What is whole child (AKA holistic) occupational therapy?

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Whole child pediatric occupational therapy is a dynamic approach based on the understanding that all aspects of a child — physical, cognitive, social and emotional — are interconnected. In short, we are more than the sum of our parts!

Is whole child occupational therapy right for my child?

Discovering your child has a challenge or a specific diagnosis is huge and can be extremely stressful. Deciding the best way to help a child/children can be confusing and overwhelming.

There are several types of occupational therapy:

  • Targeted therapy works on a specific skill such as handwriting. This is a good strategy for a child with a particular problem.
  • Some therapists teach compensatory strategies. These are used when a skill gap is considered to be too big to be bridged.
  • Therapists who use the whole-child approach view the challenge or diagnosis from the perspective of the whole child. Each of us is more than just a problem. The whole child approach is especially beneficial for children who have complex needs such as sensory processing disorder (SPD), autism spectrum disorder (ASD), attention deficit disorders (ADD/ADHD), specific learning disability (SLD), cerebral palsy (CP) or developmental disorders.

Let’s look at a problem using the whole child approach

It’s not always obvious that a skill gap can affect the whole child. Take something like handwriting, a skill that many OTs work on because it’s seen as a fine motor problem. For some children, a little practice can improve handwriting but, for others with more complex needs, practicing specific aspects, such as fine motor control to form letters correctly, does not improve handwriting skills. In focusing solely on one aspect, we often lose sight of the most important feature of writing — the content!

After around eight years old, a child’s focus shifts from ‘learning to write’ to ‘writing to learn.’ For this to happen, writing must be easy and automatic. When the mechanics of writing require thought, less attention can be devoted to content, because you cannot do two thinking tasks at the same time. If a child has to put all his energy and time into neatness and legibility, sizing and spacing letters, then original ideas, creativity, content and comprehension get much less thought and attention.

The skills children need to shift from ‘learning to write’ to ‘writing to learn’

If writing is to be easy and automatic, these are the skills a child needs:

Optimal sensory processing

Optimal sensory processing requires integration of a network of information from the sensory systems; the information must be correctly interpreted at the right time. Sensory information, crucial in learning to write, comes from movement, touch, vision and hearing. Information from these systems must be integrated for writing to become easy and automatic.

Good posture

Using the hands is easiest when we have good posture. An upright, easy, relaxed position, with stable shoulders, elbows and wrists, supports flexibility of movement in the fingers. We need both stability and flexibility to form letters that are easy to read and correctly sized and spaced.

Mature motor coordination/primary reflex integration

Motor coordination is built on early simple automatic patterns known as primitive reflexes. Primitive reflexes typically integrate during the first year. If they remain active after that time, fine motor activities, including writing, are negatively impacted because primitive reflex patterns block the flexible motor coordination skills needed for effective, easy, automatic handwriting.

Visual motor integration (VMI)

VMI is the ability to see something and be able to reproduce the image using the movement systems. The child must first learn to write each letter and then be able to access a visual memory image (in our example, a specific letter shape) and be able to reproduce it accurately each time it is written. Problems with VMI could mean that the child has difficulty writing his letters without a visual model or makes mistakes.

Cognitive readiness

Writing is an incredibly complex activity that has many cognitive components. A critical aspect is understanding language. The child must also be able to maintain attention, recall information from her memory, and sequence letters into words and words into sentences.

She must be able to express information that is relevant and begin to demonstrate an understanding of the concept of the material. The child must also be able to follow directions — written, spoken or a combination of both.

Writing and thinking

Writing helps teach a child about the rules and relationships between words and ideas. Writing helps us to organize our thoughts and refine and reflect on those thoughts. Writing allows children to show what they know and also helps others to identify gaps in understanding of a topic.

Motivation/self-esteem

If a child has challenges with a specific area or combination of the skills listed, and no amount of practice and effort improves his writing skills, staying motivated becomes challenging. Who wants to work on a task that never gets easier? Struggling with an activity that your classmates can do easily impacts self-esteem and a vicious cycle of perceived failure can emerge. This may lead to refusal to work or avoidance strategies such as clowning around.

How do the different therapy approaches address writing challenges?

A therapist who targets a specific skill may work on improving the mechanics of handwriting — legibility, sizing, spacing or speed. This is great if that is the only issue. If practice has improved quality but not shifted writing to easy and automatic, the child may work slowly and fail to finish, have difficulty grasping concepts or not fully understand the material.

A therapist using the compensatory approach might say you’ve worked on writing for a while without success; let’s try something else — typing. This can be a good strategy, especially because children are learning to type at younger ages. But when information is written down it helps with organization and refining of thought and is more likely to be remembered. Information we remember can be used as a tool for learning.

The therapist who takes a whole-child approach works on the complex aspects that integrate to develop handwriting. By working with the ‘whole enchilada,’ we turn the skill of writing into a tool for future cognitive/academic development by shifting focus to the content.

Because many of the components used for handwriting are needed for developing other skills, like self-care, fine motor activities and playing, working with the whole child gives us the most ‘bang for our buck.’

When we work with the whole child, from foundational, sensory integration and maturation of reflex patterns, to higher level motor coordination, emotional regulation and cognitive skills, we are building competence, which supports self-esteem and motivation and opens up social and academic opportunities.

How do you decide which approach to use?

Most people would agree that therapists, regardless of their treatment approach, are committed to the care and development of the children and families they work with. So I can only answer this question from my personal perspective.

I began my pediatric career in the school system, working on specific skill gaps. Many of the children I worked with learned the skill but often could not complete similar activities successfully. I didn’t understand why my little guys couldn’t use success in one area as a flexible, creative tool for learning other skills, which is what happens in ‘typical development’.

Searching for an answer to this conundrum, I found myself in a sensory integration clinic where I began a 10-year journey learning about sensory processing. During that time I became a yoga teacher and certified pediatric yoga therapist. Motor coordination and the quality of movement became an important part of my personal and professional life.

I trained in mindfulness-based meditation to deal with my own stress. I found that it worked for the children I work with too! Everyone, including children, is more effective when they are free from stress and worry.

Teaching pediatric practice and human development, through the lifespan, at a university reminded me that there are many areas that impact growth and development. I had to dive deeper into developmental milestones and things like primitive reflexes.

Returning to hands-on occupational therapy practice, I found that combining all aspects of development produced the best results. I have been studying, researching and refining the whole-child approach for eight years.

I have been an occupational therapist for 23 years. The time has flown by and I am still learning. I am excited about the future of clinical practice as researchers discover more about how we work. For me, the whole-child approach is the only way to go because what part of a child’s skill set and life is not important — is there any part that I would leave out? Of course, the answer is that every part is important and I wouldn’t leave anything out if I knew a way to improve a skill or bridge a skill gap.

In upcoming blogs, we will examine some of the parts that make up the whole child, with the understanding that the parts work together and that we are more than the sum of our parts!

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