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The OT Windup: 5 Tips for Working with Under-Responsive Kids

by Lauren Elitzak, OTR/L, PT, DPT

While some kids arrive at therapy with a full tank of gas, rearing for the green light signal so they can fly off the starting block, some kids will arrive quite the opposite. You have a list of parent concerns and goals to address, but your kiddo is practically a little puddle on the ground. The energy level almost can’t get any lower . . .

Kids with lower energy levels may have arrived at this place from a variety of paths.

Read on to discover the five Es of working with under-responsive patients!

The Entire Picture

Before planning my sessions, I try to gather information to paint a picture of what this kiddo’s “everyday” looks like, to see what we’re working with. Is he or she homeschooled? Attending a crowded public school? A small quiet private school? What is life like at home? I have one sister, so the closest I get to imagining a house full of people is Grandma and Grandpa’s house at the holidays — kids running around yelling and laughing and screaming, things going on all around you. To me, those are two very different pictures with very different amounts of peace and quiet received, attention given, and space to work with.

Not bad, just different. The latter is the reality of many of my kids, so I need to keep in mind the fact that the level of visual and auditory stimulation they’re around all day could be just as fatiguing as running around, playing and exercising can be.

Imagine you’re go go go all day long, come home from work, and lie down on your bed. You may need a lot of encouragement to get back up, but once you’ve rested in that quiet, dark, safe place for a little bit, you could be feeling re-energized and ready to go.

It’s the same thing here. If your kiddo is surrounded by an overwhelming sensory environment, try to start your session with fewer demands in a sensory-friendly atmosphere, to help facilitate a calm, organized state in which to function. This might include slow swinging, progressing to quicker, more alerting swinging - eventually working to incorporate some fine motor tasks for play inside the swing as you see your little one slowly coming out of their shell or gaining more energy for play.

On the other hand, if there is a nice, calm environment at home, and your kiddo arrives too calm that they're almost in a too sleepy, not workable state, this can be adjusted too.

In this case, you can still use the swing, but at a faster pace and with a more alerting intent from the start. You could start off with some yoga or exercise cards and engage their visual system (looking to imitate the cards), as well as having them engage their musculoskeletal systems to hold the poses. This could be a nice, grounding activity, helping them to feel secure with their footing, while giving them the information of exactly where they are in space, as received by their proprioceptive system.

The Entire System

Other strategies to consider to facilitate a calm environment include using dimmer lights, calming sounds, or even calming scents used in your sessions. Each of these parts can contribute to a calmer whole, which in turn can help ease your kiddo out of that state of low energy, promoting a calm and encouraging trust and participation in your session. If your kiddo has low energy, creating an environment that plays into the needs of each sensory system, may help:

Visual: Turn the down the lights so that their other systems can become heightened, or more alert, without the distractions of harsh or halogen lighting. If you are able, replace harsh lighting with softer lights or bulbs with a more natural color hue, which could also reduce the harshness and distraction of the visual system, providing an increase in attentiveness to the task at hand. Remember, most schools still use these harsher lights, so your kiddo may be exposed to this heightened level of visual stimulation all day.

Tactile: Even the tactile system can play a role in creating change in one’s overall mood. I have always liked incorporating tactile stepping stones into my sessions, but I do so with caution. One of the best things I learned was to try everything before giving it to my kiddos. While my sensory system has different likes or dislikes than that of my kiddos, I still don’t think it’s fair for me to push something onto someone else that I wouldn’t do myself.

Here’s what I mean: some of the stepping stones I use are pretty intense, with large ridges or bumps for those little feet - if I don’t like how it feels on my well-integrated sensory system, then I should consider what it may feel like to my kids, walking on them with bare feet. Providing toys or activities for the child to use in a session that are soothing and/or altering can really help engage them or keep their attention to the task at hand, rather than further turning them off or making them want to task avoid or escape the area.

Auditory: Many cause and effect toys or toys for the younger population play music. It’s usually pretty loud and sometimes startling or unexpected, but music nonetheless. Music is a great way to engage our kiddos and encourage their buy-in.

As with anything, we have to remember that even though research shows really great things when combining music and learning, everyone’s sensory systems are different - some of my kids with low energy don’t even notice when I turn on music or a toy that talks, so this won’t always work. But in general, engaging the auditory system can be a great way to increase buy-in or excitement about what you’re trying to get your kiddo to work on.

Olfactory: Essential oils are a nice, natural way to create an environment as well. You can apply this on a wider scale, using essential oils to fill the air in your treatment room/area, or you can use this on a smaller, more individualized scale.

