, there are some basic rules staff can follow:

If your kid makes a mess, clean it up
During cold and flu season it is best practice to wipe down equipment after using it, or use a sanitizing spray
When you must leave a mess behind, due to time constraints, or some other circumstance, leave a note and your plans to return. Example: this swing is soiled, please do not use it. I will take it home and wash it.
Keep fingers out of drawers, cabinets, closets, desks, or other “off limits” spaces. Restrict access to the sensory bin if your student is likely to throw birdseed all over the room.
Keep all sensory room materials in the sensory room.
Children should stay a safe distance from other kids on swings, being careful not to run or walk in front of or behind moving swings.
Limit visits to 20 minutes. Be prepared to leave the room if an emergency student needs to come in.
Limit the number of students in the sensory room to a certain number. This will depend on the size and space available in the room.
Be considerate of the equipment and space. Some items are expensive and budgets are small. Schools with limited budgets do not replace equipment quickly.
Supervision -Students using the room should be supervised at all times. Without one-on-one direct input, equipment can be damaged very easily. When you are on a tight budget, it is painful to see something broken.

Guidelines for your sensory space

If you are a therapy provider that was consulted to set up a sensory room in a school or if you are helping to create the sensory space, it’s a good idea to come up with some guidelines to help define how the room will be used.

These are things to consider to help keep the space effective for the students that truly need it.

Decide if the room is going to be exclusively used by therapists and their students, or accessible by teachers (who may not have the skilled training, or supervision) to bring their class.
Decide how items will be labeled or classified. It can be really helpful to itemize the items
Who has priority over this space? Is it an equal space for anyone, or does a treating therapist working with a student have the right to refuse more students coming in.
Scope out the room before bringing your class in there. If a child is out of control, or having a meltdown, it is best to wait before bringing your ten students into the sensory room. Our teachers often call down to the sensory room (also inhabited by therapists) to see who is in there, and if the time is appropriate.
Adult supervision should be a given when working with children with special needs. They may have poor impulse control, muscle movement, and reaction times.
Use the room as proactively as possible by incorporating sensory escape/space time into their daily routine
Determine the desired outcome for the student. Is it to give them an escape from the busy sensory filled classroom or a sensory break? Would the student benefit from a calming or alerting activity? What equipment are you going to use to meet the student’s needs?
Guide the student towards either calming or alerting activities, depending on what he/she needs. If the student needs alerting activities, ensure to do some calming, organizing activities afterwards before they return to class, so they are ready to focus and concentrate. Please see our movement break booklet and video here for more information
Explain how the prescribed item will be used, including the goals that the item will help to achieve, how long the item can be applied for and when it must be removed based on that assessment.
Consider the data. How will you keep track of who has used the space? How will you determine who needs what equipment? How will you know if something helped a student?
Equipment tracking- One guideline to consider is the status of the items in the sensory room. One thing we know for sure is that items that are used by kids tend to be used to their very end. So who will be responsible for making sure the sensory swings are working properly and that the ceiling attachment is still safe and secure? Who will monitor the items to make sure nothing has broken and to fix or replace them when they are?
How will you move kids through their time in the space? Will you use a visual schedule? A choice board? Timers?

Sensory Room Guidelines: Understanding Who Benefits Most and Who Doesn’t

It’s important to remember that the sensory room is not for everyone.

Sensory rooms look like great play spaces. It’s the engaging items that look like toys. There are fun play things, lights, and items that might not be seen all that often. However, these are sensory tools. They are not for everyone to use, and for good reason.

There are expensive pieces of therapy materials and equipment in there that can easily cause harm. It is also a dedicated space for sensory processing and regulation.

Just like everyone does not get to hang out in the Nurse’s office every day, they do not get to go to the sensory room either.

One of the most important guidelines is to regulate who goes in there, so there is not a constant flow of students going in and out. Teachers will need to count on this space being free and available when they need it.

Sensory Room Protocols

These sensory room protocols are not steadfast laws or rules. They are good guidelines to follow to be compliant with least restrictive environment.

There needs to be a system in place to monitor and ensure regular cleaning and disinfection of equipment and surfaces to prevent the spread of infections.
Check your equipment. Make sure your hanging device is secure and rated for the weight and size of your participant. This is important on a regular basis.
Accidents will happen, even if you are standing right there, but these will be easier forgiven if you were supervising your student when this happened. Have paperwork in the room for documenting any incidents.
The sensory room should have a phone or overhead system in order to call either the main teacher, the front office, or for staff to call into the room.
Provide some sort of floor padding or crash pad. Concrete floors are not forgiving.
Supervision- This is both a rule and a protocol because it’s so important. There needs to be constant supervision of clients, particularly those at risk of falls or those using heavy or complex equipment.
Equipment must stay in the sensory room. This is a rule you can use, or decide to have a borrowing system for certain items. Loaning equipment is nice; however, it comes with risks, and takes away from the use of everyone. If you have a large budget, you may be able to have multiples of certain items to loan.
Setting up a staff in-service is important. Providing proper training on the correct use of the equipment is a must for any school staff that will be in the room.

Supervision in a Sensory Room

One factor that we’ve mentioned over and over again in this blog post is the supervision aspect. It’s SO important for the safety of the students using the room that the time is supervised.

But, for busy therapy providers and busy teachers, there’s just not a moment to spare in the school day.

So, the question remains: Who is “in charge” of this space? And then, how do you keep the room from becoming a free-for-all where the items in the room are misused and broken or misplaced and kids are using equipment without supervision?

We came up with a few ways to go about this. Some of these are strategies that we’ve seen in place in various schools. Others are things you can try. Not every school building will see success with these strategies. There are different student needs, different levels of support from administration and educators, and there is different levels of buy-in. The main thing to do is consider the options and think about what might work in the specific school ecosystem that you are servicing as a provider.

