OCCUPATIONAL THERAPY FOR READING AND WRITING

Catherine Candler, OTR, PhD, BCP

Lenin Grajo, OTR/L, EdM

Karen Nall, MOTS

Abbey Mulder, MOTS

November 2, 2012

Texas Occupational Therapy Association

Mountain Central Conference

Short Course Objectives

At the end of this presentation, the participant should be able to:

• Describe the role of occupational therapy in reading and writing intervention.

• Describe the possible application of the Occupation of Reading Practice Model in the intervention of reading difficulties in clinical and school settings.

• Cite evidence-based strategies for handwriting intervention with reading.

Reading and Writing Connections

• LANGUAGE by• ear – listening• mouth – speaking• eye – reading• hand – writing

• Language • No organ of it’s own, teams up with the sensory and motor

systems.• Draws on common and unique brain processes to achieve

different goals.• Are separable skills.

• Skill in one mode does not necessarily mean skill in another

• Each has its own developmental trajectory• Each interacts with other language systems to some

degree at different stages of that development

LANGUAGE BY HAND

• Crayons leave marks!• Scribbles• Imitate strokes• Begin making shapes• Infants and Toddlers• Integration of perceptual and motor skills• Name alphabet letters• Connecting dots• Beginning alphabet forms• Preschoolers• Coordinating language (naming letters) with act of writing• Accurate alphabet copy• Knows letter names• Writes dictated letters• Writes alphabet from memory• First grade• Integration of language by eye - orthographic codes (letter forms), language by ear -

phonological codes (letter names), language by hand - grapho-motor codes (output)

Language by Eye and Hand• Does reading drive writing?• Does writing drive reading?• What are the relationships between the two?

Berninger, V. W., Abbott, R., Abbot, S. P., Graham, S. & Richards, T. (2002).Writing and reading: Connections between language by hand and language by eye. Journal of Learning Disabilities, 35 (1), 39-56.

Examining prediction models

• 600 typically developing children• Half girls half boys• Grades 1-6• Measures of:

• Handwriting – print alphabet from memory, copy text• Spelling • Word recognition• Composition (essays) scored for spelling, length, quality

At the level of the WORD• Does word recognition predict

handwriting and spelling?

At the level of the WORD• Does handwriting and spelling predict

word recognition?

At the level of the WORD• SO, the paths from word recognition

to handwriting are stronger than those

from handwriting to word recognition.

At the level of the TEXT• Does reading ability predict writing ability?• Specifically, does reading comprehension

predict spelling, length, and quality of

composition?

At the level of the TEXT• Does reading ability predict writing ability?• Specifically, does reading comprehension

predict spelling, length, and quality of

composition?

At the level of the TEXT• Does writing ability predict reading ability ?• Specifically, does spelling, length, and quality of

composition predict reading comprehension?

Language by Eye and Hand• Writing’s influence on Reading• Word level writing has links to word level reading

throughout elementary grades. But text level writing does not appear to influence text level reading until upper elementary grades.

 • So working with children to write words might influence

their reading skills at all grades. But working with children to write essays may have its strongest influence on reading in the upper elementary years.

Language by Eye and Hand• Reading’s influence on Writing• Word level reading does have links to word level writing

throughout the elementary grades. And text level reading does have links to text level writing.

 • So working with children to read will influence their writing

skills at all levels.

Course Outline• How is reading and writing addressed by OTs?

1. Reading Difficulties• What is a reading difficulty?• Why is reading difficulty an OT concern?• How can reading difficulties addressed by OTs

2. Handwriting Instruction• How can handwriting instruction be incorporated into a literacy

curriculum?• How can OT apply evidence-based strategies for handwriting?• Why should Pre-K children receive handwriting instruction?

Audience Survey• Who among you work with children with handwriting

difficulties?• Who among you work with children with reading

difficulties?• Who among you work with children formally diagnosed

with dyslexia?• Who among you work with children with dyslexia with

handwriting difficulties?

Reading and Writing Intervention• Reading and writing are components of literacy that help

fulfill student and various life roles.

• Reading is addressed from a skills-based approach by reading interventionists, SLPs and special education teachers.

• Handwriting is addressed from a mechanical and sensory-based approach separate from reading.

• What is the role of an OT in addressing literacy skills?

Dyslexia and Reading Difficulties• Dyslexia is characterized by an unexpected difficulty in

children and adults who otherwise possess the intelligence, motivation, and schooling considered necessary for accurate and fluent reading (Shaywitz et al., 2001).

• Typical intervention focuses on phonological processing and fluency.

• 30% of children with dyslexia do not have expected phonological deficits or do not respond to phonology-based remediation (Laycock & Crewther, 2008; Ramus, 2003; Wolf, 1999; Wright & Conlon, 2009).

