General Recommendations for a School-Aged Child

***Other options for vestibular input include (remember these are not nearly as effective as swinging linearly from a single suspended point):

• porch swing or hammock outside or in room hang a hammock or swing in doorway

• holding the individual on a large ball, bouncing, rocking back and forth onto hands and feet, rocking gently to calm with their head down towards the floor, give good strong input to hands when coming down to the floor while over the ball. Then walk out onto hands with the ball under them then under their feet.

• RIDING A BIKE!

• rocking in chair or swinging in a blanket (two people hold on either side) & gliders

• Rocking on all fours on a water bed mattress filled with air

• wrapping in blanket (weighted blankets are best) and rolling

• JUNGLE GYMS, HANGING UPSIDE DOWN, CLIMBING, AND PLAYING ON GYMS.

• Brain Gym is wonderful! See resource list

• trampolines

• Dancing, gymnastics, karate, marching, power walking with weights, aerobics for children, horseback riding

• water beds

Proprioceptive input is next after vestibular input and brushing, best if done for 20 minutes every 2 hours.

Next address muscle tone, strength and proprioceptive modulation by giving strong doses of joint and muscle input:

Proprioceptive input is sensory input to the joints and muscles and is best to do every 2 hours . Proprioception helps the joints and muscles be "awake" and more responsive to motor control and helps with motor coordination as well as calming the brain. Proprioceptive input also helps with maintaining good muscle tone and coordination. Proprioceptive input is the best source of sensory input to help keep a good balance of serotonin in the brain which helps to regulate all the other brain chemistry and keep a neutral and relaxed learning state. Proprioceptive input is the best type of input to help with sensory modulation & regulation disorders.

Some activities include:

• JOINT COMPRESSIONS to a level joint dont forget fingers, thumb, wrist, elbow, shoulder, ankles, knees, and hips a minimum of 10 times each joint. Strong, quick compressions are best! You can do joint compressions even if you can't do the brushing, you can do them more often than the brushing as well. Trying them during more difficult times such as while walking in the hall, in the car, in the grocery store, when having to sit and attend for longer periods of time, it is the best "quick" sensory diet choice! Try giving this input before, during, and after a difficult task such as a test or quiet work time as well!

  • Deep pressure down the spine through pressure on each shoulder pushing down 10 times, wearing a weighted vest, and wearing weights. You can also make a neck wrap that is weighted to wrap over the shoulders (fill a very long tube sock with large feed corn or beans), this can also be laid over the lap when sitting or over the shoulders.

• Crawling (on belly) and Creeping (on all fours) are vital to joint input as well as a great way to help with eye hand coordination, left and right awareness (laterality and directionality), fine motor skills, muscle strength and endurance, and reading and math. Crawling and creeping are the most important developmental milestone and going back to that developmental stage helps the two hemispheres of the brain talk again and communicate better which is essential to good attention, reading, and other academic tasks! Set up the house and classroom with lots of tunnels, tents, air mattresses, and other things to crawl over, under, and on! For younger children they love to play animal walk games and imitate dog, cat, bear walks. This is a great way to give a sensory motor break in the classroom as well! Many teachers place hand and feet stickers on the floor and students "follow the trail" in the room for a break from sit down work and to "wake up the brain". Do creeping and crawling for at least 5 minutes each day!

• laying on tummy over ball, you can use the bumpy side of the ball for more input (large pink massage ball at Walmart for $11 is great!) or the smooth exercise ball, or the ab roller work well too (all under $15 at walmart) in the exercise section! Rock slowly and rhythmically to hands and feet, with a strong push into the floor with good input to their hands at least 20 times. Give firm touch on their back. You can end this with a wheelbarrow walk or just a handstand off the ball for a few minutes, or as long as tolerated.

• waterbed air mattress, fill with air (walmart for approximately $35) is a great way to give vestibular and proprioceptive input together. Ask them to remain on all fours, and rock. Then task load by asking them to lift a certain leg (right leg, then left arm) etc. And maintain this position for the count of 10. Very calming also to just lay on belly on the air pillow and rock gently. Great calmer before bed as well and in a.m.

• Any weighted tasks, pushing, pulling, lifting, stacking wearing weights or lifting heavy objects above shoulder level

• Elevate anything to make them reach up high to promote stretching and elongation

• Vibration & Massager to limbs, hands, feet, mouth, and back. Do not place vibration on neck, stomach or chest area (they can do it to those areas, but from another person it is too strong to these sensitive areas).