How to structure a sensory room for success (supervision and usage)

Hang rules for usage in the sensory room.
Have a sign in sheet on the door.
Make a rule that anyone using the room MUST clean up before they leave the room. When they check out, put a box to mark that they cleaned up the room.
Limit the number of occupants at any one time. Depending on the size of the building and number of students that benefit from the room, that might be as little as 2 students to up to 6-7. Remember that co-regulation occurs even from a distance and that if a student is in a state of dysregulation, that can throw off others in the room. Consider having a station outside the room, like sensory paths or posters hanging on the wall that can be a transition space or an area where students can go if the room becomes inefficient because one individual is having a meltdown. This might lead to using the room with only one individual at a time. It all depends and should be a fluid status.
Students might benefit from using the sensory room at a specific time in their day. A paraprofessional might be the one to take them to the room.
Ensure staff is trained on the items in the sensory room.
Color code the items in the room for type of sensory input. Students will have colors associated with their needs/regulation states and can select from one of those options.
Use a check in/check out system where students can rate their levels of regulation (either with Zones of Regulation or Alert program for example). Then they can check out. Keep track of the data.
Consider having students take off their shoes when entering the room.
Consider limiting usage of the room to 10-15 minutes.
Consider setting up a sensory diet for students who use the room often. They can have a checklist of items that meet their needs and use a rating system for marking off how they feel before using sensory room items and then after.
Post a stop and breath sign at the door so that there is a period of deep breathing before entering the room and before leaving the room.
Educate the staff that the sensory rooms should not be used with students who are in an agitated state. They should not be used as a punishment (i.e. in replacement of recess or as a time out.)
Educate the staff that students should be used appropriately when the student asks for a sensory break or as part of a planned sensory diet. Here is information on how to create a sensory diet.

back to school sensory room rules for the school year.

Sensory Room Rules for Back-to-School Success

The start of the school year is the ideal time to review or establish clear sensory room rules. Just like classroom expectations, sensory room routines help kids use the space effectively.

Consider posting a simple visual chart with steps like: “Enter quietly, choose one tool, set the timer, use the tool safely, return to class.” Take time in the first few weeks of school to teach and model sensory room routines, even for kids who used the space last year. Routines can be forgotten over the summer.

Reteaching & Regulating Throughout the Year

Sensory room use isn’t “set it and forget it.” Sometimes you need to touch back on the rules again. Here are some tips:

Plan to reteach rules throughout the year, especially after breaks or if usage becomes inconsistent.
Build in proactive check-ins during transitions or after lunch when regulation needs spike.
If you notice kids treating the sensory room like a reward or play zone, revisit your classroom’s regulation strategies and work with the team (OT, SLP, and teachers) to reinforce the space’s purpose.

With consistent expectations, the sensory room becomes a trusted tool for calming, organizing, and supporting students in the classroom.

A final thought on using a sensory room

A sensory environment is a working/changing type of space. It will change depending on the needs of the current students, as well as staff. Rules and protocols may change over time, depending on the space, and who is using it. We have added several different protocols this year at our school based on experiences that have gone well, and not so great.

Ideally, a school would have several different sensory rooms. One that is quite safe with padded walls, floors, and soft everything, and another with more equipment for active regulation and heavy work. Until then, make sure you are supervising your students in this space, and training those you work with to do the same.

For additional information, check out this article for additional information on sensory needs. Here is a great resource on sensory rooms.

What you Need to Know about Interoception

September 15, 2025September 15, 2025 by Victoria Wood OTR/L

Interoception is a sensory term you may not have heard of before…but you have certainly felt or been impacted by the processing of our interoceptive sense! Internal feelings of hunger, fatigue, thirst, body temperature, digestion, and other internal systems offer a certain “feeling”, right? This is your interoception sensory system at work! Here, we’re covering everything you need to know about this complex sense, and taking a detailed look at how interoception impacts function.

How Interoception Affects Mental Health

One thing that I wanted to share is some information I’ve been hearing about on various podcasts. It seems like, recently, there is an upshift in environmental input that we’re all trying to process. It’s the never-ending distractions of notifications, more visual clutter, constant notifications, and an overwhelming stream of opinions coming from every direction. With the increase in phone use and social media scrolling, many people are tuning outward instead of inward. We’re checking for reactions, updates, and validation from others, instead of pausing to notice how we feel inside.

This constant outward focus chips away at our ability to notice internal cues like hunger, fatigue, anxiety, or even calm. The result is a kind of sensory and emotional overload that leaves our nervous systems in a chronic state of activation. When the brain is flooded with external sensory information and social comparison, there’s less space to process our own internal signals.

Over time, this can impact emotional regulation, self-awareness, and mental health, especially in children whose brains are still developing. Helping kids tune into interoceptive signals is one way we can start to counterbalance that overload and support their emotional and cognitive well-being.

That’s where emotional health and interoception comes in.

Interoception, the ability to sense internal signals like hunger, heart rate, or the need to use the bathroom, is foundational to emotional health and mental well-being. When the brain accurately interprets signals from the body, it helps a person understand their emotional state, manage stress, and make decisions that support regulation. For kids with ADHD or executive functioning challenges, the connection between brain development and interoceptive awareness is especially important.

Difficulty noticing or interpreting internal cues can lead to emotional outbursts, anxiety, or trouble with impulse control. One thing I heard in a recent podcast is the mind-body connection. This is where the vagus nerve plays a key role: it links the brain to many internal organs and helps regulate the body’s stress response.

Part of it is just being more aware of our internal ticking. Strengthening interoceptive awareness through body-based strategies supports the development of the prefrontal cortex. This is the part of the brain responsible for attention, planning, and self-control. By focusing on interoception, we’re supporting body awareness AND laying the groundwork for improved executive functioning and emotional regulation.

Interoception sensory input impact regulation, modulation, and function.

Let’s talk more about what interoception is…

Interoception The 8th sense

Did you know that the five senses we were taught in school is not actually a complete list of a human’s senses? In fact, there are 7 or 8 senses that humans experience, depending on who you ask.

Understanding our many senses helps us comprehend how we and others experience the world around us. For the sense we are highlighting today, it is how we understand what is going on inside of us. Check out this post on the OT Toolbox regarding Multisensory Learning: Emotion Activities.

