toddler

Early Intervention for Sensory Differences

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sensory seekers and intervention for early intervention in occupational therapy

Our sensory system is very complicated. A lot of times when we hear about sensory, we think about our 5 senses (taste, touch, sight, smell and hearing.) This blog will take us into a deep dive of early intervention for sensory differences and the definition of different sensory processing areas. Early Intervention services provide supports for children birth through age three who demonstrate developmental delays.

These delays could be caused by a variety of reasons, from autism, chromosome abnormalities, drug exposure, prematurity, motor impairments, language delays and more. 

Early intervention for sensory differences

Early Intervention for Sensory Differences

One of the areas that is always assessed when determining if a child is eligible for Early Intervention services is the area of sensory processing. These areas include Low Registration, Sensation Seeking, Sensation Sensitivity, and Sensation Avoidance. Also addressed are the areas of Sensory and behavioral including general, auditory, visual, touch, movement, oral and behavioral differences.

We will explore these areas in more detail throughout this blog post. Sensory diets are one of the most common and impactful ways to support children with sensory differences.

This article describes sensory diets as “A sensory diet is a set of activities that make up a sensory strategy and are appropriate for an individual’s needs.  These are specific and individualized activities that are scheduled into a child’s day and are used to assist with regulation of activity levels, attention, and adaptive responses.  Sensory diet activities are prescribed based on the individual’s specific sensory needs.”

There are four quadrants in a sensory profile. This visual clearly defines the similarities and differences between seeking, sensitivity, registration and avoidance.

The infant/toddler sensory profile is a common assessment used to determine the needs of a child in the following areas If a child is over-responsive to sensory input, they would fall in the sensory seek or slow to register sensory input sections. If a child is under responsive to sensory input, they would fall in the sensory sensitive or sensory avoider sections. 

What are sensory differences and neurodiversity? This article explains.

What are sensory differences?

These areas of sensory diversity make up the term sensory differences. Beyond the four quadrants, however, there are other sensory differences to consider. These are described below.

All of these sensory differences described are part of the neurodiversity of human life. We all are different when it comes to sensory, and we are all sensory. Just like the diversity of physical attributes, personal preferences, characteristics, sensory differences are just one more difference that makes us who we are.

Sensory seekers

Sensory Seeking

This area determines if a child seeks out sensory input. If a child is scored higher than most in this area, you may see them move around more, look at items that spin (such as fans or toys with wheels) be attracted to fast paced and brightly colored television shows.

Sensory Seeking Patterns

Children with sensory seeking patterns often appear highly active, impulsive, or constantly in motion. These children are not simply “busy.” Their nervous systems may require stronger or more frequent sensory input to feel regulated and organized. As the quote reminds us, “Some children need more input to feel organized.” When sensory input is insufficient, children may increase their movement or intensity to meet that internal need. In early intervention, the goal is not to suppress movement but to structure it in ways that promote regulation and participation.

A child who seeks sensory input may:

  • Move constantly or have difficulty sitting still
  • Jump, crash, spin, or climb frequently
  • Touch objects and people often
  • Use excessive force during play or writing

Early intervention may include:

  • Planned heavy work activities (carrying, pushing, pulling)
  • Structured movement breaks
  • Animal walks or obstacle courses
  • Teaching body awareness and graded force

Here are some wonderful home ideas for children who are sensory seekers.

Sensory Sensitivity

This area determines a child’s ability to notice different senses. If a child scores higher than most in this area, you may see a child always needing a routine to stay calm, startle to certain sounds, become upset during routine hygiene activities (such as getting hair brushed or nails trimmed) and significant preferences on types and textures of foods.

Here are some ways to support children in a controlled way, who show needs in the sensitivity area.

Sensory Registration

This area determines how a child responds to sensory input from others or their environment. This article by the pediatric development center explains how important registration is for a child’s functioning and learning.

It describes registration as: “Sensory registration is the process by which children respond or attend to sensory input in their environments.  The nervous system must first notice the sensory information, once registered the memory compares it to things they have heard or seen, and thus gives new information meaning.  Children who fail to respond or have delayed responses to sensory information have diminished sensory registration.  Diminished sensory registration is often associated with one or two weaker sensory systems, such as the auditory or vestibular system.  Without sensory registration, no other learning can take place.”

If a child scores higher than most in this area, you may see a child miss sensory input more than others do. A child in this section may miss eye contact, pay attention to only specific tones, and ignore most sounds. These children are harder to engage or seem uninterested in activities. They may need tactile, auditory and visual cues to initiate engagement in conversation or an activity.

Low Sensory Registration

Children with low sensory registration may not consistently notice or respond to sensory input in their environment. They are not ignoring directions; they may not be fully perceiving them. As the quote states, “Sometimes the world needs to be turned up.” These children often benefit from clearer, stronger, or repeated input to support engagement and responsiveness. Early intervention focuses on increasing the salience of sensory information to improve participation.

A child with low registration may:

  • Not respond when their name is called
  • Seem unaware of food or dirt on hands and face
  • Appear slow to respond to instructions
  • Seem lethargic or difficult to engage

Here are some ways to support children with low registration:

Early intervention may include:

  • Gaining eye contact before giving directions
  • Pairing verbal cues with visual supports
  • Increasing movement before seated learning
  • Using clear contrast and structured materials

Sensory Avoidance

This area determines how a child’s need to control the amount and type of sensations at any given time. If a child scores higher than most in this area, you may see a child resist playing with other children due to overwhelm, resist being cuddled when it’s not on their terms, frequently become upset if their hands are messy, have a hard time calming down in new settings and isn’t interested in trying new foods.

Sensory Avoiding Patterns

Children with sensory avoiding patterns may experience ordinary sensory input as overwhelming or unpredictable. Avoidance behaviors are protective responses, not oppositional behaviors. As reflected in the quote, “What feels small to us can feel overwhelming to them.” Their nervous systems may quickly shift into fight, flight, or freeze in response to certain sounds, textures, or busy environments. Early intervention focuses on creating safety and predictability while gradually increasing tolerance.

A child who avoids sensory input may:

  • Cover ears in noisy environments
  • Refuse messy play or certain foods
  • Resist specific clothing textures
  • Withdraw in crowded or stimulating settings

Early intervention may include:

  • Environmental modifications to reduce sensory load
  • Predictable routines and visual schedules
  • Gradual, supported exposure to new sensory experiences
  • Co-regulation and emotional support

Here are some tips on how to support an avoider.

General Processing

General Processing items measure the child’s responses related to routines and schedules. This could include daily schedules, routine schedules or task related routines including how children respond to questions, others actions, busy situations, sleeping routines, eating patterns and hygiene needs, daily transitions and other schedule related activities.

These first/then visual boards are a wonderful tool in supporting routines and schedules.

Tactile and Auditory Sensitivities

Tactile and auditory sensitivities are common in early childhood and can significantly impact emotional regulation and participation. The nervous system may interpret certain textures or sounds as threatening rather than neutral. As emphasized in the quote, “Regulation begins with feeling safe.” When a child feels safe, learning and social engagement become more accessible. Early intervention prioritizes environmental adjustments, gradual desensitization, and parent education to support comfort and resilience.

A child with tactile or auditory sensitivities may:

  • Refuse specific clothing fabrics
  • Gag or refuse foods due to texture
  • Cover ears in loud environments
  • Cry or startle easily with sudden sounds

Early intervention may include:

  • Providing softer clothing options
  • Using noise-reducing headphones when appropriate
  • Gradual introduction to new textures
  • Teaching calming and coping strategies

Auditory Sensitivity

This area addresses how children respond to things they hear. Auditory input includes responding to their name,  how easily it is for someone to get their attention and how distracted they become in noisy settings. The brain processes the sounds in our environment and according to this article, sensitivity to sound could be a reaction to a part of our brain that pays more attention to sounds then it needs to. One article explains it this way:

When there is no medical reason to explain the auditory sensitivity, researchers think that the brain is not processing sounds adequately. Researchers suggest that the part of the brain that receives and filters noise and sound, the amygdala, is working differently.  The amygdala decides on how important noises are.  It decides and which sounds we should attend to and which ones to ignore. When someone experiences sensitivity to sounds, it is thought the amygdala pays more attention to sounds than it needs to.

Visual Sensitivity

This area addresses how children respond to things they see, including bright objects, such as lights and toys. It describes how they respond to reflections in mirrors and their responses to objects that spin or move suddenly. According to this article our brains interpret the light we see through our eyes, and:

“The visual system uses light to detect information through our eyes and then interprets or makes sense of that information in the brain. It works closely with our vestibular and auditory systems to help us safely navigate our environment by orienting us to where we are in relation to other objects. The ability to cognitively process information we take in through our eyes can be broken down into several categories, called visual perceptual skills. Those with trouble in one area of visual perception may present with strong skills in another area, meaning that deficits in processing of visual information can take on many forms.”

Tactile/Touch Sensitivity

This area addresses how children respond items that touch their skin. This includes bath/water play, getting their nails trimmed and hair brushed, touching different sensory rich objects, being messy and receiving hugs. When children have a tactile sensitivity, their skin reactors are feeling the object more intensely. According to this article:

The tactile system, or sense of touch, refers to the information we receive though the receptors in our skin. It alerts us to pain and temperature and helps us discriminate the properties of things we come in contact with, i.e. texture, shape, size, and weight. From very early on in development this sense plays a crucial role in helping us gain awareness of our own bodies and understand everything we come in contact with. And how frustrating it must be to learn new skills when you can’t adequately feel the objects you’re using!”

Movement Seeker

This area describes how children move within their environment, including if they enjoy movement activities, seem accident prone or clumsy, seek out spinning and/or preferring to walking on their tip toes. Movement is how our bodies know where we are in space and how we respond to a variety of movement activities. This article explains movement seekers as “someone who has a high threshold for vestibular input. The vestibular system is housed in our inner ear, and is responsible for sending messages to our brain about the position and movement of our head. The vestibular system is activated anytime our head is tilted, upside-down, inverted, if we spin, if we run fast or run slow, when we’re on a swing or going down a slide.

We need vestibular activation and an efficient vestibular processing system in order to maintain an upright position, feel balanced, have a full sense of our body in space and focus. Some people have low thresholds, in which they perceive vestibular activation at much higher rates (e.g. hypersensitive to movement). Others have high thresholds, which means that they need more intense, more frequent and longer duration of movement in order to register it and activate their vestibular system.”

Oral

This are addresses how children respond to new foods and different textures, if they tend to overstuff their mouths, how they control chewing/swallowing foods and liquids and if they tolerate their teeth being brushed. Our oral system is based on how our sensory receptors in our mouth recognize what is in our mouth. Some people have increased sensitivities for foods while others have decreased sensitivities to food. There are differences and optional interventions explained in this article:

“We have sensory receptors in our mouths that allow us to recognize information about temperature, texture (e.g. smooth like yogurt, hard like chips/pretzels, or a mixture of textures like cereal with milk), and taste (e.g. sweet, salty, bitter, sour). They may be over responsive or have increased sensitivity to oral input, causing them to be resistant to oral sensory experiences like trying new foods or brushing their teeth.