• For younger children play in a tent, tunnel, laundry basket, or big tub or kiddie pool filled with balls, rice, beans, sand, etc. Encourage crawling, rolling, laying on tummy, and pushing up from tummy position to weight bear as much as possible. This may be too exciting for some, and may be only appropriate for a big reward time, when they can get more excited and not be expected to sit and attend soon afterward.

• Jumping on a trampoline (watch for over arousal) keep it organized by counting to 100, doing times tables, saying ABC's for each jump.

• scooter boards laying on tummy and pushing with hands, playing hide and seek (the looker is on the scooter board) or pushing a therapy ball with their head to a certain designated place, or picking up weighted items along the way.

• Anything with weight, weighted vest, wrist and ankle weights, carrying or pushing heavy grocery cart, throwing weighted ball above head, stacking books or blocks. (Weighted exercise balls or medicine balls can also be purchased at walmart for under $10 and are a great way to give good input, throw at a target lifting above shoulder level is best). Play basketball with the weighted ball!

• Weighted Vest worn every hour for up to 20 minutes. (10% of body weight evenly distributed)

• Hanging from monkey bars and pull ups

• Trampoline and jumping

• Aerobics, karate, gymnastics, HORSE BACK RIDING!

• Tug of war

• nature hikes (wear a backpack with some weight too!)

• chair push ups with hands on either side of chair and student pushes whole body up 10-20 times, or to the counting or ABC recital in the am (another great sensory motor break activity that all students can do)

The last power sensation to keep in a daily sensory diet is Deep Pressure Touch.

Deep Pressure Touch is very important every 2 hours and helps keep the brain focused, clear, and enables us to concentrate and stay with a task longer. Dopamine & Serotonin is released when there is pressure touch.

Caution: Avoid light touch and textures that they do not like, NEVER FORCE TOUCH OR TEXTURES OR ANYTHING!!! You can try new textures after all this has been given, but never force any textures onto a child!

Deep pressure touch is the total opposite of light touch. Your body has two different touch systems: Light touch is the one that is there to "protect and Defend" by telling you that someone is near by a light brush on the arm, a bug has landed on your skin, etc. This light touch system causes a Sympathetic Nervous System response which results in a "Flight or Fright" response in the body and brain chemicals are released that may cause aggression, fear, anxiety, and overall a stressor. When an individual has Sensory Defensiveness, then this light touch system in heightened and reacts very easily. This is why they often touch you too firmly, or push, wrestle, or play hard (they are giving you the input they crave: deep touch).

The best way to give deep pressure touch is make sure you are giving the Wilbarger Brushing and Joint Compression Routine every 2 hours.

Other Deep Pressure Touch activities:

• Deep, hard massages (unscented lotions are usually best, ask the child to pick) Use the flat of palm and fingers rather than fingertips. Tell body parts in a calming voice to help with body awareness. Give firm, long strokes for calming input.

• Slow but firm stroking down the arms, back, head, and legs

• Wrapping in spandex, lycra, or other firm yet stretchy material.

• Some wear ace bandages under their clothing

• Weighted vests again!

• Lay under or wrap in a massaging, weighted, very heavy soft blanket, roll ball over their body while they lay on their belly starting at upper back down to feet, the ab roller elliptical ball works well for this and the bumpy massage ball as well. Let them chose the ball and blanket they want. You can also use the ball or a bean bag and Play "What kind of sandwich are you? Turkey!" and give deep pressure squeezes.

• Pressure Vest (can be purchased in therapy catalogs on resource page or made easily if you sew, just wraps around the chest, stomach, and back firmly)

• Fidget toys available at the work areas to squeeze, rub, and hold such as putty, dog and cat chew toys, balloon filled with flour or rice, stress balls, etc. Go shopping and let child pick a hand held quiet fidget toy, often it is an eraser or something simple that they can carry in their pockets!

• May need other options for clothing such as seamless socks found in Sensory Comfort catalog online.

3. Address tactile defensiveness by continuing brushing and joint compressions every 2 hours for at least 2 months and then begin to try new texture play experiences: Whatever textures they didn't like before, now attempt after brushing and joint compressions: Remember you have to be able to touch something to the hands, before the mouth! So play with the foods with hands only in a non-eating environment before trying to eat the new food!