Definition of the interoception sense

Interoception is the sense of oneself; it is the ability to understand the body’s physical signals that tell you when you are hungry or full, thirsty or quenched, hot or cold, scared or calm, etc.

Interoception refers to the body’s ability to identify and process internal actions of the organs and systems inside the body. This lesser-known sensory system helps you understand and feel what’s going on inside your body. You can then make essential decisions about eating when you are hungry, drinking when you are thirsty, going into the restroom when you need to toilet, and other physical actions.

There are nerves throughout the body that send these signals to the brain to help regulate the body, and promote homeostasis.

Some of these signals require a conscious act, like drinking water when we are thirsty, while others are non-conscious, like sweating when we are hot.

Interoception comes into play when we consciously realize, “Oh, I am sweating because I feel hot, I should take off my jacket to cool down.”

Information on interoception, this blog post covers the definition of interoception, and interoception sensory strategies.

How Does Interoception Impact Function?

Interoception can be thought of as a mind-body connection. Having a strong interoceptive sense would mean that you have a strong sense of the physical self, and what you need to promote comfort at any given time.

Being able to confidently act on your body’s needs, makes everything a bit easier. You are likely able to make it to the bathroom before an accident, eat food before you feel light-headed, and stop eating before you feel sick.

But what about individuals who are not able to accurately process the bodies internal signals? They may find it more challenging to be potty trained, have a healthy diet, or emotionally regulate.

The ability to understand and respond to our body’s needs is a huge factor in our independence. If we don’t quite know what our bodies need, it makes everyday activities much more challenging, and focus on school or work tasks may dwindle.

Interoception even has to do with how our body moves, the action of bones in the skeleton, bone growth (growing pains have a lot of “pain” that is felt internally for kiddos who are rapidly growing! Be sure to check out this related blog on bone names to help tach kids about this concept.

Functionally, interoception impacts so many areas of everyday tasks:

Eating
Drinking
Sleep
Toileting
Getting dressed (putting on temperature-appropriate clothing, or taking off clothing before becoming overheated)
So many more considerations!

Interoception and Emotion

Interoception has a strong connection to emotional processing because of the physical way that we experience emotions. Our muscles clench when we are angry, quiver when we are scared, and relax when we are calm.

Likewise, the stomach may feel upset when we are nervous, and one might get a headache from frustration. People with good interoception can relate these physical feelings to emotions.

If a person sensory processing differences, the signals from the body may not be accurately represented or relayed to the brain. They may be muddied or confusing, leading to a misunderstanding of what the body is trying to tell the brain. Because of this, a tickle may feel like pain, or a person may not know why they are experiencing discomfort.

Without interoception, labelling emotions is then a bit more challenging, as well as understanding how to remedy undesired feelings.

Children may act out in aggression, cry or scream uncontrollably, or show other signs of sensory dysregulation, potentially due to a lack of interoception.

If you know a child who has multiple characteristics of reduced interoception, like potty accidents, over/under eating, and emotional dysregulation, they may benefit from therapeutic intervention to improve their body awareness.

The interoception system plays a part in feelings and emotions, too.

When we feel anxious or worried, we might feel a tenseness about us. Our heart rate might speed up, and we feel that anxiety coursing through our systems.

But for the child with difficulty expressing these feelings, they can’t tell us what they are feeling on the inside. They don’t have the words to identify specific interoceptive feelings they are having.

Others might not recognize a racing heart. They might not realize that physical implication of anxiety or worry because they can’t actually feel their racing heart (when it is very much racing).

When one feels anxious about a situation or an idea, we can help them to focus on their heart beat. We can help them take deep breaths to calm down. This focus on how their body is responding can help their internal state match the environment.

Other ways to help with interoceptive identification include habit and routines to help us feel organized. When we know what to expect, we feel a lot more organized. The body is able to modulate better.

As we increase the challenge, we have to also increase our supports. We can use some external organizational strategies (deep breaths, awareness, mindfulness, heavy work, routines) to help compensate for the lack of internal ability to organize ourselves.

When we are disorganized, this is where we can fall apart. We have to be mindful ahead of time, and be accommodating and accepting of immature nervous systems, whether this is with our children, our spouse, or ourselves.

Tips for Improving Interoception

There are all sorts of activities you can do with children to help increase their interoception skills. Below you will find tips for improving interoception, including mindfulness, and children’s books on topics like emotions, potty training, and problem solving.

Modelling how you understand your bodies signals may also help – be sure to emphasize how you are feeling, and what you will do about it!

Mindfulness – the act of intentionally connecting to oneself and/or the world around them. This can help an individual get “out of their head” and feel more grounded in the present moment. By doing so, it may improve self-awareness and a positive mood. Mindfulness is not just great for improving interoception – see this article for more information
- This video guides a progressive muscle relaxation. Intentionally contracting and releasing muscles brings more awareness to the physical body, and deepens the connection that we feel to it.
- Here we have another video that guides mindfulness, in the form of a “body scan”. It also adds a great piece of education for children on what it means to understand their bodies signals, and why it is important.
- The OT Toolbox has this great list of more active ways to explore mindfulness through gross motor play.
Focus on awareness- So often, parents, children, clients, educators, and even professionals are not aware of ALL of the ways that the interoceptive sense impacts everyday functioning, learning, and daily participation in everything one does throughout the day. Educate, educate, educate! Then, bring that awareness to a full circle with activities that take the concept of interoception in daily tasks home. For example, you can cover how sleep is impacted by interoception and incorporate a few of our hibernation activities. Without interoception, animals that hibernate would not instinctively know to fill up on foods before winter and to keep eating even when they may feel full. Then that sleep that allows them to slumber through the winter is in effect. It’s all related!
Try calm down toys– Use a variety of supports in the form of play to support regulation needs. This can offer heavy work, regulating movement, or calming input.

Books to Improve Interoception

Below are Amazon affiliate links to resources and books on interoception and internal states.