The Case of Matt

Matt is an 8 year-old, male, client diagnosed with Developmental Dyslexia (DD). He was referred for private OT for sensory processing challenges that affect reading performance and handwriting. The DD diagnosis was first made by the school district. He currently receives reading intervention at school but no OT services.

The Occupation of Reading• A practice model currently being developed by Grajo,

Candler and Schultz of Texas Woman’s University through a Reading Research Lab at Saint Louis University.

• Reframes reading as a meaningful activity to fulfill student and various life roles.

• Guided by the Theory of Occupational Adaptation (Schkade & Schultz, 1992).

Premise of the Model• Contexts of performance contribute to challenges that

facilitate or hinder successful performance (demand for mastery).

• Sensorimotor, Cognitive and Psychosocial systems of the person are involved.

• Children with reading difficulties avoid and dislike structured reading tasks.

• Anxiety overrides successful performance.• Avoidance leads to inability to transfer learned reading

skills.

Matt’s Occupational Profile• Developmental Reading Assessment (DRA) level at that time was

4 standard points below expected development. His handwriting was very slow, poorly aligned, and letters poorly formed. He had difficulty absorbing materials from class because of increased anxiety.

• Matt was directly referred to this occupational therapist by a child neurologist for dyslexia and dysgraphia management.

• During the interview, parents indicated that Matt dislikes going to school. They mentioned that the school environment was stressful for him, but they like the school district because of its excellent teaching and service provision for children with various challenges. They mentioned that they would read to Matt when he was younger but that he never initiated the activity and never seemed to demonstrate enjoyment when doing so. He prefers video games and rough gross motor play.

The Role of the OT• Enabler of the occupational environment.

• Facilitates an internal adaptive mechanism that leads to self-mastery and feeling of competence.

• Support skills-based approach by the Reading Intervention Team.

Assessments• Multi-contextual

• Move from performance skills to performance areas – Top-down approach

• The emphasis is NOT on reading skills but participation and engagement in meaningful reading tasks.

• How do you feel about reading vs How well do you read

Matt’s IEInitial interview with Matt and his mother using the Canadian Occupational Performance Measure reveal that he wants to be able to read and write without much difficulties, stress and embarrassment from peers in the class. This was rated with utmost importance (10). He currently rates his performance in reading as a 3, parents gave him a 4; and his writing performance a 6, parents gave him a score of 4. Satisfaction with this level of performance was low (Reading - 3 from patient, 4 from parent; Writing - 4 from patient, 3 from parent). He wants to be comfortable in his second grade classroom environment. This means that he wants to be able to participate in reading tasks successfully and efficiently, finish written tasks on time and copy from the board without much difficulty.

Matt’s IE• The therapist used the Dynamic Performance Analysis framework to

identify sources of performance breakdown during reading and writing tasks.

• Matt was asked to read a 3 simple sentence passage, second grade level, posted on the board.

• His face immediately showed signs of anxiety. He struggled with several words that could not be easily decoded, persisted on attempting to decode the words, paused for a long time and would lose his mark (next word or next line) with the text. He would show a lot of facial grimacing, knee and ankle shaking, would tap the table lightly when he encounters a challenging word.

• He stopped midway through the 2nd sentence and said it’s too hard (hyperstable behavior). He was then asked to copy this passage on a ruled pad. He immediately asked “That’s too many. Can I just do 1 sentence instead?” Mom signaled that this is his usual reaction to writing tasks - avoiding (existing response mode).

Entry-Point of Intervention

• Through the psychosocial system.

• Providing opportunities for success and feelings of competence in the student role.

Proposed Phases of Intervention

I. Occupational Readiness Training

II. Introducing chunks of reading and writing

III. Strategy Development

IV. Strategy applications with increasing amounts of reading and writing

V. Participation in highly-structured reading and writing tasks

I. Occupational Readiness• Shortest phase of intervention

• Performance components

• Visual Processing, Visual Motor, Sensory Processing, Executive Functions

• Handwriting

Matt’s Occupational Readiness Training

• Typing Tutorial and Visual Processing training using iPad games and online activities.

• Handwriting training for correct letter formation.

II. Chunks of Reading and Writing• Embedded in preferred tasks

• Coupling of less-preferred with much-preferred tasks

• Clues in treasure hunt game• Word/phrase station in obstacle course tasks• Read a key ingredient in a recipe during cooking• Fish for words while on a swing

• The key is to shunt the “primary energy” from stressful reading tasks to “secondary energy” using fun activities.

Strategy Development• Cognitive Orientation to Daily Occupations approach

(Polatajko & Mandich, 2004).

• Self-initiated, individualized strategies based on sources of performance breakdown.

• Where is the source of performance breakdown?• What does the child need to be able to do? • How can the child do it? • How can I enable the child to do it?