Other children may have decreased sensitivity to oral sensory input and therefore seek more oral input in order to help them organize their behavior and pay attention. Our brains receive further proprioceptive input from the joint of the jaw as we bite and chew on foods with different types of resistance (e.g. a crunchy carrot or a chewy sweet/gum).  Oral sensory processing also contributes to the way we move our mouths, control our saliva, and produce sounds for clear speech.”  

Behavioral Differences

This area describes children’s behaviors such as how frequently they have meltdowns, if they are clingy, how hard it is to redirect them, if they are upset in new surrounds and how hard it is to help them calm down.  Teaching children how to calm down using a variety of sensory input, will benefit every child. Soothing Sammy provides opportunity for a child to create their own behavior support tool that is tailored to their specific needs. Weather they respond better to auditory, visual, tactile or others, Sammy the Golden Dog can make redirection to a calm down corner a positive experience for the child and the adult.

Creating a sensory diet is one of the most important ways to support children with any type of sensory difference. These sensory diet cards is a must have resource if you are working with or have a child with a sensory need. 

If you are concerned about your child, you can contact an Early Intervention provider to complete an evaluation from the day they are born all the way until they turn three years old.

Early intervention occupational therapy services support children in all areas of sensory needs, and can help caregivers create sensory diets that will help children in a variety of situations. Visual, tactile, auditory, oral and movement interventions that are supported in a controlled environment, can help every child learn how to adapt and respond to different situations and environments.

Jeana Kinne is a veteran preschool teacher and director. She has over 20 years of experience in the Early Childhood Education field. Her Bachelors Degree is in Child Development and her Masters Degree is in Early Childhood Education. She has spent over 10 years as a coach, working with Parents and Preschool Teachers, and another 10 years working with infants and toddlers with special needs. She is also the author of the “Sammy the Golden Dog” series, teaching children important skills through play.

Play Tunnel Activities

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If you are an occupational therapist like me, then you know the power of using play tunnels in an occupational therapy obstacle course. The heavy work input provided by crawling through a tunnel is unmatched, especially when we use it as a warm up to fine motor tasks or functional activities.

Let me explain…

How Play Tunnels Help Kids

Play tunnels are one of the best tools for therapy as you can work on so many skills if you just put a little creativity into it. Tunnel activities simply invite kiddo fun and engagement while working on very important skill development across a spectrum of areas. You can use fabric tunnels or nylon, pop-up tunnels depending on the skills you want to address with tunnel play. With a little imagination you can build your own DIY tunnels too!

Tunnel for Occupational Therapy

There is a reason why OTs love using tunnels in occupational therapy sessions!

Keep reading to get some play tunnel ideas using different materials. For home-based therapists, DIY tunnels are a great tool for families to use in the home environment providing an opportunity for a fun and easy to implement home-based program. Some of these tunnel activities for babies and tunnel activities for toddlers can be used to address specific needs through play.

Play tunnel activities using a sensory tunnel
Tunnel activity for sensory input

Play Tunnels and Sensory

During tunnel play, not only do therapists want to work on the obvious gross motor skills such as crawling, bilateral coordination, motor planning, core strength. Then there is the neck/upper extremity strength, lower body strength, and body awareness.

They also like to use tunnels for sensory needs such as vestibular and proprioceptive input. In the simplest of terms, the vestibular sense is known as the movement sense telling us where our body is in space, while the proprioceptive sense is known as the deep pressure sense telling us the direction, speed, and extent of our body movement in space.

These senses are important to help a child develop balance, body awareness, understand the position of their body in space as well as knowing how much speed and pressure their bodies are exerting when completing an activity or moving within their environment.

Adding a play tunnel into sensory diet activities to meet a variety of needs. It’s an easy way to encourage sensory input in the school environment, home, or clinic.

Tunnel activities using pool noodles

So, you may be asking, how can children gather vestibular input from tunnel time activities? You can have children roll within the tunnel, perform various body movements such as forward and backward crawling, balancing on all fours while simply crawling through the tunnel, slither on their backs, or have them crawl in the tunnel placed on top of cushions and pillows.

These activities are great for supporting the development of crawling in babies and toddlers, especially because we end up seeing challenges down the road for kids that skip crawling. Here’s what an OT has to say about types of crawling.

Fabric tunnel for proprioceptive input.

Proprioceptive input can be obtained while the child is bearing weight on the upper and lower extremities during crawling providing input to the joints and muscles. They can push objects through the tunnel such as large therapy balls or large pillows, army crawl through the tunnel, and shaking the tunnel while child is inside can provide valuable proprioceptive input.

By using a play tunnel to address proprioception to improve body awareness, the proprioceptive sense allows us to position our bodies just so in order to enable our hands, eyes, ears, and other parts to perform actions or jobs at any given moment. Proprioception activities help with body awareness. Using a fabric tunnel that is snug against the body can provide good input which can also have a calming effect for some children.

DIY tunnel activity using cardboard boxes
Use these play tunnel activities to improve motor skills and sensory activities.

Play tunnel activities

When using a tunnel, you can work on other skills that address multiple areas for children. Try some of these fun tunnel time activities:

  1. Play Connect Four with pieces on one
    end and the game played on the other end.
  2. Assemble puzzles with pieces on one
    end and then transported through the tunnel to the other end.
  3. Clothespins attached on end to transport
    and place on the other end. You can use clothespins with letters to spell words.
  4. Push a large ball or pillow through
    the tunnel.
  5. Crawl backwards from one end to the
    other.
  6. Slither through the tunnel (rocking
    body left and right) to get from one end to the other.
  7. Scoot through the tunnel using hands
    and feet or even crab walk through the tunnel.
  8. Recall letters, shapes, or words from
    one end and highlight on paper at the other end.
  9. Recall a series of steps to complete
    a task at the other end.
  10. Blow a cotton ball or pom-pom ball through the tunnel. Kids
    love this to see how many they can blow in a timed fashion.
  11. With pennies on one end, have child transport them to the
    other end to insert into a bank. You can even give them the pennies at end of
    the session if you want.
  12. Push a car through the tunnel to drive it and park it at the
    other end.
  13. Build a Lego structure by obtaining blocks at one end of the
    tunnel and transporting to the other end to build.
  14. Intermittently crawl through the tunnel and lie within one
    end to work on a drawing or handwriting activity. This is just a different and
    motivating way to encourage handwriting practice.
  15. Crawl over pillows or cushions placed inside or outside of
    the tunnel.
  16. Use a flashlight and crawl through the tunnel gathering specific
    beads that have been placed inside to string at the other end of the tunnel. You
    could work on spelling words with letter beads or simply just string regular
    beads.
  17. Place Mat Man body pieces at one end and have child obtain
    pieces per verbal directive and then crawl through the tunnel to build at the
    other end.

tunnel activities for preschoolers

Ok, so for the preschool age range, let’s come up with tunnel activities for preschoolers that support development at this stage.

  • Crawl through a tunnel while holding a puzzle piece like a letter from an alphabet puzzle. Then they can place the puzzle piece in the puzzle when they get through the tunnel.
  • Set up an obstacle course with tunnels to crawl through
  • Play “follow the leader” through the tunnel. This is great for direction following and body awareness for preschoolers.
  • Crawl through a tunnel to match objects or sort colors. I like using blocks to sort into baskets.
  • Pretend the tunnel is a cave or secret hideout during imaginative play.

tunnel activity for toddlers

Next up are some of my favorite tunnel activities for toddlers. These also help to support development at the toddler stage.

  • Crawl through a fabric or pop-up tunnel
  • Push a toy car or ball through a tunnel
  • Play peek-a-boo at each end of the tunnel
  • Roll a ball back and forth through the tunnel
  • Crawl to retrieve objects placed inside the tunnel. I like to pair this idea with our ball in a muffin tin activity.
DIY tunnel activity

Next, I want to share some DIY play tunnel ideas because as occupational therapists, we are always coming up with fun play ideas using everyday materials!

DIY Play TUnnel Ideas

So, as mentioned previously, what if you don’t have a tunnel or you want to create one within a home for developing a home-based program? Well, make one! How can you do this? Read on for a few fun ideas.

  1. Create a tunnel by crawling under
    tables or chairs.
  2. Create a tunnel in the hallway with
    use of pool noodles. Bend them over in an arch to fit or simply cut them down
    to size to slide directly between the walls.
  3. Use large foam connecting mats and assemble
    a tunnel.
  4. Use tape or yarn and string to
    alternating walls down a hallway to crawl under.
  5. Use sturdy pieces of foam board
    positioned or connected together to make a tunnel.
  6. Use an elongated cardboard box. Sometimes
    you can get large boxes at an appliance, hardware, or retail store.
  7. Stretch a sheet or blanket over
    furniture and crawl.
  8. Simply place a sheet or blanket on
    the floor and have child crawl under it (a heavier blanket works well).
  9. Place a therapy mat inside a series
    of hula hoops.
  10. Use PVC pipe to build a tunnel. Add sensory items to the PVC
    frame to create a fun sensory element to the crawling experience. One such
    tunnel was built by my wonderful fieldwork student, Huldah Queen, COTA/L in
    2016.  See the picture below.
  11. Sew a fabric tunnel (if you have that skill).
  12. Use pop up clothes hampers connected together after cutting
    out the bottoms.
  13. Simulate tunnel crawling with simple animal walks or moves.

Tunnel activities can facilitate child engagement while providing an optimal skill development setting.  Tunnel time can address gross motor and sensory needs while also incorporating other activities making tunnel time a skill building powerhouse tool. Incorporate fun fine motor and visual motor activities to make tunnel time a “want to do” activity every time!

Regina Allen

Regina Parsons-Allen is a school-based certified occupational therapy assistant. She has a pediatrics practice area of emphasis from the NBCOT. She graduated from the OTA program at Caldwell Community College and Technical Institute in Hudson, North Carolina with an A.A.S degree in occupational therapy assistant. She has been practicing occupational therapy in the same school district for 20 years. She loves her children, husband, OT, working with children and teaching Sunday school. She is passionate about engaging, empowering, and enabling children to reach their maximum potential in ALL of their occupations as well assuring them that God loves them!

Retained Primitive Reflexes & Child Development

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Images of babies. Text reads Primitive Relaxes and occupational therapy

This post is all about retained primitive reflexes, what retained reflexes look like, and how they impact child development. You’ll find specific strategies to integrate retained primitive reflexes as well. In a recent blog post, we discussed what are primitive infant reflexes, and why they are so important to infant development. Now, it is time to discuss what can happen if these reflexes hang around for too long.

Remember that every case is unique, and if your child matches these characteristics, that does not necessarily mean that they have retained that reflex. If you are concerned about your child’s abilities and how they may relate to retained reflexes, we recommend talking to your pediatrician.

For more information on primitive reflexes and their impact on child development, be sure to check out some of these books on primitive reflexes.

Retained primitive reflexes

retained Primitive Reflexes

The term “retained primitive reflexes” might be a phrase you’ve heard before. But what does that mean and what do retained reflexes look like in children? Well, there is a lot to cover.

Basically, as infants develop into toddlers, their primitive reflexes should do what health care professionals call “integration”. The response that comes with the primitive reflex should integrate into a more mature or voluntary movement. When primitive reflexes are retained, those instinctive actions, movements will remain past the typical age range…they continue to exist. They are retained.

If primitive reflexes are still present long after they should have integrated, the child will display certain characteristics specific to the retained reflex, many of which limit their development and academic skills.