We Listen to Our Bodies is a book that follows a young girl as she feels emotions through her day. The physical representations of emotions are highlighted in ways that are familiar to young children.
For a similar read pick up this book, that follows a boy and his day full of feelings at the zoo!
Time to Pee by Mo Williams is a great book that helps kids understand how to respond when they have that ‘funny feeling’ in their tummies.
I Feel… activity books have been praised by therapists for their ability to make learning mindfulness fun! The activity book linked here focuses on sickness in the body and what it feels like to be sick in different ways.
The OT Toolbox has a great resource called the Sensory Lifestyle Handbook to tie sensory processing together
For more children’s books on mindfulness to elicit peace and calm, check out this resource:

Sensory lifestyle handbook- How to create a sensory diet

While interoception is new and lesser known, it is an important sense to have.

3 Easy Interoception Exercises

Here are 3 simple, OT-informed interoception exercises you can add to your blog post to help kids or adults build awareness of internal signals connected to mental health and emotional regulation:

1. Heartbeat Check-In

Purpose: Build awareness of internal rhythms
How to do it:

Sit or lie down in a quiet space.
Place your hand on your chest or wrist and try to feel your heartbeat.
After some light movement (like running in place or doing 10 jumping jacks), stop and notice the change in heart rate.
Ask: Can you feel your heart beating faster? What does it feel like inside your body?

This builds connection between physical exertion and interoceptive feedback which helps the brain tune in to emotional states like anxiety or excitement.

2. Breath Awareness with Temperature Shift

Purpose: Increase mindfulness of breath and physical sensations
How to do it:

Take a slow breath in through your nose and out through your mouth.
Place your hand in front of your lips and notice the temperature of your breath as you exhale.
Alternate between fast and slow breathing.
Ask: What do you feel? Warm air or cool air? How does your body feel when you breathe slowly vs quickly?

Noticing temperature, speed, and rhythm of breath can help kids understand when they feel calm vs overwhelmed.

3. Stomach Signals Scan

Purpose: Tune into hunger, fullness, and emotional gut feelings
How to do it:

Before a snack or meal, pause and ask: What do you feel in your stomach? Is it growling? Empty? Full? Comfortable?
After eating, check in again: How does it feel now?
Practice describing the sensations with emotion words too: Does nervous feel like butterflies? Does sad feel like a heavy feeling?

This exercise helps strengthen the connection between body cues and emotional labels. This is critical for emotional regulation and self-awareness.

What do you think? Would these simple interoception exercises help you?

How to do “Push In” Occupational Therapy

September 8, 2025 by Victoria Wood OTR/L

Are you a new school based occupational therapist wondering how to implement a “push in” therapy service delivery model? Perhaps you have been practicing for a while and are looking for some tips to transition your services from your therapy space to the classroom. For additional reading, the OT Toolbox has a comprehensive post on occupational therapy in school system.

How to implement push in occupational therapy and push in therapy services in school based occupational therapy interventions.

What is Push-in occupational therapy in schools?

“Push in” services is a term used to describe school based occupational therapy services provided when students are participating in their natural environments.

At school, these environments can include the classroom, the cafeteria, the playground, or any other setting that a student accesses during the school day.

We’ve worked in the cafeteria on sensory needs for example, or to work on feeding needs.

Push-in Occupational Therapy Services

Changes in legislation with the addition of the No Child Left Behind law, began a shift in service delivery models for school-based occupationlal therapy over the last 20 years. This shift has refocused school based therapists on inclusion, providing services in the natural environment.

While occupational therapy in schools has always had it’s fair share of challenges (schedules and caseloads to name a few), shifting our focus to providing therapy services in the student’s natural environment, is supported by research and highlights our strengths as occupational therapists.

This challenge is a good change for related services.

We can rely on evidence, but what does it say about push in services in the school environment?

What Is Push-In Therapy?

Push-in therapy is a collaborative service delivery model where therapists, like occupational therapists and speech-language pathologists (SLPs), work directly in the classroom setting instead of pulling students out for separate sessions. This allows for real-time support, integration into classroom routines, and alignment with instruction.

Research by Cirrin and Nelson recommends clinical reasoning as to the approach for improving communication outcomes and functional participation in the least restrictive environment.

How Push-In Therapy Supports Kids in the Classroom

During push-in therapy sessions, therapists might work alongside the classroom teacher during circle time, small group instruction, or a planned classroom activity.

They may embed prompts to support communication skills, use curricular vocabulary, or incorporate fine motor strategies for students with OT needs. This model benefits not just the student with IEP goals, but also their peers, by promoting inclusion and shared learning.

Benefits of Push-In for OT and SLPs

For school-based SLPs and OTs, push-in therapy allows for greater collaboration and real-world application of skills with the educators actually teaching the students each day.

For example, a speech therapist might focus on social communication and articulation during group lessons, while an OT might work on posture and tool use during writing tasks. The therapist can adjust support dynamically, ensuring engaging, functional interventions for age-appropriate children in elementary school classrooms.

Push-In vs Pull-Out: What’s the Difference?

While pull-out therapy can provide focused one-on-one intervention, push-in services offer a unique opportunity for generalization of skills in the natural learning environment.

Studies examining the effects of different service delivery models show that integrating therapy into the classroom supports better long-term communication outcomes and academic participation.

What are Push In therapy services? Wondering what push in occupational therapy looks like for the school-based OT? This resource explains how to implement OT services right in the classroom.

Are push in services as effective as pull out?

Yes! Push in services can be just as effective, or even more so, than pull out. Several studies (Reid et al, Villeneuve) have examined school-based services and the effectiveness of collaborative consultation.

Not only do students make progress at a faster rate, teachers and parents report improved satisfaction as well. Many occupational therapists can probably relate to the experience of having a teacher ask you what “magic” you performed with a student while in a pull out therapy session.

One of the huge benefits of push in therapy, is doing that “magic” in context so other educators can see it happening in real time!

As a school based occupational therapist, it might feel easier or more effective to pull your students out of class into a controlled therapy room to provide intense one on one therapy.

While your session might feel successful, it is not realistic. The difficulties your student is having is within the classroom, not the self contained therapy room.