*New and different textures on a daily basis such as cold, wet, slimy, sticky, rough, as well by doing play dough, finger paints, making cookie dough, playing in sand boxes, pouring rice and beans, playing in cold water, and making crafts using scissors, glue, and sticky textures. Let the textures stay on the skin for as long as they play, do not wipe clean. Let the textures be explored on all parts of the body, hands, feet, arms, legs, face, etc. Make shapes and letters and write name in the letters!

In the summer and spring you can fill up a kiddie pool with different textures and play in it outside, such as starch and water, flour and water, and other gooey and sticky textures. Year round in a basement is great!

For clothing try to wear around the house new clothing textures first, never put on something that may be irritating to go to school, church, or other social functions. This way if they can't handle the texture, then they can take it off at home without a meltdown in public!

If the texture is not accepted, don't force! Give firm pressure and massage and brushing and joint compressions before it is introduced again. Mix unaccepted textures with other textures the child does like and gradually introduce more of it.

4. Address texture preferences in the mouth by giving strong desensitizing oral touch daily and completing the brushing and joint compression protocol:

Remember: if they don't want to touch something on their hands, they usually won't put it in their mouth, let them explore with hands as well as mouth!

• oral defensiveness: See handout for better details.....always explore textures with feet and hands before mouth if child is defensive to oral textures. Use textures that they normally don't like to eat to play with hands and feet at a time different than meal time to make it fun and non-intrusive. Let hands stay messy, do not immediately clean hands.

* ****Use vibrating toys, vibrating star (baby teething section of Walmart), Nuk massage brush, or Spin Brush ($4) at Walmart around mouth and in mouth. Do this "brushing and vibration" in the mouth in the palate and tongue before trying to eat a new food texture.

* Have several available throughout the house, car, and school that you can give them whenever inappropriate biting, chewing, licking, or mouthing objects happens to replace the behavior but give them the oral input they need to calm themself.

Also, you can give very strong tastes such as sour worms, chewy things such as gummy bears, and very crunchy foods for snacks to help give very strong oral input at appropriate times. Drinking water from a squeeze bottle in which they have to suck hard to get it out helps with attention while sitting as well!

• Tooth brushing: Using an electric or spin brush for tooth brushing and letting them play with it and explore it along with other types of vibration to hands, arms, shoulders, and letting them hold it against cheeks and lips firmly to decrease oral defensiveness. Also, more importantly, continuing fun oral toy play with bubble blowers, noise makers, and musical instruments that make touch to the mouth fun and non intrusive.

5. Once they have received a regular "sensory diet" of these above activities every two hours in their day, then attention and a calm yet ready to learn state of mind can be achieved. You will begin to learn their "cues" and emotions and know when they need some input, and you will find 2-3 inputs that they like and really calm them quick for awhile, then they will change and want different inputs. Giving them a choice list of inputs to choose from is best, or giving two verbal choices.

Classroom and Home Modifications to the Learning Environment are vital!

• Start the day at home with brushing & Joint compressions and linear swinging

• Use a picture schedule for the days events and review this at breakfast, in the car, and teacher reviews events of day at school. When an activity is completed, then the picture goes in the all done basket, with the next activity always at top. Make sure there are sensory diet breaks at least every hour, with short intense learning periods mixed in with movement and sensory diet activities.

• ROUTINE, ORGANIZATION, AND PREDICTABILITY are vital to their ability to focus and attend! Anything that is unpredictable, chaotic, unorganized, or cluttered makes them feel very unfocused and they can't attend to what is important.

• Use regular sensory breaks using the above suggestions and Tool Chest handouts.

• Place the student with SID at the side front of the room, so that they won't get touched very often by people walking by their desk, but yet they can focus more easily on the teacher and not have to filter out so much stimuli between the teacher or board and their desk.

• CUT DOWN ON WALL ART!!! Visual distractions are very hard for them to "filter" and get used too, this only takes away from them looking at you the teacher! The colors Blue and green are great calming colors and are best if walls are left with nothing on them.

• Allow for standing times at a desk, or laying on belly on the floor, or sitting on a therapy ball when trying to listen or recite or answer questions. Get up and have structured movement times very often!

