When should a child be referred to an occupational therapist? 

When to refer a child for OT

 It is important to keep in mind that each child develops at his/her own pace. 

The moment a child’s performance is impaired/influenced/limited in a life sphere (school, play, social skills, self-care, communication) the child should be referred for an occupational therapy assessment. 

If a child shows impairment in one of the following areas and/or struggles to cope with his/her current grade this child can be referred for an occupational therapy assessment 

1. Fine eye-hand coordination? 

This is the ability to use eyes and hands together to perform a task. 

We all use this skill every day in different kinds of situation: tying shoelaces, 

writing, cutting, dressing, the list is endless. 

It can only be the child’s hand function that is causing the impairment but 

vision (acuity and eye-muscle functioning) also play a big part. 

Children that struggle with in-hand manipulation/hand strength and/or individual fingers movements will find this skill difficult. 

Children that don’t have a dynamic tripod grip may also find writing/colouring/drawing difficult. 

How will I know if a child has a problem? 

  • The quality of the child’s writing/colouring/drawing is insufficient for his age 
  • Your child will struggle with activities that kids the same age finds easy 

e.g. buttoning small buttons when dressing, picking up small objects, threading beads, etc. 

  • Your child will rather get involved in gross motor activities than table-top tasks 

2. Muscle tone and/or postural control 

Muscle tone refers to the natural stress in the muscle when at rest. It is not the same as muscle strength. 

Postural control is influences by the proprioceptive (internal GPS of 

the body) system and the vestibular (movement and balance) 


A child that that had impairment with postural control or low muscle 

tone will use more effort to assume and maintain different postures/ positions. 

Impairment here may influence gross motor skills, fine motor skills and weight bearing tasks. 

As these kids find it difficult to sit still their concentration will also be negatively influenced. 

How will I know if a child has a problem? 

  • Tires more easily than other children 
  • Struggles to sit upright in a chair (slouches) 
  • Appear clumsy / uncoordinated 
  • Wants to sit when the have to stand and lie down when the have to sit 
  • Rides on her chair 
  • Find it difficult to maintain one position for a long time 
  • Slouch in chair 
  • May use a broad base of support when sitting – e.g. w-sitting 
  • May drool 
  • Finds it difficult to sit still – fidgety 
  • Usually doesn’t part-take in endurance sport 

3. Visual perceptual skills? 

These skills are necessary to interpret seen information in the brain. 

These skills are the building blocks for reading, writing and maths. 

How will I know if a child has a problem? 

  • Kids who struggle with foreground-background will ‘steal’ words/letters from other sentences/words and add it to the word/sentence they are busy reading. Also struggled to find one items amongst others 
  • Kids with a limitation in position in space and/or spatial relationships will confuse p/b/d, reverses letters/ numbers e.g. 7/L, 2/s, ei/ie, 31/13 
  • Kids with a limitation in form-constancy will struggle to read different 

Fonts, to copy the teacher’s handwriting, struggles to know that a capital and lower-case A is the same letter and struggles to find e.g. a triangle that is hidden begin other shapes 

  • Kids with impairment in closure struggles to take parts and make it a whole e.g. building puzzles, struggles to see the picture when only the outline is visible, struggles to place letters (visually) together to form a word 
  • Kids with impairment in discrimination will for example struggle to find a certain word/number on a page and to find the differences between 2 pictures 
  • Kids with a limitation in memory will for example struggle to copy work from the black board and to follow visual instructions 
  • Kids that struggle with consecutive memory will for example find it problematic to copy words/sentences/numbers correctly from the black board 

4. Visio-motor integration 

This is the ability use visual perceptual skills and finger-hand movement together to copy what you have seen. 

It is important to test a child’s visual acuity and eye-muscle functioning when you suspect a problem here. 

How will I know if a child has a problem? 

  • The child struggles to copy work from the black board/a book 

5. Bilateral integration? 

That is the ability of both sides of the body to work together to perform a task in a coordinated way. 

We use this skill daily e.g. skipping, riding a bicycle, eating, swimming, running and much more. 

Gross impairment here will influence laterality and midline- 

crossing negatively. 

How will I know if a child has a problem? 