CO-OP: Global Strategies• Global Strategy: GOAL – PLAN – DO – CHECK

• GOAL – What do I want to do?• PLAN – How am I going to do it?• DO – Do it.• CHECK – Did I do my plan, Did it work?

• Guided Discovery – Ask, Don’t Teach!

(Polatajko & Mandich, 2004)

Matt’s Goal-Plan-Do-Check

T: So Matt, what is your goal?

M: I will read the clue for the treasure hunt without mistakes.

T: What is the plan?

M: I will cross the balance beam, pick up the clue. Scan the line, follow it with my fingers, and read the words slowly.

T: Alright, let’s do it.

M: Jump three times and c-c—call under the s—stall to get the next clue.

T: Let’s check that line….

CO-OP: Domain Specific Strategies

Verbal Guidance:

• Body Position• Attention to task• Task Specification/Modification• Supplementing Task Knowledge• Feeling the Movement• Verbal Motor Mnemonic• Verbal Rote Script

Matt using Specific StrategiesT: Matt, you said “Jump three times and call under the stall…” There

were 2 words that were incorrect. What did you say you could do when you are not sure of a word?

M: Cover the word with my finger, slowly show the letters and make the sounds.

T: Okay let’s try that again. What do you think is your goal?

M: Read the clue without mistakes.

T: What will be your plan?

M: Read the clue slowly, cover the words I am unsure with my finger and make out the sounds.

T: Let’s do it!

M: Jump three times and c-cr-awwwww-craw---crawwww-l, crawl under the s-t---oooooo-st---stoooo-l, stool to get the next clue.

T: You got it!

Strategy Applications• Practice using strategies• Increasing amounts of reading

• Key is feeling of competence• Feedback and monitoring systems: audio-recording

Sample Strategies for Handwriting

Participation in highly-structured tasks

• As self-mastery and competence increases, increase the amount of structure to tasks.

• The goal is to simulate actual reading tasks in various forms.

• Create self-monitoring aids: level of anxiety, time logs, variety

Signs of Increasing Adaptiveness• Child recognizes mistakes.• Child remembers strategies.• Child creates additional strategies.• Child begins self-correction.

Evidence-Based Strategies for Handwriting

• Video Modeling with Handwriting at a Montessori Preschool: A Quasi-Experimental Study Using The TV Teacher• Purpose: Is VBM an effective way to teach handwriting?• Intervention: The TV Teacher DVD

• Effects on legibility, sequencing, and phonics

Occupation-Based Approach• Montessori method (Montessori, 1967a, 1967b)

• Self-discovery approach • Facilitation rather than direct instruction

Montessori Handwriting Instruction• Indirect Preparation

• Practical life activities

• Direct Preparation• Metal insets• Sandpaper letters• Moveable alphabet

Phonics Program• Readiness• Beginning Phonics• Phonics Boxes

Readiness

Letter matching task

Sandpaper letters Moveable alphabet

Beginning Phonics

Letter matching matrix

Sorting Sticks

Sandpaper letters

Beginning sound matching

Phonics Boxes• 75 color-coded boxes• Progress in difficulty

Video Based Modeling (VBM)• Definition (Mason, Ganz, Parker, Burke, & Camargo, 2012)

• 3 Variations

• Video modeling with other

• Video self-modeling

• Point-of-view video modeling

VBM Continued• Evidence-based intervention (Bellini & Akullian, 2007; Delano,

2007; Mason et al., 2012)

• Advantages• Educational television• VBM for handwriting instruction

• The TV Teacher (2011)• Steps4Kids (2012)• Pencil Pete (2012)

The TV Teacher• The TV Teacher’s Alphabet Beats: Lowercase DVD

• Video modeling with other and point-of-view modeling• Targeted skill of handwriting• Children with typical or atypical development from 3-5 yrs old• 5 minute chapters for each letter of the alphabet• A model demonstrates lowercase block letter sequencing• Auditory instruction on letter formation• Principles of phonics and vocabulary words introduced

(The TV Teacher, 2011)

• Video Clip

Method• Pre-test data collected

• Post-test data collected 15 weeks later

• Students in one classroom had access to The TV Teacher DVD• DVD requested during daily 90-minute work time

Results• Students were interested in watching The TV Teacher

intervention• 584 total viewings• 17 average viewings per student (range of 7-25)• Viewed on 50 of the 76 school days during intervention

• Mean differences for pre-test and post-test data

Results Continued• Sequencing, legibility, and

phonics levels increased for both classrooms.

• The group of students who viewed The TV Teacher had higher legibility scores.

Application• Where can this intervention be used?• How can this tool be implemented?• Who can benefit from this strategy?

References

Bellini, S. & Akullian J.(2007). A meta-analysis of video modeling and video self-modeling interventions for children and adolescents with autism spectrum disorders. Council for Exceptional Children, 73, 264-287.