Just to add some background information, when we say that primitive reflexes are integrated, that means that the movements (or reflexes) are absorbed and contributing to characteristics, actions and neurological responses. To put it in other words, a reflex moves along a neurologic arc and when integration of those reflexes occurs, a process where specific stimulus results in a predictable response (or lack of that predictable response) so that movements are more efficient. This occurs so the neurologic system is connected and communicating efficiently. It’s all part of the nervous system.

PALMAR REFLEX

The palmar reflex is important for the development of purposeful grasping, something that an infant is learning throughout their first year of life. The palmar reflex can be seen when you place your finger in the palm of an infant’s hand and their reflexive response is to hold on to your finger. What an adorable reflex, right?

This is not something we want to see in an older infant or child, though. While the response is necessary for a newborn to learn how to use their hands, it limits an older infant or child to only using their hands and fingers for a strong grip.

retained palmar reflex

Children with a retained palmer reflex may:

  • Get fatigued very easily with handwriting or fine motor tasks, like stringing beads.
  • Have a sensitive or “ticklish” palm
  • Open and close their mouths while using their hands for tasks like writing or cutting with scissors.
  • Have difficulty in speech articulation

The mouth and the hands are connected via neural pathways in infancy, and that connection is still strong in those who have the palmar reflex. This is why the movements of the mouth and speech may be involved in the retained palmar reflex.

How to integrate the Palmar Reflex:

  • Tasks that encourage separate use the fingers
    • Squeeze a ball with one finger and thumb, alternating fingers to squeeze
    • Stringing Beads
    • Playing with small Legos or similar toys

MORO REFLEX

The Moro reflex is also called the startle reflex – it can be seen in a frightened infant up to about 4 to 6 months old. The reflex causes a baby to stretch out their arms and legs, and quickly bring them back in, in jerky movements. This is in response to the feeling of falling, a loud sound, or a drastic change in temperature.

Retained Moro Reflex

Children with retained Moro reflexes are often very sensitive to stimuli – sounds, tags on clothing, lights, etc. They tend to lack emotional and self-regulation skills and have a difficult time paying attention in class. Without an integrated Moro reflex, their fight or flight response can be activated very easily causing them to have deficits in many areas of life.

How to integrate the Moro Reflex:

  • Starfish Exercise
    • While seated, open up into a big “X” shape with straight arms and legs.
    • Cross right ankle over left & Cross right arm over left
    • Open up to big “X”
    • Cross left ankle over right & Cross left arm over right
    • Repeat
  • This is also how you can test for its presence! If a child has a very difficult time completing these actions, without another known cause, they may have a retained Moro reflex.

TONIC LABYRINTHINE REFLEX

The tonic labyrinthine reflex (TLR) is used for head and postural control. We know that baby has poor control of their head and neck when they are born, and this reflex is part of what helps them gain control over this part of their body.

Retained Tonic LABYRINTHINE reflex

This reflex typically integrates around 4 months old, but if it persists, the following may occur:

  • Difficulties judging space, speed, depth, and distance.
  • Toe walking
  • Discoordination in simultaneous movements, such as walking or swimming.
  • Avoiding lying on their stomach.

Children with retained TLRs tend to be perceived as clumsy and often have a difficult time sitting upright and still in their chairs. This can decrease their ability to pay attention in the classroom setting. When posture exercises in kids don’t work, sometimes it’s easy for teachers or parents to wonder what is going on, when a look at retained reflexes may be in order. In some cases, integrating the TLR reflex can support posture.

How to integrate TONIC LABYRINTHINE REFLEX

  • Incorporate activities on their stomachs as much as possible, or for as long as they can manage each day.
  • Try reading, watching TV, or playing with a toy while on their tummies
  • Daily practice will strengthen their muscles and correct this response.

ASYMMETRICAL TONIC NECK REFLEX

This reflex is important to the initiation of crawling, as the arms and legs move as a baby turns their head while on their belly. While infants are on their bellies, and while crawling, they are exposed to a ton of visual stimulation by looking at their arms moving, looking and grabbing toys, etc. Tummy time is so important for this reason and more!

The ATNR should disappear around the time an infant is gearing up for crawling, around 6 months old.

Retained ASYMMETRICAL TONIC NECK REFLEX

If asymmetrical tonic neck reflex doesn’t integrate, the following may occur:

  • Poor Coordination during movements like skipping or riding a bike
  • Trouble crossing midline
    • Example: Moving right arm to left side of the body to buckle a seat belt.
  • Poor visual tracking = academic issues
    • Difficulty reading and writing

A quick test for a retained ANTR starts with having the child stand with both arms directly out in front of them. Ask the child to slowly turn their head all the way to the left. Their left arm will remain straight and their right arm will bend if the reflex is still present.

How to integrate the ATNR

  • Lizard Crawling Exercise
    • Start on the stomach
    • Look to your left, and bend your left elbow and left knee
    • Look to your right, and bend your right elbow and right knee

There are many more primitive reflexes, as well as postural reflexes, that are important to child development and student success. We have not covered everything here, but we hope to have given you a nice place to start building your understanding of what may happen when primitive reflexes are maintained over time.

Want to learn more about primitive reflexes, what to do when reflexes are retained, and how to know there might be an issue? Check out the primitive reflexes course below. (affiliate link)

Assessment And Integration Of Primitive Reflexes For Improved Independence In Daily Activities is a course on primitive reflexes where you’ll learn how to, screen, test and integrate retained primitive reflexes and find tools to help your client or child improve motor, social and daily functioning skills by implementing fun, therapeutic, and functional activities!

In this primitive reflexes course, created by two occupational therapists, you’ll find modules and functional intervention activities for:

  1. Moro reflex
  2. The Tonic Labyrinthine (TLR) & Landau Reflex 
  3. The Rooting Reflex
  4. The Asymmetrical Tonic Neck Reflex (ATNR)
  5. The Spinal Galant Reflex
  6. The Palmar Grasp Reflex
  7. The Symmetric Tonic Neck Reflex (STNR)
  8. Support for kids who push back
  9. Printable handouts, screening tools, and checklists
  10. Information on postural reflexes, yoga, sensory diets, and more
  11. Case studies
  12. Research
  13. AOTA continuing education: 1.05 AOTA CEUs

If your child has retained primitive reflexes, learning to integrate them could lead to improved development in many areas:

  • Social Skills
  • Learning
  • Motor Skills
  • Executive
  • Functioning
  • Coordination
  • Reading & Writing

Primitive Reflexes and Occupational Therapy

This article was originally published in 2021.  While reflexes have not changed since then, there is new research and resources available on primitive reflexes. This is important to keep up to date with as an occupational therapist working with children. Inevitably, we will see a child who has retained reflexes impacting daily functional skills.

When it comes to primitive reflexes and occupational therapy, there is a lot of connection because of the motor and sensory components that impact function.

This article talks about the link between retained primitive reflexes and autism spectrum disorder. The authors go on to say that this connection is due to a brain imbalance and connectivity. They offer a specific set of exercises, with EEG testing done at the beginning and end of treatment to show progress.

The research is limited on the efficacy of integrating reflexes thus far, however there is plenty of evidence on reflexes.  Reflexes are important for survival in infancy and early childhood. They need to be integrated so we can produce smooth movements, which later might impact motor planning and body awareness. Without this integration we often see uncoordinated movements, an increased startle reflex, difficulty with frontal lobe maturation. 

Because the research about the “integration of reflexes” is not there, the AOTA is suggesting using exercises and activities to improve coordination and performance in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), rather than calling it the integration of reflexes.

Images of babies. Text reads Primitive Relaxes and occupational therapy

A Therapist’s Perspective on Reflex Integration in OT

Whenever I have parents or other professionals questioning the validity of certain treatment ideas such as sensory integration, therapeutic listening, vibration, astronaut training, and more, I try the “what can it hurt” approach.  

“What can it hurt”, is a worthwhile approach to life and taking risks. I am much more willing to take risks if the reward is greater than the potential drawbacks. This holds true for a lot of what we teach as OTs.  This includes primitive reflex “integration” therapy.  Whether you believe in integration/retained reflexes or not, think about the treatment methods provided. 

Treatment methods for reflex retention include strengthening, coordination, and stretching exercises.  Whether the cause of incoordination is reflex retention or something else, practicing strengthening and coordination exercises can help either way. While finding the “why” during treatment is helpful, it is not always available. There are times we may never know the cause of a disorder.  In this case we treat the symptoms we see. 

According to Samantha Heidenreich, OTD, MOT of occupational therapy .com, There are theories as to the cause of primitive reflex retention including: 

  • the birth method, like Cesarean section versus vaginal delivery
  • Trauma during pregnancy, birth, or shortly after
  • exposure to toxins
  • Anesthetics during pregnancy/birth
  • medications

Additionally, other possible causes for retained primitive reflexes are decreased tummy time in infancy, a lack of crawling, early walking, head injuries, or chronic ear infections. In the OT world, we are always looking at decreased tummy time and that lack of crawling during our intakes and assessments. 

Based on what we do know, the back to sleep program and container baby syndrome, are having an effect on development that needs to be counteracted. When we take a step forward for safety, innovation, and technology, there are often consequences if not used in moderation or with caution. (Being a “tech-wise” family means having an awareness of this from the start. Its something that we as OTs can educate our families on, even when working with children of a very young age.)

Education and early intervention are the keys to success. Whether you are talking about retained primitive reflexes, or another difficulty seen in children, we can do more by letting people know how to care for young children, and intervening early. 

How can you add to your OT Toolbox to better educate yourself about reflexes and treatment?  Check out some of our resources!

The resources at the OT Toolbox are endless.  Want to find an easier way to locate resources instead of clicking and scrolling?  Become a member today!  One of the perks of being a member is access to restricted content, and easy search categories.

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.

Sensory Red Flags and Toddler Behavior Red Flags

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sensory red flags

Parents of young children may notice sensory red flags, or sensory preferences in their children that bring up a few questions. For parents of toddlers, this can be a gut feeling that milestones may be delayed, regressing, or “off”. Below, we’re covering red flags related to sensory, including toddler behavior red flags that might indicate a need for consultation with a pediatrician. Let’s go deeper…

sensory red flags

Sensory red flags can help parents recognize their child’s’ sensory processing issues. These gut feelings can help kids to get the sensory input they need for independence and functioning.

One consideration is overstimulation anxiety. Worrying about the sensory input from different experiences because there are sensory stimulants that impact function is one example of a sensory red flag.

Sensory Red Flags

Sometimes parents just know there is something “off” with their child.  That deep, inner gut feeling is what lets us know that there is just something different about the way their child interacts, processes information, or performs in daily tasks.  

That ability to recognize gut feelings allows us to know there is an unsuspected ear infection in our toddler or it might be the one red flag that nags at us during sleepless nights that something bigger is going on with our child.


You might have heard it said before: Mom’s always have that gut feeling about their child.  Well, sometimes that inner voice can be a loud scream that a child has sensory issues or it can be a quiet nagging sense that there are underlying sensory processing problems.


Below, you’ll find common and more unique “gut feelings” that might indicate a sensory processing problem in children.  These are the quieter indications that might make you furl your eyebrows or question a behavior that your child seems to show over and over again.