• Vary learning times so that intense short "sit down times" are no longer than 15 minutes at first, then you can work up to 30 minutes. After sitting for longer than 30 minutes, give a 10 minutes movement break, this doesn"t mean that they have to run around disorganized. Be creative and find ways to incorporate the academics into the movement and keep it structured and organized movement!

• Avoid a lot of worksheets with a lot of paper and pencil tasks, learning needs to be through movement and hands on and more visual than writing! Look at Montessori teaching techniques and other hands on learning books for ideas! Think of how you learn the best, through touch and movement!

• Use a timer (one that is visual with the red area for the remaining time is great, or a silent kitchen timer) when they must sit for certain period of time, and tell them that they cannot get out of their seat until timer goes off, and when the timer goes off then they can choose a sensory diet activity. This helps the student know when the work will end, and a sensory motor break is coming.

• After an unorganized and unstructured time such as cafeteria or recess, or a classroom visitor popping in, do a classroom calming activity such as Soldier Walks to a metronome beat: Russian soldiers with same arm and leg up and down, then British soldier with opposite arm and leg. Clap patterns to a beat, creeping and crawling, etc.

Another one is tree waving: Have class march around the room following a path that is marked clearly on the floor (can also use path to follow for creeping activities)with no obstructions in the way and have students pretend to be trees waving in the breeze, "How slowly can you wave?" You can do this standing behind chairs as well if the marching is too distracting and unorganized.

• Often the cafeteria is too much for these students and fights and aggression show their face. May want to look at creating a "quiet lunch group" picking a small group that eats separately and play soft relaxing music.

• Have a calming area in the classroom or a sensory area at home. This is an area that the child can go to when they are feeling overly stressed, and can swing calmly, rock in a glider or chair, sit on a bean bag and look at books, lay a bean bag on her body, go into a small tent, or cover a table with a dark cloth and let child go under there and calm down. This area has to be used wisely and cannot continue to be a way out of work. Use headphones with Gregorian chant or other calming music such as light classical music in this area as well, or play for the entire classroom.

• Some need "white noise" to help filter background noises this is often a fan or a CD made especially for white noise found in sensory catalogs.

• Use a reward system that is easily achieved such as the sensory diet choice, tokens, or sticker sheet, with a larger reward at the end of the day or week when goals are achieved. This often has to be changed as they may get bored with the rewards pretty quickly. A good reward at the end of the day or week is often to be able to do a big sensory motor task such as swinging at the end of work, or at the end of the week going to a local jungle gym. These children need as much positive feedback and encouragement as possible, they already feel like a failure and self esteem is always an issue, avoid as much failures as possible, look for the good in everything!

• Give each child a sign like a raised fist, or red card, or some kind of sign language that can be shown and raised to your attention when they feel like they are losing control. Give an immediate calming tool break, swinging in linear direction is usually a good choice at this time or going to the calming area of the room in a tent or under a table. This prevents explosions and outbursts!

To increase attention to tasks and increase sit down time at a work area when working one on one: A more structured adult led activity time in which environmental distractions like the T.V., alerting music, other toys, and bright colors are limited and student can focus only on you and the activity presented with no other distractions. This is often best accomplished in a cubicle type area in which you can use a corner with a desk and chairs and high walls around you to block out visual stimulus. Using a refrigerator box cut on one side and putting around you works well. You can call this area the "office" or work station and let the child paint and color the outside of the box, leave the inside plain to decrease distractions.

**Sit on the left of the student and present activities one at a time and use a green box for "go" to have items to work on and the red on the right for "all done" and work from left to right in presentation. This helps with the left to right movement necessary for hands and eyes when writing and reading.

** if fidgety in the seat, use a Move and sit seat insert, weighted vest, sit on big ball instead of chair, or other adaptions to help get the wiggles out. See attached Tool Chest activities for more ideas.

6. Classroom and Home Adaptions: Schedules are Wonderful!

All children need routines, and schedules that the student can understand help to establish predictability and routines which help the child tremendously...

1. Start each morning with an outline of the schedule for the day, highlight any changes that may be different. For younger children, you will have to keep it simple with shorter lengths of time, such as for the morning schedule before lunch, then review the afternoon after lunch. Use large picture symbols, and PECS system and place it where it can be seen such as on the desk, or on the board so that it can be found easily. Take off symbols and put in an all done basket when that task is accomplished to help the child keep track of what is next.