How do you make the shift from pull out to push in? First, you need the support of your special education team – the parents, administrators, and teachers. Get this support by teaching and showing them what you know, and the benefits of being in the classroom.

It will take time to earn their trust, as you are seen as an intruder in their classroom.

Conducting Observations during Push-In Therapy

The first step is conducting observations of your students during the evaluation process. These observations should take place across school environments where they are engaged in occupations and activities of daily living.

This can include the playground, cafeteria, mainstream class, special education, resource, art, computer, library, or all of the above.

It is important to try to gather information from the teacher and parents to narrow your focus and understand their concerns, before deciding when and how to observe a student.

Depending on the areas of difficulty, you may need to observe transitions for children, work time, managing clothing at arrival/dismissal, the lunch routine in the cafeteria, or their ability to access the playground at recess.

Push-in Services and Goals

Once your evaluation is complete and you are recommending occupational therapy services in the natural environment to the team, how do you get teacher and parent buy-in? This may take time, and more importantly, it will take data collection.

Here is a breakdown of the fine motor skills needed at school to help with your goals setting and data collection.

One of the most important factors in success will be writing goals and objectives that are clear enough for anyone to observe the skills and collect data.

Clear, measurable, observable behaviors and/or skills need to be documented in the IEP or 504. It needs to be measurable, relevant, and doable!

Check out the SMART goals ladder worksheet on the OT Toolbox for information on creating goals.

The OT Toolbox has a great resource available for Occupational Therapy documentation in the school setting.

When educators feel empowered to carry out OT interventions, the success of the students will increase. Additionally, when parents can easily observe skills at home, they will be more supportive of the therapy model.

When the skills being addressed are supported throughout the school day and at home, students have a much greater possibility of generalizing those skills across all environments.

OT Collaboration in the classroom

As you begin to provide push in occupational therapy services for your students, it is important to collaborate with the team.

While the Occupational Therapist provides services in the natural environment teachers and/or paraeducators can observe, ask questions, and get feedback from the therapist. The entire team will be the ones implementing your interventions and collecting data when you are not there.

It is essential they feel confident in executing your interventions.

Ways to build collaboration as a school-based OT:

Set the tone through open and reciprocal communication that all members of the team are valued and equal. Get input from all members of the team including; teachers, paraeducators, parents, and the student.
Provide modeling for staff. Advocate to administrators it is critical for staff involved to observe you working with a student on their occupations.
Provide coaching to the educators implementing your plan. Once you have been able to model for staff, spend time observing and coaching them while they are working with the student. We explain this in great detail in our blog post on executive function coaching.
Make data collection easy and doable. Develop simple, easy to use data collection forms that do not require time and/or effort to complete. It could be as simple as a tally mark or checking a box on a chart.
Check back in with the team frequently to monitor how it’s going and to make changes to the plan if needed.

One final thought… keep the focus on participation and occupation! The team will see results and your students will find success. Don’t be afraid to let your school community see the value occupational therapy adds to your student’s participation in school!

Occupational therapy collaboration in the classroom handout

Free OT Collaboration Handout

Want a free printable handout explaining OT collaboration in the school environment? This is a useful tool for school-based occupational therapy practitioners to explain OT services in the educational model as a collaborative member of the team.

Enter your email address into the form below, and the handout will be delivered to your inbox. Or, if you are an OT Toolbox Member’s Club member, log in and then head to Educational Handouts section of the membership. Not a member? Join today and access hundreds of free resources here on the website without having to enter your email address for each item. Plus gain new resources each month.

Katherine Cook is an occupational therapist with 20 years experience primarily working in schools with students from preschool through Grade 12. Katherine graduated from Boston University in 2001 and completed her Master’s degree and Certificate of Advanced Graduate Study at Tufts University in 2010. Katherine’s school based experience includes working in integrated preschool programs, supporting students in the inclusion setting, as well as program development and providing consultation to students in substantially separate programs. Katherine has a passion for fostering the play skills of children and supporting their occupations in school.

References

Reid, D., Chiu, T. Sinclair, G, Wehrmann, S., Naseer, Z. Outcomes of an occupational therapy school-based consultation service for students with fine motor difficulties. Canadian Journal of Occupational Therapy. 2006; 73: 215-224.

Villeneuve M. A critical examination of school-based occupational therapy collaborative consultation. Canadian Journal of Occupational Therapy. 2009;76(1_suppl):206-218.

Add this handout to our other school resources:

Back to school activities for occupational therapy or the classroom — Back to School Bundle

Back-to-School Motor Skills Kit — Back to School Activity Kit

Sitting Positions on the Floor

September 16, 2025September 8, 2025 by Victoria Wood OTR/L

Image has pictures of different sitting pictures and labels of names of sitting positions.

In this post we will explore the classic crisscross style of sitting, as well as acceptable alternative sitting positions on the floor. We will explore floor sitting for circle time, gym class, and other classroom learning situations. Not only are we learning about alternative sitting positions on the floor, I am hopeful you will become an advocate for the students you serve. Another resource to check out is our post on flexible seating options for the classroom.

When it comes to sitting positions for kids, the classic criss cross applesauce is often the go-to during circle time and classroom activities. But for many children, especially those with sensory needs, motor planning challenges, or postural control difficulties, this position can be uncomfortable or even inaccessible. It’s important for educators, therapists, and caregivers to recognize that alternative sitting positions for circle time are not just acceptable, they’re essential for an inclusive learning environment. Whether a child is a kinesthetic learner or needs additional support to feel regulated, offering flexible floor sitting positions can make a big difference.

We need to think about the spine, the lower back, tight hamstrings…there is a lot more than just sitting up straight and paying attention during circle time or floor time learning. Let’s talk about best positions for sitting on the floor in the classroom…

children sitting on the floor in different positions, text reads "sitting positions"

There are many versions of sitting positions on the floor and depending on the sensory motor considerations of each child, these floor sitting positions facilitate learning.

We made this image of types of sitting positions but this visual is just the beginning. There are many other sitting positions that can be used for comfort, function, and sustained positioning on the floor.