Use these sensory processing red flags as a way to put the whole picture together for your child.  Any one behavior or tendency that shows up with your child may be a meaningless coincidence, however if a child presents with several items on the list below, it may be necessary to speak to your child’s pediatrician.  

Use these sensory processing red flags to ease that gut feeling that you have and seek out the information or help that is needed for your child.

 
Sensory processing red flags for parents to help identify sensory needs in kids

 

Identifying sensory issues can mean there is a need not being meant. These sensory red flags are just some things to consider. One or two items on the list may not mean anything. Seeing many of the red flags listed below may mean that a consultation with your child’s pediatrician is in order.


Sensory Processing Red Flags

Get a free printable checklist version of this list below.
 
  • My child has specific behaviors during his/her day.
  • My child has strange tendencies.
  • My child seems different in many ways than other children his/her age.
  • My child has trouble “switching gears”.
  • My child has trouble with transitions.
  • My child seems “off” during outings such as the grocery store, church, or doctor’s offices.
  • My child has trouble in social situations such as holiday get-togethers, birthday parties, or classroom free time.
  • My child doesn’t seem confident.
  • My child prefers certain textures, sounds, sights, tastes, scents, positions, or movements.
  • My child avoids certain textures, sounds, sights, tastes, scents, positions, or movements.
  • My child doesn’t act like other kids.
  • My child gets upset by confined spaces.
  • My child gets upset by certain sounds like lawnmowers.
  • My child is difficult to calm down at times.
  • My child wakes up at “full speed” and doesn’t stop all day.
  • My child can not control the volume of his/her voice.
  • My child can not stop jumping/spinning/bouncing/crashing.
  • My child strictly avoids jumping/spinning/bouncing/crashing.
  • My child is drawn to specific repetitive motions or activities.
  • My child strictly avoids specific repetitive motions or activities.
  • My child seems to have a problem that is difficult to pin point.
  • My child seems to struggle to keep up with other kids.
  • My child has no fear.
  • My child has extreme fears.
  • My child seems withdrawn at times.
  • My child doesn’t seem to notice details.
  • My child seems overly preoccupied with details.
  • My child doesn’t seem to notice when they fall and get hurt.
  • My child doesn’t notice dangerous situations (age-appropriately).
  • My child avoids certain food textures.
Sensory red flags checklist



Do any of these gut feelings sound familiar?  There are many red flags on the list above that are conflicting signs of different problems.  Not every concern that is noted above will be seen of every child with sensory processing difficulties.  

toddler behavior red flags

Parents of toddlers are often the first to notice when something seems different or “off” with their child’s behavior. When we refer to toddler behavior, remember that we are referring to the way that the toddler acts or behaves in any given situation. 

Toddler Behavior Red Flags

When therapists refer to “behavior” in the context of a toddler’s development or therapy, they are typically talking about the observable actions exhibited by the child in various daily situations. This includes how the child responds to their environment, interacts with others, and manages their emotions and impulses. There is a lot going on in toddlerhood that we can observe!

While it’s essential to remember that children develop at their own pace, there are signs that may prompt parents to seek guidance or evaluation from a healthcare professional.

Here are some common toddler behavior red flags that might be connected to sensory needs and preferences:

  • Social interactions
  • Fearful of others
  • Little to no communication with others
  • Doesn’t engage with others at all
  • Won’t copy facial expressions
  • Doesn’t respond to their name
  • No stranger danger 
  • Extreme separation anxiety
  • Regression in skills
  • Repetitive actions like rocking, hand flapping
  • Rigid patterns in play and daily activities
  • Not aware of others in a room
  • Limited interest in other children
  • No interest in daily functional tasks such as dressing, feeding, etc.
  • Fearful of stimuli
  • Repetitively seeks out stimuli   
  • Difficulty managing certain foods or textures
  • Sensitive to sensory stimuli such as lights, sounds, or textures
  • Aggression
  • Behind on several developmental milestones like walking, speaking words, etc.
  • Delays in language or speech
  • Frequent meltdowns that are out of proportion for typical toddler development
  • Little to no gesture use  in communicating wants or needs
  • Regression in previously acquired skills such as self-care, language, or social skills

  • Self-injury

 
Typically, at a toddler well visit appointment, the pediatrician staff will request the parent or guardian to fill out a questionnaire.  
 

The parent questionnaire for guardians of toddlers can include some of the sensory red flags listed above, however it is geared toward the typical toddler development that happens in the 1-3 age range. This may be a time when sensory red flags become apparent to parents and guardians.

A parent questionnaire for a toddler well visit, particularly when assessing developmental milestones and potential signs of Autism, may include questions related to various aspects of a child’s behavior, self-care skills, and communication. These could be related to sensory processing needs, which impact functional performance and typical development at this age. 

Here are some sample questions that could be included:

1 Communication: Some children with sensory needs may struggle with social skills and communication, which can impact their ability to understand, participate in daily activities, follow self-care instructions, etc. Communication support and social skill development may be necessary. Being aware of these milestones is important.

    • Is your child using words to communicate their needs and desires?
    • Can your child follow simple instructions, such as “give me the ball” or “come here”?
    • Does your child make eye contact when interacting with others?
    • How often does your child engage in babbling or attempts to speak?

2. Social Interaction: Social skills and sensory red flags go hand in hand. For more information, check out our social skills checklist.

      • Does your child show interest in playing with other children or adults?
      • Does your child respond to their name when called?
      • Is your child able to imitate simple gestures or actions, like waving goodbye?
      • How does your child react to new people or unfamiliar situations?

3. Behavioral Concerns: For some, activities like rocking, hand-flapping, or spinning objects may provide a calming or organizing sensory input. Noticing these behavioral habits can be a predictor of sensory needs.

    • Are there any repetitive behaviors or unusual movements that you’ve observed in your child?
    • Does your child have intense reactions to sensory stimuli (e.g., lights, sounds, textures)?
    • How does your child handle transitions or changes in routine?
    • Are there any specific fears or phobias that your child exhibits?

4. Self-Care Skills: Taking a look at age-appropriate self care skills in children, (or the ability to complete functional tasks like dressing, potty training, feeding, etc.) is important because at the toddler age, there should be an interest in “doing things myself” or becoming more self-sufficient. A sensory red flag may mean that there sensory sensitivities and preferences that impact the child’s ability to notice or perform age-appropriate self-care tasks independently.

    • Is your child showing interest in self-care tasks like dressing themselves, feeding, or potty training?
    • How well is your child able to use utensils and drink from a cup?
    • Can your child independently perform basic self-care tasks, such as washing hands or brushing teeth?

5. Play and Imagination: Play is the work of the child but when sensory needs predominate, play can seem habitual or repetitive as a means to support sensory preferences. This can offer a sense of predictability and comfort to some children. Noticing these play preferences may convey their needs, sensory preferences, or discomfort.

    • Does your child engage in imaginative play, such as pretending to cook, play house, or use toys to represent real-life scenarios?
    • Is your child interested in a variety of toys and activities appropriate for their age?
    • How does your child explore their environment and play with objects?

6. Sleep Patterns: Sleep hygiene impacts functional performance of the whole family and sometimes during the Toddler years, we see a change in these habits, possibly related to sensory needs.

    • What is your child’s sleep routine like? How many hours does your child sleep at night?
    • Does your child have difficulty falling asleep or staying asleep?

7. Feeding Habits: Sensory preferences may impact the food tolerance, resisting trying new foods, food texture issues, a tendency toward extremely picky eating, or other sensory food aversions.

    • What is your child’s typical diet like? Are there any aversions or strong preferences?
    • Is your child able to self-feed with utensils, or are they still primarily using their hands?

8. Safety Concerns- Do “sensory” considerations seem to impact direction following, the child running off in a crowded space, not listening about touching the stove or outlets, seeming to seek out unsafe situations, or other safety aspects?

    • Are there any safety concerns or behaviors that you find challenging to manage?
    • Does your child engage in any repetitive or potentially harmful behaviors?

It’s important to remember that these questions serve as a screening tool and not a diagnostic tool. If parents have concerns about their child’s development or behavior, they should discuss them with their healthcare provider for a thorough evaluation and appropriate guidance. This may be part of an indicator for exploring early intervention for Autism or other developmental needs.

Every child is different, but the concerns noted above will be indications to seek out more information and issues that should be brought up to your child’s pediatrician.

Be sure to check out our resource, our sensory processing disorder chart, to better understand how differences impact kids in different ways.


Get a free printable checklist version of our sensory red flags checklist below.

Parents and gut feelings about sensory processing issues

 

sensory processing red flags
You may also be interested in the free printable packet, The Classroom Sensory Strategy Toolkit.
The Classroom Sensory Strategy Toolkit is a printable packet of resources and handouts that can be used by teachers, parents, and therapists. Whether you are looking for a handout to explain sensory strategies, or a tool for advocating for your child, the Classroom Sensory Strategy Toolkit has got you covered.

 

And it’s free for you to print off and use again and again.

 

In the Classroom Sensory Strategy Toolkit, you’ll find:

 

  • Fidgeting Tools for the Classroom
  • Adapted Seating Strategies for the Classroom
  • Self-Regulation in the Classroom
  • 105 Calm-down Strategies for the Classroom
  • Chewing Tools for Classroom Needs
  • 45 Organizing Tools for Classroom Needs
  • Indoor Recess Sensory Diet Cards
 
Sensory Strategies for the Classroom
 
 
 

Free Classroom Sensory Strategies Toolkit

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    red flags checklist

    Print off a copy of our Sensory Red Flags checklist. This printable tool can be a helpful resource when it comes to noticing and identifying sensory considerations that impact day to day functional performance.

    To get the printable, enter your email address into the form below. You will receive a handout via email.

    As always, if you suspect an area of need, consult with your child’s physician for individualized information and recommendations. This sensory red flags checklist and the toddler red flags list in this blog post is for informational and educational purposes only.

    This red flags checklist is also available inside our Membership Club, along with all of the printable downloads available on The OT Toolbox website. Level 2 members can also access over 1500+ resources, sensory activities, handouts, ebooks, and much more.

    Free Sensory Processing Red Flags Handout

      We respect your privacy. Unsubscribe at anytime.
      Built with ConvertKit

      Colleen Beck, OTR/L has been an occupational therapist since 2000, working in school-based, hand therapy, outpatient peds, EI, and SNF. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. Read her story about going from an OT making $3/hour (after paying for kids’ childcare) to a full-time OT resource creator for millions of readers. Want to collaborate? Send an email to contact@theottoolbox.com.

      For more information on sensory processing, development, and how to incorporate sensory needs and preferences into daily life, check out our ebook, The Sensory Lifestyle Handbook.

      The Sensory Lifestyle Handbook
      The Sensory Lifestyle Handbook

      The Sensory Lifestyle Handbook walks you through sensory processing information, each step of creating a meaningful and motivating sensory diet, that is guided by the individual’s personal interests and preferences.

      The Sensory Lifestyle Handbook is not just about creating a sensory diet to meet sensory processing needs. This handbook is your key to creating an active and thriving lifestyle based on a deep understanding of sensory processing.