2. Use timers, such as the Red timers or digital timers that the child can understand for each activity length. This helps the child know when a sensory motor break is coming, hopefully a small break in between each 30 minute schedule, then larger 20 minute breaks after each 2 hour block.

3. Discuss or create stories about unexpected events such as fire drills to prevent meltdowns when they occur, take children to the gym or cafeteria before everyone arrives or a big event, or tape record these more stressful times and play in preparation for the actual event.

4. Use adaptions for each transition, such as the working left to right and all done basket routine; the clean up song, or other ways to cue the child that it is time to transition. Giving two choices with symbols helps with transitions as well.

5. Assist older children with homework organization, write it down in a specific place in their binders, or tape record assignments.

6. Color code notebooks and book covers to go together, or dividers in one large notebook to match so that they can keep track of each class.

7. Create classroom schedule with many breaks for movement and sensory motor activities. A good schedule goes as follows:

*Start the day with movement: Swinging, jumping to letters or spelling words, bdpq code charts, soldier walks, Simon Says, etc.

If you can start your day with gym or recess with structured play, this is best. Try to encourage linear calming swinging, limit erratic movements and unorganized play.

• Give small sensory motor breaks after each task or 30 minute class, such as Animal walks, chair push ups, wheelbarrow walk, jumping, weighted ball, therapy ball activities, calisthenics, carrying or pushing heavy objects...

• Give a larger and longer (at least 20 min.) sensory motor break every two hour (gym, recess, any movement works well in tight schedules) making sure that the child receives vestibular (swinging best) and proprioceptive (joint & muscle heavy work).

7. For auditory defensiveness the brushing and joint compressions should help, but in the meantime try to give them the filtering that her brain is not accomplishing by the following:

1. Limit extraneous auditory input from the hallway by closing your door or windows, cover the loud speaker with material to filter down the loud surprise factor. As much as possible, prepare the child for bells, announcements, etc.

2. Use headphones that cover the entire ear to help the child filter out extraneous background noises, white noise in the room often helps such as a fan or static. Or play white noise, calming music, or Mozart or Chants into headphones.

Sometimes ear muffs or the old large ear phones that cover the entire ear are enough to filter out some noises.

*If an FM system or auditory trainer is available through SPED dept. then this can help tremendously.

3. You can also play Mozart or Gregorian Chant music softly. Mozart is a neutral brain stimulant and stimulates more parts of the brain then any other music and Gregorian chant is calming and organizing and helps with the rhythm of reading as well.

4. Preferential seating at the front of the room, directly in front of the teacher.

5. Rugs, carpet, and even carpet or fabric on the walls and floors helps to decrease echo and extraneous noises. Remember the colors green and blue!

6. Chewing gum, sucking on water bottles, sour candies, gummy worms, fruit roll ups, crunchies all help to increase concentration on auditory.

7. Request an auditory processing evaluation, these children often have Cental Auditory Processing Disorders!

***Use ear phones or ear muffs (ones that cover the entire ear) to filter out excess noise, if this doesn't work then look at earphones from Sensory Comfort catalog that help to filter background noises. Treatment for auditory processing disorders helps this a lot too!

TRANSITIONS AND BEHAVIORS RELATED TO THEM:

8. If transitions and behaviors are a problem there may be a possible need for a picture schedule with activities for the day and what order they come so that student knows that unstructured activities such as TV watching is limited to certain amount of time and what is expected next such as going outside, or to the store, school times, so that they will know and have a reminder other than verbal cues of what transitions are coming.

• Visual reminders can be as simple as a picture of activities, a word, or an object representing each transition. Using a timer like an egg timer can help when working on structured tasks, so that the student understands when the timer goes off, then they can play. You can reset the timer again to show how long they have to play before the next transition.

• May need to combine verbal choices when student is upset with the actual object or pictures of objects. Often when a child is upset they cannot tell you what is wrong and if they have another option other than a verbal response then they may be able to tell you what they want by pointing to a picture or taking the object that represents the picture. If it is something that you cannot give her at that moment then you can show pictures saying, "This now, then...(what they want)".

**Remember to have a picture list or a written list of calming sensory activities for them to choose from when they are upset. Put in a central location in the home and classroom that they can go to and choose from while upset. If they are not able to do this, then give them the choice of two activities (usually linear swinging and brushing and joint compressions are the most calming).