Sitting positions on the floor

At least ten times a day I hear a teacher say, “come on in and sit crisscross applesauce.” This type of cross-legged sitting used to be called “Indian style” or “Tailor sit” before that was deemed insensitive. I cringe when I hear this, not only because of the silly name “crisscross applesauce, but because this sitting position on the floor should not be a universal request, or the only choice students have for seating.

In the preschool setting, we usually have a circle time or floor activities where sitting on the floor is part of the school day. For kids that struggle with sensory motor skills, this can be a real challenge.

Read our blog post about Crossing Midline Activities for Preschoolers for a developmental explanation of this age range and how we can support young kids in functional midline tasks like sitting on the floor for story time or for preschool circle time.

One way to support these sitting positions is by using a ball pit as a therapy tool.

Types of SITTING POSTIONS ON THE FLOOR

There are several different types of sitting positions on the floor that are seen in classrooms. There are pros and cons to all of them.

Teachers may tell you that sitting on the floor in one specific way (criss cross applesauce) creates uniformity and structure. If everyone is sitting quietly in the same position, there is less distraction in the group. Children benefit from rules and regulations.

This is a great answer, however, not all children can comfortably sit in this position, thus causing more distraction as they struggle to find a comfortable seating posture or retain crisscross applesauce.

You might see a version of these various sitting postures during circle time activities, during play, or during various centers. Let’s go over each type of sitting position.

Cross-legged position

Since “crisscross applesauce” or cross-legged position is the most often used, let us start there.

This cross-legged position involves both knees bent, crossing feet at the ankle, with both ankles on the floor.

There is a rhyme that accompanies the crisscross applesauce phrase:

“Crisscross, applesauce

Hands on lap, gingersnap

Sit up straight, chocolate cake

On your rear, root beer

Zip your lip, cool whip.

Shhh, now you are ready to listen!”

Pros of Criss Cross Applesauce Sitting Position: the body is in a compact form with legs and arms “inside the vehicle.” It is a universal sitting position, known or taught to most children. If everyone is in the same sitting positions on the floor, there tends to be uniformity and less distracting chaos.

Cons of Criss Cross Applesauce Sitting Position: it is uncomfortable for many people. It can be difficult to stay in the same position for long periods of time, due to fatigue, discomfort, sensory challenges, and inattentiveness. There is not a wide base of support with the knees off the ground and arms tucked inside the lap. Some students need more support.

Alternative Sitting Positions for Circle Time

Not every child can or should be expected to sit the same way during circle time. Offering alternative sitting positions for circle time can help meet the needs of all learners while promoting engagement and attention.

Some children may benefit from long sitting (legs extended), side sitting, kneeling, or even tall kneeling to stay regulated and focused. These options help reduce discomfort and allow children to choose the position that works best for their bodies. Encouraging choice also fosters autonomy and supports self-awareness during group learning activities.

Criss Cross Applesauce Alternatives

Although “criss cross applesauce” is a common classroom cue, it’s not a one-size-fits-all solution. Kids with sensory processing differences may find the posture overstimulating or too restrictive.

Others may lack the core strength or flexibility to maintain this position for any length of time. Instead, allow children to use alternatives like side sitting, tailor sitting (with legs loosely crossed), or even lying prone on their stomachs with elbows propped. These criss cross applesauce alternatives still allow for group participation without forcing an uncomfortable posture.

Alternative Sitting Positions for Kids

1. Tailor Sitting

Similar to criss cross applesauce but with the legs more loosely crossed and knees wider apart. Easier for kids with tight hips or core weakness.

2. Side Sitting

Both legs are bent and tucked to one side of the body. One hip is on the floor, and the child may lean slightly to that side. Offers a more relaxed position and can help with balance.

3. Long Sitting

Legs are extended straight out in front of the body while sitting upright. Great for stretching the hamstrings and promoting postural awareness.

4. W-Sitting

Knees are bent, and legs are positioned outside the hips in a “W” shape. This position is common in young children but may place stress on the hips and joints, so it should be used with caution or avoided if advised by an OT.

5. Kneeling

The child sits on their knees, with legs folded underneath and buttocks resting on their heels. Can offer more postural support than cross-legged positions.

6. Tall Kneeling

The child kneels with hips extended and buttocks lifted off the heels, creating a straight line from the knees to the shoulders. Engages core muscles and can provide proprioceptive input.

7. Half Kneeling

One knee is on the floor while the other foot is flat in front, creating a “lunge” shape. This position can help with balance and muscle strengthening.

8. Prone (Tummy Time) Position

The child lies on their stomach with elbows bent and propped under the shoulders, supporting the upper body. Great for building upper body strength and providing calming input.

9. Squat Sitting

Child sits low to the ground in a squat with feet flat on the floor and knees bent. This position supports proprioception and is often natural for younger children.

10. Standing or Wall Sitting

Child stands or leans against a wall during group time. Helpful for those who need movement or find floor sitting uncomfortable.

11. Sitting on a Cushion or Wedge

Child sits on a small cushion, wobble seat, or wedge to provide more comfort and/or movement while staying seated.

12. Sitting on a Therapy Ball or Active Stool

Although not a floor option, this is ideal for seated classroom activities at a desk. Allows for movement and builds core strength.

Floor Sitting Positions

There are many types of floor sitting positions that support different needs. In addition to tailor and side sitting, children may prefer w-sitting, sitting on heels, or using a floor cushion or wedge for added comfort.

A therapy ball, wobble cushion, or floor rocker seat can also be helpful for children who need a bit of movement while seated. Having a variety of options available helps meet the needs of kinesthetic learners, children with core weakness, or those who benefit from sensory input during learning.

Think About Postural Support

Proper postural support is key when it comes to sitting for extended periods. Without support, children may slump, fidget excessively, or disengage altogether. Supporting posture can include simple strategies like providing a firm seating surface, allowing children to lean against a wall, or placing a visual cue on the floor to guide leg positioning.

For some children, adding external tools like a small footrest, cushion, or low stool can help stabilize their core and promote more upright posture. These supports can make floor sitting positions more comfortable and sustainable for kids with motor or sensory needs.