      Identify Emotions with Pumpkin Emotion Faces

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      pumpkin emotions

      This pumpkin feelings activity is an OLD one here on the site. But there is just something fun about pumpkin emotion faces that little ones love! It’s a social emotional activity for preschoolers and toddlers that foster emotional development…with fun and interactive pumpkin feelings!

      This fun Fall activity helps with learning to identify emotions using pumpkin emotion faces! It’s a great emotional development activity for toddlers and preschoolers. Kids love moving the faces on the pumpkins and practicing different facial expressions is a bonus.

      Kids love this emotions activity, and it would be fun to use along with our pumpkin sensory bin this Fall!

      pumpkin feelings

      Pumpkin Emotions Activity

      You can use interactive felt pieces to create pumpkin emotions, or facial expressions on pumpkins to create different feelings on the pumpkins. This is a great way for toddlers and preschoolers to play with facial expressions, practice emotions, and put a word to the emotion.

      You’ll need just a few items for this activity:

      • Orange poster board
      • Green paint or green marker
      • Black paper
      • Tape

      Time needed: 10 minutes

      How to Make a Pumpkin Emotions Activity for Preschoolers

      1. Cut out a Pumpkin Shape

        Use orange poster board and cut out a large pumpkin shape. Add a few lines with a black marker for more pumpkin details if you like.

      2. Paint the stem green.

        You could use green paint or a green marker. Or, use green paper and glue the green paper over the stem area.

      3. Cut out face pieces from black paper.

        Cut out circle eyes, a triangle nose, and different smiles. You can create angry eyes, surprised eyes, a circle mouth, a frown, a smile, etc.

      4. Add tape to the back of each pumpkin emotions piece.

        Roll the tape into a donut and stick to the back of each facial expression. You could also use sticky tack.

      Identification of Emotions

      The tricky part of developing self regulation in preschoolers is the development of an essential skill that impacts self-regulation in later years. Giving young children the words, or the emotion vocabulary, to explain how they feel by identifying emotion faces is the perfect starting point!

      That’s where these pumpkin emotion faces come into play!

      Young children often have difficulty expressing their emotions.  Recently my 18 month old son has reverted to hitting, screaming, and throwing things, which is part of typical development.

      I was trying to think of a way to help him learn how to express himself in a calmer more acceptable manner and that’s how this pumpkin faces emotions activity came to life.  With all the fall fine motor OT activities and Fall-inspired posts lately, I got to thinking about decorating a pumpkin…

      First, let’s break down the identification of emotions aspect. 

      This is an important developmental process in toddlers and preschoolers. Emotional intelligence is a skill that needs practice to develop, and is essential for social situations, communicating with others, and self-regulation of emotions and feelings. Identifying emotions is one of the first steps for young children.

      One way to do this would be to pair the pumpkin feelings activity with a feelings check in. Children could identify their own feelings and match it to the pumpkin facial expressions.

      There are ways to support emotions identification in preschoolers, toddlers, and older children:

      • Use this social emotional learning worksheet to help kids match emotions to behaviors and coping strategies.
      • Put words to feelings. Do you feel sad? Are you unhappy? You feel mad. I am happy.
      • Point out facial expressions and emotions in books. Picture books are a great way to talk about emotions and see facial expressions in the context of a story.
      • Another fantastic resource that can help develop social and emotional skills is the activity book, Exploring Books Through Play.

      pumpkin emotion faces with a paper pumpkin activity
       
       
      Paper pumpkin with a happy face
       
       
       
      Preschool pumpkin emotion activity, child places paper pieces on a pumpkin to make a smile

       

       

      Identifying and Expressing Emotions with pumpkin Faces

       My 4 year old helped cut out the shapes of the eyes, nose, and mouths. The different shapes and the sturdy paper (we used cardstock) makes this a great scissor skills activity for preschoolers.

      After the pumpkin emotion pieces were cut out, we started identifying emotions. Happy, sad, angry, etc. We have a great resource on emotional vocabulary that helps to teach preschoolers about identifying emotions.

      Then, we talked about the shapes and what those mouths looked like. We talked about positive and not so positive ways to express our feelings. “When I get sad, it is not OK to hit”. 

      At the preschool age it is important for her to be able to express her feelings with words and associate them with how her actions make others feel.  Learning about feelings helps with her social emotional development.

      Preschool pumpkin emotions activity using a paper pumpkin
      Paper pumpkin with facial expressions
      Use a cardstock paper to make a pumpkin and facial expressions for a preschool activity


      “This one has a mustache!”

      Sad pumpkin face for preschoolers

      “This guy is sad because his sister took away his toy.”

      Paper pumpkin fine motor activity

      Toddler Pumpkin Emotion Activity 

      This is also a great activity for helping toddlers build emotional development skills. Toddler play is where all of the development happens, and this activity is a powerhouse.

      Toddlers can use the activity for several skills:

      • Spatial relations activities
      • Fine motor skills
      • Working on a vertical surface to develop eye-hand coordination, fine motor work, and core strength
      • Social emotional development

      We also had fun lining up the shapes. We had a row of triangles, circles, and ovals.

      Another great emotions activity for toddlers and preschoolers are our emotions playdough mats to support naming and identifying emotion names and facial expressions to match the emotion name.

      Toddler playing with pumpkin face pieces on a refrigerator.

       For little guy we placed the pumpkin on the refrigerator with a magnet and tape on the back of the shapes.  He had a blast making the pumpkin fall down…over…and over…and over again!  

      Toddler copying pumpkin facial expressions playing on a fridge with magnet pieces.

        I would help him put a different shape mouth on the pumpkin and mimic the face. He thought I was pretty silly, but I think he started catching on 🙂

      Toddler copying a surprised pumpkin face

        Surprised face!  

      Toddler placing pumpkin facial expression magnets on a fridge.

        This also helps with learning spatial relations and where a nose, mouth, and eyes belong on a face.  He was trying to put the mouth where the nose goes…he will learn eventually!

      Toddler moving pumpkin face pieces to make a smile

        We all know that babies and toddlers have feeling just as we as adults do, they just need a little help trying to figure out what they are feeling!  Hopefully this will help my little guy learn to deal with his frustrations a little better…I will keep you posted!

      Pumpkins

      Colleen Beck, OTR/L has been an occupational therapist since 2000, working in school-based, hand therapy, outpatient peds, EI, and SNF. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. Read her story about going from an OT making $3/hour (after paying for kids’ childcare) to a full-time OT resource creator for millions of readers. Want to collaborate? Send an email to contact@theottoolbox.com.

      Development of Eye-Hand Coordination

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      hand eye coordination

      Hand eye coordination plays a powerful role in daily activities. Through the integration of fine motor skills and visual processing, we see intentional and controlled motor skills. But there’s more to catching and throwing a ball at a target than the coordinated use of the hands and eyes. Let’s break down hand eye coordination development skills as well as the other underlying skills needed.

      hand eye coordination

      We have included affiliate links to resources in this blog post on hand eye coordination milestones. As an Amazon Influencer, I earn from qualifying purchases.

      Hand Eye Coordination

      Hand eye coordination refers to the coordination, or integration, of visual input and the processing of that visual information for coordinated movement of the hands. These skills impact fine motor dexterity and motor movements in functional tasks for so many tasks while manipulating movements and objects.

      Eye-hand coordination is essential in handwriting, scissor use, threading beads, reading, throwing a ball, placing a cup on a shelf, coloring in lines, feeding, self-care, and much, much more.

      The phrases “Hand-eye coordination” and “eye-hand coordination” are used interchangeably, however, we tend to use the phrase eye-hand coordination more appropriately, because input comes through the eyes first and the hand responds in motor tasks. However, the general population may primarily use the phrase “hand-eye coordination”.

      In this blog post, we will use both phrases interchangeably, in order to reach the populations seeking information on either phrase.

      In essence, hand-eye coordination, or eye-hand coordination, are the  Visual motor skills used in motor tasks.

      Part of this development is the refined motor skills led by arch development in the hands. Paired with dexterity and precision skills, along with visual motor components, we see hand-eye coordination.


       
       
      Eye hand coordination develops from a very young age! Here is information about the development of visual motor skills, specifically eye hand coordination in babies, toddlers, and preschoolers.

       

      Eye Hand Coordination Development

      Eye-hand coordination development typically occurs through movement, beginning at a very young age. The visual components of oculomotor skills (how the eyes move) include visual fixation, visual tracking (or smooth pursuits), and visual scanning. These beginning stages of child development play a big part down the road in taking in visual information and using it to perform motor tasks. 

      These hand-eye coordination developmental guidelines listed below are general guidelines of development based on approximate development of the visual motor skills needed for play, motor skills, and visual motor development.

      Holding and talking to baby in the very young ages plays such an important part in the puzzle of visual motor skills. 


      Additionally, tummy time and as the baby gains head strength and control, they eyes become stronger in their ability to fixate, track, and scan from the prone position. This is why we place toys around a baby on a baby blanket and encourage reach.

      That pivotal stage when baby begins to roll is a social media-worthy time in the parent’s life. But there is more to celebrate than baby’s new rolling skills. Control of the eyes with movement is a big accomplishment and something that baby strengthens with movement. 

      Hand Eye Coordination

      These skill areas are broken down by months, all the way up through the preschool years. 


      Disclaimer: Amazon affiliate links are included in this post.

      ONE MONTH:
           Tracking a rattle while lying on back                                    
           Tracking a rattle to the side                
         
      TWO MONTHS:
           Infant regards their own hands
           Tracks a ball side to side as it rolls across a table left to right and right to left.
           Tracks a rattle while lying on back side to side
         
      THREE MONTHS:
           Extends hands to reach for a rattle/toy while lying on back
         
      FOUR MONTHS:
           Reaches to midline for a rattle/toy while lying on back
           While lying on back, the infant touches both hands together.

      hand Eye coordination and Crawling

      Crawling on the hands and knees plays a vital role in hand eye coordination, too. When baby positions themselves up on all fours, they are gaining awesome proprioceptive input, strength in the shoulder girdle, core, and neck.

      When crawling, baby is gaining mobility, but also using targeted movement toward a goal they visually process.

      Research shows that hands-and-knees and walker-assisted locomotor experience facilitate spatial search performance. Spatial awareness, or visual spatial relations, and visual skill development is needed for coordinated use of the hands in motor tasks.


      In fact, crawling improves so many areas needed for refined eye-hand coordination, including the fine motor skills, gross motor skills, gross motor coordination, balance, and strength needed for tasks like precision of in-hand manipulation, positioning in activities, and sustained endurance. We cover more on this topic in our blog post on spatial awareness for baby.

      Eye hand coordination develops from infancy! Playing with baby in tummy time is a crucial element to eye hand coordination development.


      SIX MONTHS:
           Brings hands together to grasp a block/toy while sitting supported on an adult’s lap
           Extends arm to reach up for a toy while laying on back
         
      SEVEN MONTHS:
           Transfers a block/toy from one hand to the other while sitting supported on an adult’s lap.
           Touches a cereal piece with index finger
           Bangs a toy on a table surface while sitting supported on an adult’s lap

      NINE MONTHS:
           Claps hands together

      TEN MONTHS:
           Removes loose pegs from a Peg Board (affiliate link) 

      ELEVEN MONTHS:
           Removes socks
           Releases a cereal bit onto table surface
           Places blocks (affiliate link) into a cup

      A lot of eye hand coordination development occurs in the toddler years. Here are developmental milestones for eye hand coordination from 1-3 years.