• If new places are difficult and stressful, recording the sounds and video tape that place before they have to go there, playing the tapes at home or in the car for several weeks before they have to be there. This works great before they transition to a new classroom, therapy room with children playing in it, basketball games, gym, and other new and possibly stressful environments and playing these tapes at home for a few hours a day may help them integrate and become more accustomed to the new environment. May need to do this for many weeks prior to a new stressful task. Adapting environment as needed to create a calming learning environment. Remember to brush and joint compress and swing before going to this stressful environment, and wear a weighted vest, pressure vest, and ear muffs if necessary to prevent a meltdown.

Quick List of Organizing Sensory Activities to fit into Daily Schedules

Sensory input is a natural calming drug for the brain, we all need it to stay calm, focused, and feel "put together", children w/ SID need more of it & more often...

Calming and Organizing Input:

• Vestibular: linear swinging or gently rocking back and forth, move n sits

• Proprioceptive: wearing weighted vests, joint compressions (including wheelbarrow walking and jumping), creeping and crawling, placing hands on shoulders and give firm pressure down into the seat, marching (Russian and British), chair push ups, lying on stomach with weight on elbows, elastic material around chair legs for resistance in seat, and carrying or stacking books, and helping with chores.

• Oral motor: chewing on gum, gummy bears, sour worms, rice cakes, carrots, or other firm and crunchy snacks. Water bottles at their desk can help with focus and organization. Oral toys, bubbles, blow paints, and other oral blowing toys are great as well!

• Calming spaces: it is very important that a child with SID have a way out of an environment that causes them stress. Each classroom should have a quiet space in which there is minimal visual and auditory stimuli. A reading corner behind a bookshelf, under a table with pillows or bean bag chair, rocking chair in a corner behind a curtain, a small tent, or a swing that only goes in a linear direction the classroom are great ways to provide a calming time. Children will often choose these areas on their own, just make adaptions to make sure other children are not invading their quiet time. Let them have a way of telling you they need a break as well before a meltdown occurs.

• Posture: make sure that the desks and chairs are at the right height for each child, feet touching the floor all the way (not on toes), elbows resting comfortably on desk without humped shoulders, 90 degree rule for all joints.

Some children need inclined writing boards to help with posture, as well as the move and sit seat wedges, weighted vests, and proper pencil grips to stay seated and focused for harder fine motor and table top tasks.

• Motor planning: to help children with motor planning difficulties try to give short instructions with one step at a time, use other students to model and buddy with the student. Use multi sensory approach to teaching new skills: remember all senses when teaching. Remember the child's best learning sense, find what that is, and teach first with that sense!

• Use adaptions to worksheets such as limiting visual stimuli by using a black piece of paper to go under each line of work or reading, use graph paper for math, and only expose one or two lines at a time.

• Use the computer for skills that are very difficult, limit long writing times.

9. Address visual motor and perceptual delays by first having a developmental Optometrist do an evaluation and vision therapy.

You can also increase opportunities for visual perceptual tasks such as creeping, marching, bdpq code charts, copying greater than 6 block or bead designs with different shapes and colors to match, copying complex shapes from an example or picture, complex shape sorters, parquetry block designs, games such as find the missing part, or complete the picture work books, or where is Waldo type visual games. Movement activities associated with eye-hand coordination such as swinging while throwing a ball at a target, standing on an balance board while playing catch, or jumping on a trampoline and throwing a ball.

10. Address fine motor delays by:

Crawling and creeping and other weight bearing on the hands is vital to developing the arches and fine muscles needed to write and manipulate objects!

• Use the Stetro pencil grip making sure that the arrow is pointing toward the pencil lead, it is secure on the pencil (no movement of the grip), and that their thumb is on the star and first and second fingers in the indents appropriately.

• Increase web space strength by using coffee filter separators (utensil section of Walmart) or small tongs to pick up and squeeze objects.

• Increase distal finger strength by making very small circles, loops, shapes, and practice cursive letters. Making sure it is a very small stroke using the finger tips, not the hand or arm movement.

• Giving regular opportunities for performing fine motor tasks such as stringing tiny beads, placing tiny objects into a small container, using tongs to pick up cotton balls or other objects and release into small opening, moving coins, beans, and paperclips from palm to finger tips and back to palm, and lacing boards. Emphasize using only left hand, without assistance from right, then right alone, and always cross midline! Using clothespins, modeling clay, and other manipulatives to increase finger strength and coordination. See Fine motor can handout