Proprioception and Sitting

The proprioceptive system plays a huge role in helping children understand where their bodies are in space, especially during seated tasks. Proprioception and body awareness are closely connected and sometimes, kids just don’t realize the way they are sitting. For kids with sensory processing challenges, sitting still can be hard without additional proprioceptive input.

Offering heavy work activities before circle time, like animal walks or wall pushes, can help “wake up” the body and prepare it for stillness. Seating tools like weighted lap pads, firm cushions, or kneeling positions can also provide that needed input during sitting. By tapping into the proprioceptive system, we support regulation and improve the child’s ability to focus during group activities.

About W-Sitting

Did you ever try to W sit? Do you know what a W sitting position looks like?

I know many of you are cringing just thinking about the dreaded “w-sit.” It is a popular sitting position on the floor among young children, especially those with low strength and/or muscle tone.

In this position the legs literally form the letter W on the floor. When a child sits in a W sit position, their hips are internally rotated, while the knees are bent facing the midline, and the feet are positioned away from each side of the body.

Pros of the W Sit Position: offers great stability while playing, due to the wide base of support. It is very comfortable for long periods of time, for those flexible enough to effectively achieve this position.

Cons of the W Sit Position: w-sitting is terrible for the knees and hips. They are not meant to be in this position long periods of time. This wide based sitting position on the floor takes up a lot of space, especially when there are several children seated close to each other. The hands do not naturally have a “bunny hole” to go into to keep them busy while sitting.

Prolonged w sitting can be a sign of developmental difficulties. For others, w sitting offers a wider base of support which offers more proximal stability so the individual can use the arms and hands with refined dexterity. For the individual who struggles with core strength and stability, and sitting balance, a W sitting position can help with attention and focus.

Children’s Hospital of Los Angeles has a different opinion. Their research claims that w-sitting does not cause hip problems, and most often children, by the age of eight, grow out of this habit on their own.

Dr. Goldstein explains, some children have more inward twist in their thigh bones than other children, so they can easily bring their knees in and feet out. In fact, for some children, sitting with their legs crossed in front of them may be uncomfortable because their thigh bones have less twist in the forward position than the inward position.

Note: some children need this wide base in order to sit for several minutes. Without this wide base, they are unable to use the rest of their body to play with toys and engage. As they build core strength, students may be able to transition to a cross-legged pose.

Long Legged Sitting position on the floor

In this sitting posture, the hips are generally at 90 degrees with the legs extended out in front. The width of the legs, or how far apart the feet are, may vary depending on the type of support needed, and tightness in the back and hip structures.

There are times when this is the only position a person can achieve on the floor due to tightness in the hips or legs.

Long legged sitting is a typical stage of development in children as they gain core strength, but is integrated into higher level sitting positions.

Pros of the Long Legged Sitting Position: it can offer a larger base of support than cross-legged sitting. Long sitting may be comfortable. This position may provide enough support to free the upper body to move and engage.

Cons of of the Long Legged Sitting Position: this sitting pose takes up a lot of room. If 30 children in the class sit like this, they will run out of carpet space. Long sitting can lead to posterior pelvic tilt, or slouching due to the stretch of the muscles, although some people have remarkable posture in this position. It can lead to increased tightness as the student bends their knees or abducts their legs to get comfortable, thus making it difficult to straighten their legs later. It is hard to reach forward to play with items while in this position. Sometimes this position is less stable as the child can easily tip over to the side or lean back too far.

As with w-sit, some children can only sit in this position due to disability, tightness/weakness of muscles, or instability. In my opinion it is better to allow a person to sit this way, if sitting in other positions impairs their function. The end goal is function.

An alternate seating option related to the long leg sitting posture is:

Bent Long Sit- The legs are both forward and the knees are bent. In yoga, this might be called a mountain sitting posture
Bent Legs Holding Knees- This position has the individual sitting with their legs in front of them with the knees bent. They may lean forward and hug the knees.

Mermaid Sitting Position

An alternative to the long leg sitting position is the mermaid sitting style, where the knees are both positioned to the side and back, in the same direction. This positioning offers greater base of support.

Short kneel Sitting Position

In the short kneel sitting position on the floor, the learner is sitting on their feet with their legs tucked under them. This position can offer not only comfort, but needed sensory input.

Short kneel is a developmental milestone that leads to pulling up to stand.

Pros of a short kneel sitting position on the floor: this is a compact position with the legs tucked underneath. It can be comfortable for long periods of time. Short kneel provides proprioceptive or deep pressure input while sitting, and often helps with self-regulation needed to attend to a lesson.

Cons of a short kneel sitting position on the floor: children are sitting up higher in this position, making it difficult for those behind them to see. It can cause pain in the knees.

An alternative sitting position to the kneel sit is:

Open knees kneel sit– the individual sits on their legs with their feet tucked under their bottom, but the knees are spread apart. This option offers greater base of support and stability through the core.

Drawings of deferent sitting positions showing posture and deferent positioning of legs and arms in sitting postures.

Image of different sitting positions on the floor from the World Distribution of Postural Habits, published in American Anthropologist in 1955.

These are the most common alternate sitting positions on the floor we see in schools. There is also side sit, lotus, squat, tall kneel, and more. This drawing illustrates over 35 different sitting positions on the floor!