       

      Development of Eye Hand Coordination for Toddlers

      Development of hand eye coordination accelerates during the toddler years because motor skills develop at an increasing pace during the years of 1-3. 

      TWELVE MONTHS/ ONE YEAR:
           Turns pages in a board book
           Imitates stirring a spoon (affiliate link) in a cup

      THIRTEEN MONTHS:
           Imitates tapping a spoon on a cup
           Begins to places large puzzle pieces in a beginner puzzle (affiliate link) 

      FOURTEEN MONTHS:
           Scribbles on paper

      SIXTEEN MONTHS:
           Imitates building a tower of 2-3 blocks (affiliate link) 

      NINETEEN-TWENTY MONTHS:
           Builds a block tower, stacking 4-5 blocks (affiliate link) 

      TWENTY THREE-TWENTY FOUR MONTHS:
           Imitates copying vertical lines


      TWENTY FIVE-TWENTY SIX MONTHS:
           Removes a screw top lid on a bottle
           Stacks 8 blocks (affiliate link) 
           Begins to snip with scissors

      TWENTY SEVEN-TWENTY EIGHT MONTHS:
           Imitates horizontal strokes with a marker
           Strings 2 Beads (affiliate link) 
           Imitates folding a piece of paper (bending the paper and making a crease, not aligning the edges)

      TWENTY NINE MONTHS:
           Imitates building a train with blocks
           Strings 3-4 Beads (affiliate link) 
           Stacks 10 blocks (affiliate link) 

      THIRTY ONE MONTHS:
           Builds a “bridge” with three blocks (affiliate link) 

      THIRTY THREE MONTHS:
           Copies a circle

      THIRTY FIVE MONTHS:
           Builds a “wall” with four blocks (affiliate link) 

      Eye hand development continues in the preschool years. Here are ways that eye hand coordination develops in preschool and how to improve these visual motor skills.

       

      hand Eye Coordination in Preschoolers

      During the preschool years, we see even more fine motor and gross motor development. These refined skills, along with more coordinated efforts enable precision and dexterity with hand-eye coordination. Check out some of the preschool activities that we love to use to support this development.

      Additional information and resources are covered in our blog post on crossing midline activities for preschoolers, as the eye-hand coordination at this age develops quickly and the sensory motor skills needed for play is an important part of development.

      Preschoolers are beginning to use tools such as crayons, scissors, markers, glue sticks, and more. You’ll see greater control in using these materials. 

      Preschoolers are also playing with more pretend play, and are able to use different toys with more refinement. While the preschool age may be able to use a pencil to create forms, occupational therapy practitioners prefer that handwriting is not encouraged at this age.

      Read about the detrimental impact that handwriting has when pushed before preschoolers build the visual motor experience in this stage.

      THIRTY SEVEN MONTHS:
           Cuts a paper in half with scissors

      FORTY MONTHS:
           Lace 2-3 holes with string on Lacing Shapes (affiliate link) 
           Copies a cross

      FORTY TWO MONTHS:
           Cuts within 1/2 inch of a strait line.
           Traces a horizontal line

      FIFTY MONTHS:
           Copies a square
           Cuts a circle within 1/2 inch of the line
           Build “steps” with blocks (affiliate link) 

      FIFTY FOUR MONTHS:
           Connects two dots to make a horizontal line.
           Cuts a square within 1/2 inch of the line
           Builds a “pyramid” with blocks (affiliate link) 

      FIFTY FIVE MONTHS:
           Folds a piece of paper in half with the edges parallel
           Colors within lines


      There is so much happening through regular play, interaction with babies and toddlers at each stage. What’s important to know is that the development doesn’t stop there! 


      Studies have shown that eye-hand coordination impacts learning, communication, social-emotional skills, attention, and focus. Wow! 

      Coordination Skills

      Here are some ideas to work on eye-hand coordination for preschooler kids and older: 
      This Letter Eye Hand Coordination Activity helps with bilateral coordination and the visual processing skills needed for reading and so many other skills. 

      Try this scooping and pouring eye-hand coordination activity that can be adjusted to meet the needs of many ages and abilities.

      More visual processing activities

      For even MORE information on eye-hand coordination and activities to use in your occupational therapy practice, you will want to join our free visual processing lab email series. It’s a 3-day series of emails that covers EVERYthing about visual processing. We take a closer look at visual skills and break things down, as well as covering the big picture of visual needs.

      In the visual processing lab, you will discover how oculomotor skills like smooth pursuits make a big difference in higher level skills like learning and executive function. The best thing about this lab (besides all of the awesome info) is that it has a fun “lab” theme. I might have had too much fun with this one 🙂

      Join us in visual processing Lab! Where you won’t need Bunsen burners or safety goggles!

      Click here to learn more about Visual Processing Lab and to sign up.

      Free visual processing email lab to learn about visual skills needed in learning and reading.
      Work on eye-hand coordination with preschoolers by building with blocks!
       
      Try activities like geoboards, pegboards, and lacing beads to improve eye hand coordination development in kids.

      References:
      Kermoian, Rosanne & Campos, Joseph. (1988). Locomotor Experience: A Facilitator of Spatial Cognitive Development. Child development. 59. 908-17. 10.2307/1130258. 

      Colleen Beck, OTR/L has been an occupational therapist since 2000, working in school-based, hand therapy, outpatient peds, EI, and SNF. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. Read her story about going from an OT making $3/hour (after paying for kids’ childcare) to a full-time OT resource creator for millions of readers. Want to collaborate? Send an email to contact@theottoolbox.com.

      Spring hand eye coordination fine motor worksheets

      Hand eye coordination activities can be as simple as lacing cards, hole punching activities, and paperclip tasks using printable OT activities. The ones in the image above are found in our Spring Fine Motor Kit, but there are many others in our other Fine Motor and Therapy 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
      Kit de motricidad fina de verano
      Summer Fine Motor Kit
      Outer Space Fine Motor Kit
      Space Fine Motor Kit
      Spring fine motor kit
      Valentines Day fine motor kit
      winter fine motor kit
      Winter 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!

      Truths About Toddlerhood The OT Wants You To Know

      by
      toddlerhood

      The toddler years can be a struggle! From the age of one year to 3 years, toddlers grow and develop immensely. But when parents are in the midst of toddlerhood, it can seem like the never-ending tantrums, meltdowns, sometimes crazed attempts at independence, and picky eating, sleep issues, etc… never end. Not to mention learning new words (with little-to-no filter), sleep changes, appetite and eating considerations, toddler years can be a real challenge to parents. But as an occupational therapist, there is a very real developmental need for these toddler antics.

      Be sure to read our resource on newborns not sleeping through the night, because sometimes sleep habits can carry over to toddler sleep issues that impact function, development, and family dynamics.

      Toddlerhood gets a bad rap with terms like the “terrible twos” and the “three-nager years”. But is it all bad? Here’s what your friendly OT wants you to know…

      Strategies for toddlerhood

      Toddlerhood Development

      So, what is it about the toddler years? These cute packages of rolly, squishy, no-longer babies are little people with BIG emotions, BIG personalities, and BIG smiles. Some of the sweetest memories I have from when my kids were younger come from the toddler stage, when little voices pronounce words totally incorrectly…but in the cutest way possible. Those big teethy smiles and non-stop play was nothing but learning and developing skills.

      As a mom, I loved to watch my littles learn. I loved to kiss their sweet heads to sleep each night. Oh, there were meltdowns, demanding, whining breakdowns that these cuties experienced (daily). There were messes, spills, diaper issues, and the house was in a constant state of disaster zone.

      But as the occupational therapist? I knew this was all part of the stage of development and toddlerhood means messy repetition. (i.e. Yes, we will need to practice cleaning up blocks 37 times a day. Yes, we will do it again tomorrow).

      But, from that perspective of a pediatric developmental professional, there is so much more to say about the toddler years. ALL of that pushing buttons, whining, changing minds, meltdowns, carrying purses full of toys, getting into the kitchen cupboards, streaking naked through the house…it’s all essential toddler development! Really!

      We have a great resource on child development that covers developmental milestones. From that blog post, you’ll discover the toddler developmental stages that occur from 1-3 years.

      This developmental checklist can help to define specific milestones.

      Early childhood is a critical time when children develop skills they will use throughout their lives. These areas of development include:

      • physical
      • cognitive
      • communication/language
      • emotional
      • social skills

      It is during the first years of life that children show a tremendous level of growth in each of these areas.

      Occupational Therapy and Toddlerhood…

      As a pediatric OT, there are a few sticking points that is important to remember.

      The toddler years get a bad rap for behaviors, saying “no”, tantrums, going “boneless” as we used to say about sudden tantrums where the toddler flops on the floor in refusal for some task, activity, or thing like getting dressed. However, if there are extreme issues, regressions, or you have a gut feeling about certain developmental concerns, these may be toddler behavior red flags to explore in further detail along with a pediatrician.

      But, here are a few things about the “good” of toddlerhood…

      1. Have patience with your toddler.

      Because of the tremendous amount of development, it is easy to become overwhelmed by skills (running, hopping, getting dressed, manipulating toys and materials, self-feeding…the list goes on and on!) Plus, young children want to exhibit independence in these areas. They want to do what mom or dad or big siblings are doing, but they may not have the skills to do so. Frustration ensues!

      Things to remember is that the child is developing in all of these areas at once. By watching routines, listening to parents talking, watching siblings, they learn to throw, carry, put away, wash, color…these are multi-faceted skills. There is sensory, motor, cognitive, visual all happening at once with daily tasks.

      Plus, the cognitive development occurring at the same time means that following directions are not always on target with what the small child wants to do. They want a piece of toast for breakfast. Then they don’t. It can be easy to lose patience as the toddler has a tantrum on the floor, but they are managing emotions, thought processes, decisions, and communication challenges all at once. It can be a lot to process! Be patient as the adult in the situation.

      Patience is key as your little toddler develops skills at the rate that is right for them.

      That brings us to our next point.

      2. Remember that each child is different.

      Toddlers grow and develop at a fairly predictable course and rate. There are general developmental expectations that happen during the toddler years, called developmental milestones. However, not all child achieves these milestones at the same time. And that’s ok!

      It can be easy to become upset as a parent when a friend’s child achieves skills or abilities. Remember that each child is on their course of development. From birth to three years, a child visits the pediatrician many times.

      You’ll experience many questions on development during those visits, where the doctor or staff ask about milestones. If there is a concern with development, or evident delay, this is where you can explore services to support needs.

      Even through each toddler is different and development occurs in different stages, it’s all part of showing independence. This can mean picky eating, throwing food, saying “NO!” or any other aspect of showing independence.

      3. Development occurs through play.

      Occupational therapy practitioners use play as a tool to promote more play! And it’s through play that toddlers develop skills.

      It’s through play that toddlers achieve stability, build relationships with parents, siblings, and others.

      They test boundaries and explore the world around them.

      Play offers opportunities to use their reflexes, transform motor skills, and distinguish refined motor skills (i.e. using their arms and legs to achieve a desired action such as getting up those stairs!)

      Sensorimotor skills expand and toddlers gain control in play objects and tool use; They begin to use crayons, spoons, forks, and manage clothing. Previously, we’ve shared the best crayons for toddlers that support this development through functional play.