Laycock, R., & Crewther, S. G. (2008). Towards an understanding of the role of the ‘magnocellular advantage’ in fluent reading. Neuroscience & Biobehavioral Reviews, 32(8), 1494-1506. doi:10.1016/j.neubiorev.2008.06.002

Mason, R. A., Ganz, J. B., Parker, R. I., Burke, M. D., & Camargo, S. P. (2012). Moderating factors of video- modeling with other as model: A meta-analysis of single case studies. Research in Developmental Disabilities, 33, 1076-1086.

Montessori, M. (1967a). The Montessori method. New York: Schoken.Montessori, M. (1967b). The discovery of the child. Notre Dame, IN: Fides.Pencil Pete. (2012). Pencil Pete’s Educational Software and Worksheets. Retrieved from:

http://www.jjmdesigns.com/Polatajko, H. & Mandich, A. (2004). Enabling occupation in children: The Cognitive Orientation

to daily Occupational Performance (Co-Op) approach. Ottawa, Ontario: CAOT Publications ACE.

Ramus, F. (2003). Developmental dyslexia: Specific phonological deficit or general sensorimotor dysfunction? Current Opinion in Neurobiology, 13(2), 212-218. doi: 10.1016/S0959-4388(03)00035-7

ReferencesSchkade, J. K. & Schultz, S. (1992). Occupational adaptation: Toward a holistic approach to

contemporary practice, Part 1. American Journal of Occupational Therapy, 46, 829-837.

Schultz, S., & Schkade, J. K. (1993). Occupational adaptation: Toward a holistic approach to contemporary practice, Part 2. American Journal of Occupational Therapy, 46, 917-926.

Schkade, J. K., & McClung, M. (2001). Occupational adaptation in practice: Concepts and cases. Thorofare, NJ: Slack.

Shaywitz, B. A., Shaywitz, S. E., Pugh, K. R., Fulbright, R. K., Mencl, W. E., Constable, R. T., . . . Gore, J. C. (2001). The neurobiology of dyslexia. Clinical Neuroscience Research, 1(4), 291-299. doi:10.1016/S1566-2772(01)00015-9

Steps4Kids. (2012). Steps4Kids ABCs: traditional printing. Retrieved from: http://www.steps4kids.com

The TV Teacher (2011). The TV Teacher’s alphabet beats: lowercase. Retrieved from: http://www.tvteachervideos.com/index.html

Wolf, M., & Bowers, P. G. (1999). The double-deficit hypothesis for the developmental dyslexias. Journal of Educational Psychology, 91(3), 415.

Wright, C. M., & Conlon, E. G. (2009). Auditory and visual processing in children with dyslexia. Developmental Neuropsychology, 34(3), 330-355. doi:10.1080/87565640902801882

At the level of the WORD• Does word recognition predict

handwriting and spelling?

• YES. Having good word recognition has an influence beyond a simple relationship with better handwriting and spelling performance

• Working with children on recognizing words should help them with their handwriting and spelling.

At the level of the WORD• Does handwriting and spelling predict

word recognition?

• SPELLING does. Having good spelling has an influence beyond a simple relationship with better word recognition performance.

• Handwriting doesn’t. Having good handwriting has less influence with better word recognition performance.

At the level of the WORD• SO, the paths from word recognition

to handwriting are stronger than those

from handwriting to word recognition.

If you want the child to do better in handwriting, incorporate word recognition.

If you want your kid to do better in word recognition, better handwriting is not the way to go. Spelling will work better.

At the level of the TEXT• Does reading ability predict writing ability?• Specifically, does reading comprehension

predict spelling, length, and quality of

composition?

• Reading comprehension does predict spelling in text. Better reading comprehension meant better spelling in essays.

• Reading comprehension does predict quality of composition. Better reading means more in depth ideas shared in essays.

• Reading comprehension was a little less predictive of length of composition. Being able to read better didn’t necessarily mean kids would write more.

At the level of the TEXT• Does reading ability predict writing ability?• Specifically, does reading comprehension

predict spelling, length, and quality of

composition?

• Reading comprehension does predict spelling in text. Better reading comprehension meant better spelling in essays.

• Reading comprehension does predict quality of composition. Better reading means more in depth ideas shared in essays.

• Reading comprehension was a little less predictive of length of composition. Being able to read better didn’t necessarily mean kids would write more.

At the level of the TEXT• Does writing ability predict reading ability ?• Specifically, does spelling, length, and quality of

composition predict reading comprehension?

• Spelling does. Spelling has an influence beyond a simple relationship on reading comprehension throughout elementary grades. Working on spelling at most grade levels may positively influence reading skills.

• But length and quality of composition only predicts reading comprehension levels in the upper grades (4-6). Text level writing does not appear to influence text level reading until upper elementary grades. So working with 1-3rd graders to compose essays may not have a strong an influence on their ability to read, but working with 4-6th graders to compose well may have a positive influence their reading.