How to offer alternative seating positioning on the floor

Teach children to stay in their personal space without touching others. You can do this by using a carpet with colored squares, taping squares to the floor, using rug samples, or mini swimming pools for each student.
Teach children that they cannot block another student’s vision of the circle time activity.
Unobtrusively put out the new possible seating options (cushions, fidget toys, lap pads, etc.) during free play so they are not so new and exciting that they take children’s attention away from the circle time activity.
Teachers can offer chairs in the back of the circle time area. Cube chairs, stadium seats, carboard boxes, wiggle cushions, or other alternatives. Consider DIY seating options.
How about weighted lap pads for children who cannot stay in one spot? They can be as simple as a sock weighted with rice, or sitting with a heavy backpack.
What about those children who seem to be in constant motion? Maybe they can have a squishy ball or fidget toy. This opens another can of worms. Fidgets need to be tools, not toys, and taught to be used in a non-distracting manner. Here are some quiet fidgets you can try. This article, The Ultimate Guide to Fidgets on the OT Toolbox provides some great ideas. Note that fidgets of any type should be used with caution and based on the individual skills and level of each child. It’s up to the educator/therapist/etc. working with the child to select appropriate and safe fidget tools for the child. Also note that The OT Toolbox is not liable for any fidget or recommendation used with children.
Maybe children who do not want to come to circle time can do a quiet activity in another area of the room. While this does not seem like the right idea, it can allow the other 24 children to have a successful lesson. Then work on problem solving getting this student involved in circle time.
Respect children’s attention span and keep circle time to 10 minutes.
Plan your circle time to include a welcoming time, an activity focus, and a closing tradition.
Tell children daily what is going to happen at circle time, first, second, third, so they know what to expect.

Neurodiversity and sitting positions on the floor

Above we illustrated some good reasons for children to all sit cross-legged on the floor. If all the students in today’s classrooms were neurotypical, with average tone, muscle strength, attention, and self-regulation, teachers might be able to expect all their students to sit in a uniform fashion.

However, classes are full of neurodivergent students who do not fit into the same box as typical peers.

Focus in classrooms needs to be on learning, not sitting positions on the floor. In my opinion, as an occupational therapist, we need to offer students more options in classrooms to enhance their learning potential.

Some teachers are getting on board with this, while others are resistant to change. If you are a therapist in the schools, a big part of your role is education. Use your knowledge to explain why you are requesting changes to the classroom.

FAQ: Common Questions About Sitting on the Floor

As pediatric occupational therapists, we get a lot of questions where educators, admin, and other service professionals want to “pick your brain” about how to support students. Here are some common questions we get about sitting positions and attention, learning, etc.

Q: Why can’t some kids sit criss cross applesauce?

Some children have difficulty sitting criss cross applesauce due to challenges with core strength, hip flexibility, motor planning, or sensory processing. This position requires balance, postural control, and body awareness. These are gross motor skills that may be delayed or underdeveloped in some kids. For others, the position can feel uncomfortable or even painful, making it hard to focus during circle time.

All of this is to say that kids sitting in a variety of positions is OK!

Students with sensory needs may benefit from sitting options that offer movement, proprioceptive input, or a more stable base. Great choices include:

Sitting on a wobble cushion or therapy ball
Kneeling or tall kneeling
Side sitting or tailor sitting
Lying on the stomach (prone position) with elbows propped
Providing sensory-friendly seating helps these students regulate their bodies and better participate in classroom activities.

Q: What is the best classroom seating for kinesthetic learners?

Kinesthetic learners often learn best through movement and physical engagement. Ideal seating options for them include:

Floor cushions or rocker seats
Standing desks
Therapy balls or active sitting stools
Opportunities to switch positions frequently
Incorporating movement breaks and active learning also supports their learning style throughout the day.

Q: How can I support kids who struggle with sitting?

Start by observing what makes sitting difficult. Is it posture, attention, sensory discomfort, or restlessness? Support strategies may include:

Offering alternative seating options
Allowing frequent position changes
Using visual cues or carpet spots
Adding movement breaks before seated tasks
Collaborate with an occupational therapist if sitting challenges are persistent or impacting learning.

Q: What is flexible floor seating for preschoolers?

Flexible floor seating means offering a variety of sitting positions that support a preschooler’s developing body and sensory needs. Examples include:

Criss cross, side sitting, or kneeling
Long sitting (legs straight out)
Cushions, small mats, or wedges
This approach gives young learners the ability to choose positions that help them feel comfortable, regulated, and ready to learn during group time or quiet play.

Occupational Therapy Tips for Floor Sitting

Here are some tips for supporting learning when sitting on the floor. Start with some posture exercises to get started. Another tip is to take a look at retained reflexes. Then other tips include:

Choose the Right Surface for Support

The type of surface makes a big difference in floor sitting comfort. A firm but padded mat, folded blanket, or even a yoga block under the hips can reduce joint strain and improve spinal alignment. For kids who struggle with core strength or postural stability, sitting at the edge of a folded blanket slightly elevates the hips and helps maintain a more upright position.

Encourage Proper Posture and Spinal Alignment

Maintaining a straight spine and proper spinal alignment is important for reducing lower back pain, neck pain, and overall strain during floor sitting. Supportive tools, along with attention to posture, can help reduce fatigue and prevent discomfort. Encourage back support (e.g., sitting against a wall) when needed.

Gentle stretching or tension release techniques can make sitting feel more relaxing and functional.

Teach Floor Sitting Variations That Reduce Pressure

For children who can’t sit criss cross applesauce, introduce alternative floor positions like the straddle, bent sit, or even a wider stance with feet hip-width apart. Kneeling variations may involve knees shoulder-width with the tops of the feet flat against the floor. For more advanced postural work (or when pairing with physical therapy), positions involving a front leg bent and back knee extended, like a modified lunge, can build awareness and mobility. Be mindful of weight distribution across wrists, front knee, and opposite knee if a child is using hands for support.

Balance Duration and Movement for Better Function

Sitting on the floor should be done in short periods, especially for kids working on human performance goals like blood flow, core strength, or lower body muscle development. Incorporating movement breaks, seated stretching, or switching positions often can support bowel movement function, increase circulation, and reduce stiffness. OT practitioners often integrate short seated tasks with embedded movement to encourage regulation and engagement.

Focus on body awareness. This is huge. A lot of positioning needs comes back to strength, coordination, motor planning, body awareness, visual motor skills, and more. All of these areas contribute to functional performance.

references on Sitting Positions on the Floor

Hewes, Gordon W. “World Distribution of Certain Postural Habits.” American Anthropologist, vol. 57, no. 2, 1955, pp. 231–44. JSTOR, http://www.jstor.org/stable/666393. Accessed 26 Sept. 2023.

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