      Young children are fascinated by mastering new skills and learning new things. You might see them drawn to activities or experiences that offer sensory experiences, are repetitious, or involve exploration. But even though novel opportunities support child development, routine is essential.

      Read about the power of play for more ideas to support your toddler.

      Physical Development during toddlerhood

      Going back to the development aspect, you can generally expect to see the following skills developed during toddlerhood:

      12-18 months

      • First steps
      • Walking
      • Climbing stairs

      18-24 months

      • Running

      24-36 months

      • Jumping
      • Begin to ride a tricycle

      3 years

      • True run with both feet leaving the ground
      • Walk upstairs with alternating feet
      • Walk downstairs
      • Able to remove most clothing

      Cognitive Development During Toddlerhood

      From 1-3 years of age, so many cognitive skills are built and expanded upon. You’ll notice in the list below that many of these cognitive skill components are grounded in play. Remember that play builds skills! Let’s break down the skills by age:

      12-18 months

      • Includes others at recipients of play behaviors
      • Imitates new behavior

      18-24 months

      • Demonstrates invention by combining mental combinations
      • Finds hidden objects (separation skills)
      • Shows differed imitation
      • Uses toys or dolls in pretend play

      24-36 months

      • Substitutes objects in pretend play
      • Integrates themes in play

      3 years

      • Begins operational thinking
      • Counting words up to 5
      • Can solve nesting cup problems

      Language Development for Toddlers

      The first few years are a huge time for development of receptive language and expressive language. Here are some specifics:

      12-18 months

      • Expresses self through jargon, sounds, cries

      18-24 months

      • Understands multi-word phrases/sentences
      • Uses multi-word phrases to express thoughts (“Me up” to indicate a desire to be picked up; “Mommy go” to indicate that mommy has left the house)

      24-36 months

      • Initiates a conversation with words or phrases
      • Uses 2 part sentences or phrases (“Me go home.”)

      3 years

      • Understands positional terminology (in, on, under)
      • Uses more complex sentences
      • Distinguishes between images and words or text on paper or in books
      • Begins to generalize rules for verb tenses and using plurals

      Toddler Social-Emotional Development

      Social emotional development occurs even from the young age in toddler years. Social skill development occurs through interaction with others, play, and day to day tasks. Here are some milestones you may see:

      12-18 months

      • Experiences peak of separation anxiety

      18-24 months

      • Demonstrates less separation anxiety
      • Begins to show empathy for another person, animal, toy

      24-36 months

      • Begins to respond with empathy to another person’s distress
      • Includes others in pretend play

      3 years

      • Shows physical aggression over verbal aggression when distressed or upset

      Toddlerhood Tips

      So, how can you and your toddler thrive during these hectic years? A pinch of patience, play, play, and more play! We actually have actionable strategies over on our toddler play page, including fun ways to play with your toddler that inspire development.

      Some quick tips (described in more detail over on that main toddler page) include:

      1. Meet the level of the child.
      2. Set up a toddler safe space.
      3. Be a balanced play partner.
      4. Enjoy & have fun with the play.
      5. Limit screens. (Or use in moderation.)

      Transforming Toddlerhood With Play

      Ask any occupational therapist and you’ll see that play is the way and the means to develop skills during these years. Looking for therapist-approved activities to inspire learning through play for toddlers? These are some of our favorite ideas:

      Or, try making a craft with 2 year olds and 3 year olds…an easy suncatcher activity using items you have in the house!

      Colleen Beck, OTR/L has been an occupational therapist since 2000, working in school-based, hand therapy, outpatient peds, EI, and SNF. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. Read her story about going from an OT making $3/hour (after paying for kids’ childcare) to a full-time OT resource creator for millions of readers. Want to collaborate? Send an email to contact@theottoolbox.com.

      Perineal Hygiene

      by
      perineal hygiene and pericare tips

      Here, we are covering an aspect of potty training that comes up for every parent: pericare, or perineal hygiene, and teaching kids how to wipe when toilet training. So often, a young child learns to use the toilet and other aspects of potty training, but then struggle for a long period of time with the wiping aspect. Teaching children to wipe thoroughly is a hygiene task that can be limited by many underlying areas. Here, you’ll find strategies to help wiping bottoms and interventions for perineal hygiene. Also check out ADLs for more information on daily tasks.

      How to teach pericare, or perineal hygiene needed to wipe completely during toileting.

      What is pericare?

      For the uninitiated, pericare (or peri-care) is short for perineal care. Perineal care refers to the hygiene and self-care of the perineal area following toileting, cleaning, and wiping of the perineal area of the body is the “private parts” area. Pericare is a term for the hygienic tasks involved in this part of the body, such as wiping one’s bottom.

      Anyone of any age may need help wiping their bottom with their perineal care, but it is especially important to teach our little ones the proper way to manage their bottoms as they become more independent. 

      This component of toileting is one that impacts overall independence and self-care with the toileting process. So often, we cheer and celebrate making it to the toilet on time, but the perineal hygiene aspect is equally as important.

      Related: Potty Training Seats for Special Needs

      You may be thinking, “Why do I need to teach my child how to wipe!?!”. For something that is such a natural task for many, it can feel odd to teach somehow how to do it.

      However, learning how to maintain a clean bottom is important for one’s health and confidence. Wiping properly, washing gently, and wearing appropriate clothing decreases the risk of yeast infections, urinary tract infections, and odors. Plus, discussing peri-care can open the door to many other conversations about the body, health, and safety – if that’s something you are interested in exploring with your child.   

      A great time to educate your child about peri-cares is while potty training. It is easier to teach the correct way first than to re-learn how to do it later. If you are stuck on potty training, we feel you there! Check out this Toliet Training Book that can help you help your children of varying needs.

      Don’t be discouraged if your child is already potty trained and they have yet to learn how to take care of their bottoms independently – it can take time and practice! 

      Development of Pericare

      An important area to cover first is the development of pericare skills. It is so important to remember that we are talking about young children who are learning a whole new skill with toileting. There are many considerations: autonomy, body awareness, interoception, self-awareness, the sensory processing and interoception aspect, family perspectives…potty training can be very overwhelming for kids.

      Then, to break it down even further, the hygiene aspect of toileting is another ball game!

      In our book, The Toilet Training Book, we cover the development of potty training and really cover what underlying skills play into potty training and independence with toileting.

      But, one important thing to remember is that a three year old child may be able to make it to the toilet in time to go, flush, and wash their hands, but the wiping aspect can developmentally, come with time.

      Developmentally, perineal hygiene, or wiping completely after toileting, may be a skill achieved during a range of 4-6 years. This range is so wide due to the underlying skills, sensory considerations, motor skills, and cognitive growth needed for perineal hygiene including knowing when and where to wipe after a bowel movement or urination, using enough pressure on the toilet paper to clean completely, wiping enough times to clean completely, and maturity to complete the task.

      The emergence of these skills takes time, but there are ways to support development of perineal hygiene.

      GET COMFORTABLE with perineal hygiene

      Everyone wants a clean bottom, let’s start there. It can be smelly and embarrassing to talk about, but it is an important step to understanding personal healthcare.

      We want to give you the confidence to discuss this in any way that you and your family feel comfortable with because it is a “touchy” subject for some. The more comfortable you are with peri cares, the more comfortable the child will be. 

      Let’s start off the potty training wiping techniques by talking about good hygiene.

      Here are some ideas to talk about perineal hygiene with kids:

      • Make it silly: Some people respond best to humor but watch out for demeaning jokes. 
      • Make the conversation about pericare hygiene scientifically accurate: It becomes less embarrassing when you hardly know what is being said! 
      • Make pericare sound similar to washing hands: We have to clean away the germs; they can make us sick! 
      • Make discussions about perineal hygiene your own: You know your family best. Think about terminology that works for the individual. In what ways can you increase trust and comfort for all? 

      GENERAL GUIDELINES for teaching perineal hygiene

      Here are some general tips for a healthy bottom that should be shared for children and adults alike. Please speak to your family physician if you have any questions or concerns related to your child’s unique needs. 

      • Wear breathable (preferably cotton) underwear that is not too tight. Change daily or when soiled. 
      • Don’t hold it in. While it is good to wait to “go” until you reach the toilet, holding in pee or poop for too long can result in a variety of issues. 
      • If it is comfortable, sit on the toilet with elevated feet. You may have heard of the (Amazon affiliate link) Squatty Potty – placing the legs in more of a squatting position helps bowel movements pass. More importantly, children should have access to a either a smaller potty or a footstool (or a box,etc.) near the toilet so that their feet do not dangle. 
      • Wipe from front to back to reduce bacteria entering the urethra. Talk about anatomy and why wiping front to back is effective and safe.
      • Wipe gently with 3-4 squares of folded toilet paper (each household can determine the amount – some kiddos use way too much!) until clean. I always recommend to look at what you are wiping away so that you learn about how much you need to wipe. 
      • Consider use of warm or cool wipes over toilet paper.
      • When bathing, wash the genital area gently with mild soap and rinse with clean water. No soap should be entering the body through the anus or the vagina. 
      • For bathing a uncircumsized child, refer to this article for great information and consult your family doctor for personalized advice.   

      Pericare INTERVENTION IDEAS

      Children will not know unless we lead them, so here are some fun ways to teach pericare! 

      Areas that can be broken down to increase overall self-care include:

      • Address balance
      • Pulling up and down undergarments
      • Wiping front to back
      • Wiping thoroughly
      • Wiping with enough pressure
      • Gripping the toilet paper
      • Washing hands after wiping
      • Reaching around to the back

      Each of these areas can include aspects of balance, gross motor skills, fine motor skills, strength, coordination, sensory processing, executive functioning skills, and visual motor skills. It’s important to look at each individual’s area of difficulty and then break it down into the underlying areas that are impacting success with pericare.

      First look at the area of difficulty. Then, consider how underlying areas are impacting that particular area. Come up with intervention strategies that support that need and create a “just right” challenge to build independence and pericare functioning.

      Let’s look at each of these areas of perineal hygiene…

      Pulling up and down undergarments:

      • Fine motor strength and coordination fine motor activities to the rescue! There are so many fantastically fun ways to increase this skill, but here are some that are more directly associated with potty training.
        • Lei Obstacle Course: Grab some Hawaiian-inspired leis, hula skirts, or long necklaces and create a long pathway. As a child walks through the pathway (hopefully to another fun activity in the course), they must step inside the lei and pull it up as high as it will go. If it fits over their arms/head, they can wear it as a necklace. Pulling up the lei and wiggling their body through will strengthen the same skill as in pulling up pants. Reverse the challenge to mimic pulling pants down.
        • Silly Socks: Grab a variety of socks in fun colors and different sizes and see how many you can put on in one minute! Layering socks up the arms and legs (and removing them, too!) mimics the skill of pulling up and down undergarments. 
        • Stickers: Challenge them to peel off stickers all along the waistband of their pants. Don’t forget the backside! 

      Pericare: Wiping Activities

      Balance and reach are huge parts of perineal hygiene. Staying balanced on the potty while wiping is a big challenge for our core strength, flexibility, and range of motion. To practice this skill through play-based activities, see the ideas below! 