Oils can be integrated into your fine motor or other such activities, including:

Oral: Do you find it helps you focus when you’re chewing gum? Drinking a warm beverage? Having a crunchy or chewy snack? Drinking water or chewing cold ice? Use any combination of your clinical judgment skills, sensory measures, and/or parent input to determine if and how you may want to incorporate this system into your sessions or for recommendations at home.

Proprioception: People with less muscle mass or greater hypermobility tend to receive less proprioceptive input naturally registering in their system. Simply put, imagine someone giving you a nice, tight squeeze. Either wrapping their arms around your body or wrapping yourself in a tight or heavier blanket. These can feel very calming and/or organizing to your sensory system, thus helping you focus on the task at hand.

Vestibular: Fast swinging can increase alertness, and slow swinging is more known for relaxation. Think: laying out on a hammock swing. Relaxing, right? I love using a platform swing to encourage participation in an activity. Use this time to incorporate a fine motor task when their brain is feeling a bit more centered or organized.

Preferred items can be used to promote buy-in and increase alertness to the task, and more difficult components can be incorporated into the activity. For example, stringing or lacing activities, fasteners, bean bags toss all incorporate the use of fine and visual motor skills, bilateral coordination, crossing midline, laterality, dexterity, etc.


The Ease In

Your kiddo may be used to sitting around all day at home.

Consider the effects of various lifestyles on movement, organization, balance, and energy. If you’re used to a desk job where you sit for most of the day either you will rejoice in the opportunity for a walking break or you may dread exercise altogether - it’s an extra battle to get your I’m-used-to-sitting-all-day body up and moving around. On the hand, if you’re used to being up and on your feet all day, short rest breaks may be a welcomed change; however, sitting for a longer duration may feel just as fatiguing as was an exercise to someone in the first example.

Our kids are much the same way - if they’re used to sitting all day at school, sitting in front of a TV or gaming console, going to bed, and then starting over the next day, any amount of exercise may seem especially daunting… the hard thing is, is that in order for a movement to feel better, you have to get over the initial hurdle of “I don’t feel like doing this.”

Start slow: I’ve tried to do a full set of 5-6 exercises with a kiddo who plays a lot of video games and it was rough — for both of us! Too much exercise was inundating that little not-used-to-all-that-work body, and it tired them out too fast.

Balance: Try to intersperse exercises here and there. We may end up doing 10-15 exercises throughout a session, but it may just be 2 or 3 at a time, spaced out between other tasks.

The Energy Booster

Think of things that can help to motivate, spark interest, and keep your kiddo focused. If your kiddo has low energy, then moving around the room may be a good strategy at times; however, there’s value in balancing it out and staying in one place for awhile too. Completing seated fine motor activities at the table can help encourage your kiddo’s focus and attention to stay in that localized area. If you’re moving around the gym too much, you might lose them. Multi-sensory activities including Play-Doh, sensory bins, puzzles, or other such games, are a good place to start. Let’s take a look!

Play-Doh has a distinct smell and comes in just about any color you want! Use Play-Doh tools to help pique their interest, increase resistance, facilitate motor planning, problem solving, ideation, bilateral coordination, and to get those creative juices flowing and waking them up.

As I mentioned in my article on slowing down over-responsive kids, you can implement the elevator where your primary working surface is at midline, table top height, and some pieces may be off the left in front, a little out of reach to the right, on the ground to the left, etc. This can help to increase energy levels and attention to task by adding an unpredictable or changing element to your activity, causing the kiddo to have to be paying attention and looking around, rather than just doing repetitive work over and over in the same spot.

Puzzles can increase one’s engagement by increasing visual attention (scanning the pieces, referencing the picture on the box, identifying matching pieces or end pieces). Puzzles with sound (letters, songs, animal sounds, etc.) or multi-sensory pieces (soft, rough, bumpy, spikey) can be a good ways to increase arousal levels, and subsequently, attention to a task. Puzzles geared to the appropriate ability level for your kiddo, that is — you can easily lose someone by choosing a puzzle too high over their level.

The Engaging Task

In order to try and keep or increase attention, provide a toy or activity in a localized spot, but with lots of engaging components: sounds, lights, music, etc. try to engage your kiddo by incorporating these sensory components into an activity to meet their needs: cause-and-effect level play, TV or movie stars, imaginary play, or a game with immediate feedback or positive reinforcement. By using toys that are instantly engaging, you can eliminate some of that “down time” build up that may take too long for the current level of energy or attention of your kiddo.

Now that we’ve talked about different strategies to increase your kiddo’s energy levels and/or attention in your sessions, I’d love to hear some of the techniques you like to use with your kids. Do you take a sensory approach? Change the environment to meet their needs? Get them working on different levels to build in vestibular or visual challenges? Share your ideas with us below!

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