      Play-pretend: Place peanut butter on the back of a disposable or washable diaper and have your child wipe it off. Any familiar paste will do – sun butter, nutella, cookie butter…anything to wipe! When they think they are done wiping, show them the diaper to see if they actually cleaned it. 

      Art-based: Wipe a plastic plate with toilet paper to create an art project – the toilet paper acts as the paintbrush. They must wipe clean the whole plate! For an extra challenge, place the plate behind their backs, and the work of art in front of them. 

      Play activity: Using static electricity, tape, or velcro, have your child squat to “pick up” pom-poms or other sticky and lightweight items on their bottoms (think: window stickers, damp tissues, etc.). They carry them carefully to a container and remove them one by one. You can really make this game your own!

      Wiping Front to Back

      There are so many ways to work on perineal hygiene to cover other aspects besides the balance consideration. Consider these strategies to teach kids to wipe front to back:

      • Use toys, books, clothing, and other items to work on teaching front and back directional concepts.
      • Teach children to count to help with wiping a certain number of times.

      Reaching Back to Wipe During Perineal Hygiene

      • Clip and unclip clothes pins on the back of clothing to work on reaching back and around..
      • Use a pool noodle to reach around and through the legs to work on reach, visual attention, scanning, and eye-hand coordination. You can tap the pool noodle on a target and create a game.
      • Practice wiping the backside in the bathtub.
      • Put a handkerchief or scarf in their back pocket for the child to reach for and pull out.
      • Put stickers on the child’s back or pants for them to reach for and grab.

      Wiping with enough pressure

      • Work on tearing paper for hand strength and eye-hand coordination to pull off appropriate sizes of toilet paper.
      • Use play dough, LEGO, tong activities to develop hand strength.
      • Wipe dry erase marker off a dry erase board. Then, position the dry erase board on the ground between the feet to bend and wipe. Then, position it behind the back to reach and wipe.
      • Wipe peanut butter or washable paint from a plastic baby doll.
      • Help kids to wipe thoroughly by painting with toilet paper with having them try to wipe a blob of paint off a plastic plate and remind them to keep going until the plate was empty.

      More perineal care and potty training tips

      Looking for more information on underlying considerations that impact toileting? Need strategies, supports, and tools to facilitate independence with toileting skills? Need support strategies for potty training an older child, but not know where to begin?

      Looking for ways to help individuals with toileting skills when cognitive, behavioral, motor skills impact participation in independent toileting? Trying to initiate or progress with potty training when a diagnosis of Down Syndrome, Autism, or a motor skills challenge is at hand? Check out the Toilet Training Book: A Developmental Take on Potty Training for Kids of All Abilities.

      Resources for toilet training kids of all abilities
      The Toilet Training Book: A Developmental Look at Potty Training for Kids of all Abilities

      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.

      Early Intervention and Autism

      by
      early intervention autism

      When it comes to the early signs of autism spectrum disorder and potential interventions, early intervention for autism can cover a variety of areas. Here, you’ll discover strategies for parent advocates to add to their toolbox.

      There are many different signs associated with autism, and research strongly shows the earlier a child receives intervention supports for autism, the more progress they make in all areas of their lives. Early intervention, a federally funded program, provides support for the youngest children, ages birth through three years old, who demonstrate developmental delays. This blog will talk about the early signs of ASD and interventions that support development in all areas. 

      Early intervention and autism as well as early signs of autism and interventions to support development.

      Early Intervention and Autism

      Today, autism affects 1 in 44 children. According to the CDC, autism spectrum disorder is four times more likely to occur in boys. The best way to support children who are showing signs of a developmental delay is to get them therapy supports as early as possible. These supports are available from Early Intervention Programs, Health Insurance and private agencies. 

      Every child is different and develops at different rates, so how are we supposed to determine if an Autism Evaluation is appropriate for a child under three years old?

      The Early Intervention program is available to all children ages birth to three that live in the United States. The purpose of this program is to help identify and support children who have delays in all areas of development, with or without a diagnosis of autism.

      One of the most commonly used questionnaires to determine if a child does have red flags for ASD is called “The Modified Checklist for Autism in Toddlers (MCHAT). This questionnaire can be filled out for free by a clinician or a parents. You can find the free online version here.

      The five areas typically monitored when determining if a child should be referred for an autism evaluation are joint attention, social engagement, receptive language, expressive language and behaviors. If there are concerns in some or all of these five areas, completing the MCHAT assessment and talking to your child’s pediatrician is the first step to determining if more testing should be administered. 

      1. Joint Attention

      Joint attention is a skill that affects a child’s ability to interact with others.

      The definition of Joint Attention is when two people purposefully pay attention to the same thing and for the same reason.

      For example, when an adult calls a child’s name, and the child responds by looking at the adult, they are engaging in the first step of joint attention. The adult would then ask the child a question and when the child responds, the adult and child are talking to each other about the same thing, in that very same moment. The same goes for when an adult points to an object and the child follows that point to see what object the adult is showing them. Together they are able to talk about the same item.

      According to the UNC School of medicine, “Children who are learning social and communication skills in a typical way will often show examples of joint attention from the time they are 12 months old. Joint attention is important in helping people communicate with each other all through life. Children with autism have a hard time with this kind of communication. For these children, delays in developing joint attention skills lead to delays in developing language.”

      1. Social Engagement

      As soon as a baby is born, they are in awe of their mothers voices and eyes. Infants thrive off social interaction, from playing peek-a-boo, being sung to and engaging in simple play activities.

      As they grow, social skills become the foundation for other areas of development. They learn spoken words through imitation of adults and peers, babies and toddlers model behaviors of those they see around them, they get the attention of others to share their wants and needs, and they imitate other children’s play and movement.

      One component of autism is a lack of social engagement, such as when a child doesn’t show interest in playing near or playing with other children or using words to communicate with primary caregivers.

      1. Receptive Language

      Understanding the meaning of words is the first step to language development. Without understanding the meaning of words, children won’t be able to use spoken words to communicate their wants and needs with adults.

      Children start to show understanding of words as early as 4 months old, when they look towards objects and family members when they are named. As they get older, they start following points, imitating gestures and show interest in imitating sounds and words that adults use. 

      Autistic children may have a harder time engaging in social reciprocity which impacts their receptive language development. This article from Raising Children describes how joint attention directly affects receptive language development in infants:

      “Autistic children might have difficulty learning language because they tend to show less interest in other people in the first 12 months of life. They might be more focused on other things going on around them. Because they might not need or want to communicate with other people as much as typically developing children do, they don’t get as many chances to develop their language skills. For example, a three-month-old baby who is distracted by a ceiling fan is less likely to tune into a smiling and tickling game with their parents. By nine months, if the baby still isn’t tuning into parents, the baby is less likely to point at things they want to share with parents. The baby is less likely to listen to their parents as they name things. This means the baby misses these chances to build vocabulary.”

      1. Expressive Language

      Expressive language is the key to communicating our wants and needs with others. This can be through visuals, verbal words or using gestures.

      When infants start to use gestures (such as pointing, waving “hi”, and lifting their arms to signal wanting to be picked up,) adults are able to understand what their child is wanting and respond to their requests.

      From there, expressive language develops quickly into babble, jargon, word imitation and then children using one, two and three word phrases to communicate with those around them.

      Children that develop early signs of autism don’t typically follow this language progression. Children might be more quiet then others, babbling less, use rote phrases (lines they hear in movies), use language that isn’t functional in nature, or label a variety of objects. This article does a wonderful job explaining the differences between a language delay and language concerns that point to Autism. 

      1. Behaviors

      Behaviors associated with children who may have Autism may also be an indicator of sensory differences. An autistic child may show repetitive movements (such as rocking consistently), showing aversions to being touched or sensitivity to sounds and lights in unpredictable environments (such as the grocery store.)

      Children sometimes become upset for unknown reasons and are hard to calm down. Some autistic children become fixated on objects, only wanting to complete tasks in specific ways (such as lining up toys), always wanting to hold onto specific objects or getting upset when someone else changes the play sequence. Children who show signs of ASD also tend to need consistent daily routines and become upset when their routines change. 

      The most common diagnostic tool for Autism in young children is called the ADOS (Autism Diagnostic Observation Tool), a play based assessment that is completed by a clinician with the child present. This assessment can be given to a child as early as toddlerhood. There are four different modules that can be administered to young children. Clinicians determine the correct module to use based on the skill level of the child. The ADOS assessment, along with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) results will determine if a child meets the criteria that pertains to autism spectrum disorder. 

      The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a completed diagnostic tool completed by the American Psychiatric Association that encompasses different psychiatric diagnostic criteria. The diagnostic criteria for Autism in the DSM-5 is described in this article. 

      “A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history. 

      B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history.

      C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life).

      D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

      E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.”

      Interventions for children with a diagnosis of ASD:

      1. Early Intervention Services

      The Early Intervention Program is a federally funded program that supports children in all areas of development, including language, cognition, motor skills, social skills and adaptive development.

      The services available for children under the age of three are directly associated with every child’s individual needs. These could include feeding therapy, nutritional supports, speech and language therapy, occupational therapy, physical therapy, behavioral therapy, social language groups and more!

      If a child is enrolled in the early intervention program, their parents or guardians play a key role in the implementation therapy services. Therapies usually occur at home, with parents involved. When a child turns three, their therapies are funded through the local school district Special Education Program to support school readiness, and medical insurance to support medical needs and behavior supports at home. 

      1. Visual, Tactile, and Auditory Supports

      Children with low social reciprocity and joint attention skills benefit from other forms of communication. These communication strategies utilize other senses and break down communication to simple and direct forms. If a child is having trouble calming down, creating a calm down corner using “Soothing Sammy Emotions Program” supports a positive calming experience with a golden retriever dog and sensory tools. 

      Visual cue cards such as these First/Then choice boards and transition cards,  give children the ability to follow daily tasks and routines in a way that is easy for them to follow, without the need to look those who are talking to them.

      Early intervention services can support with strategies:

      • To increase on-task behavior or social interactions
      • To teach new skills e.g., life skills, communication skills, or social skills
      • To maintain self control and self monitoring procedures to maintain and generalize job-related social skills
      • To generalize or to transfer skills from one situation or response to another (e.g., from completing assignments in the resource room to performing as well in the mainstream classroom)
      • To restrict or narrow conditions under which interfering behaviors occur (e.g., modifying the learning environment)
      • To reduce interfering behaviors e.g., self injury

      As children become more comfortable with back and forth interactions with adults, first/then boards can be used as a back up option for communication. These visual schedules help children transition from one activity to the next. 

      A final note on early intervention and autism

      If you have  concerns about a child’s developmental progress, it is best to seek out professional assessments through a pediatrician or an Early Intervention team. If the child is over three, requesting a developmental evaluation through your local school district is also an option.

      When children receive the intervention therapy they need at an early age, their skills in all areas of development improve. There are many different interventions we can do to support even our littlest family members. 

      Jeana Kinne is a veteran preschool teacher and director. She has over 20 years of experience in the Early Childhood Education field. Her Bachelors Degree is in Child Development and her Masters Degree is in Early Childhood Education. She has spent over 10 years as a coach, working with Parents and Preschool Teachers, and another 10 years working with infants and toddlers with special needs. She is also the author of the “Sammy the Golden Dog” series, teaching children important skills through play.