  • Appears to be uncoordinated when doing tasks 

e.g. eating 

  • Difficulty in performing gross motor tasks e.g. skipping, galloping, 

jumping jacks, etc. 

  • Struggles more to perform a task using both hands together but performs adequately when doing the same task using only one hand 

6. Midline-crossing and laterality 

Dominance will start to develop between age 2 – 4 years and should be intact by 5 years 6 months of age. 

Only 5% of the population is truly ambidextrous – the rest of the kids that that swaps their hands/feet exhibits cross-dominance. Cross-dominance influences processing speed negatively and will this influence work speed as well as his fine-motor skills negatively. 

The ability to cross the imaginary midline of the body is midline-crossing 

Kids that show impairment here may also struggle with fine-motor skills, bilateral integration and processing speed. 

How will I know if a child has a problem? 

  • Choses a dominant hand later than expected or not at all 
  • Swaps/changes hands while performing a task 
  • Uses her left hand on the left side of her body and the 

right hand on the right side of her body 

  • Don’t want to cross the midline of her body 
  • Moves the book to the left/right when drawing/writing 
  • Turns/leans her body to the left/right when drawing/writing 
  • Turns the paper while drawing/colouring 
  • Poor sense of direction 
  • Confuses left/right after 7 years of age 

7. Praxis 

Praxis (also called motor planning) is the ability of the brain to 

conceive, organize, and carry out a sequence of tasks/actions. 

Praxis is the ability to self-organize. 

Praxis includes ideation – motor planning – task execution. 

Impairment here will influence gross motor skills, planning tasks, 

work speed and task execution negatively. 

How will I know if a child has a problem? 

  • Appear clumsy 
  • Difficulty in learning new motor skills e.g. riding a bike, skipping, jumping jacks, etc. 
  • Struggles to follow instructions 
  • Struggles to copy from the black board 
  • Difficulty in completing tasks with multiple steps 
  • Difficulty in doing tasks in the proper sequence 
  • Difficulty in adjusting to new situations or new routines 
  • Forgetful and disorganized 
  • Need to go right back and begin again at the very beginning of the task when having trouble, instead of just ‘getting on with it’ 
  • Have difficulty using tools – cutlery, scissors, pencils 
  • Hesitates before commencing a task 

8. Sensory integration 

This is the ability to modulate the 7 senses of the body to effectively 

function in your environment. 

There are 7 senses: vision, hearing, touch, smell, taste, proprioception and vestibular. 

I fa child over- or under-react to input in one of the above mentioned senses he will find it difficult to copy in certain situations/environments. 

How will I know if a child has a problem? 

Here are just a few examples: 

  • Doesn’t like it when his hands are dirty (over-reaction to touch input) 
  • Scared to climb jungle-gyms or jump on trampolines (over-reaction to 

vestibular input?) 

  • Easily distracted in visually busy environments (over-reaction to visual 


  • Easily distracted by noise (over-reaction to sound input) 
  • Gets easily nauseous when smelling certain odours (over-reaction to olfactory input) 
  • Loves rough-and-tumble play (proprioceptive seeking behaviour) 
  • Doesn’t feel it when he has a runny nose (under-reaction to touch input) Can’t spin on a swing for hours (under-reaction to vestibular input) 
  • Not aware of changes in his environment (under-reaction to visual input) 
  • His name must be called more than once before he listens (under-reaction to sound input) 
  • Shows under-reaction to smells that bothers other kids 
  • Drops items or walks into people/furniture (under-reaction to proprioceptive input) 

9. Proprioception 

This is the internal GPS of the body. 

It helps us to know what our body parts are doing when vision is occluded e.g. to walk in the dark from your room to the bathroom or to walk from the back of the classroom to the front without bumping into other kids/furniture. It further assists us in knowing how hard/soft we are doing movements and with timing of our movement. 

How will I know if a child has a problem? 

  • Plays to rough/’hard’ with other kids and is then  seen as a bully 
  • Strokes the cat/dog to ‘hard’ 
  • Drops objects 
  • Breaks toys without meaning to 
  • Sits ‘hard’ on a chair scraping it backwards on the floor 
  • Pushes hard with the pencil on the paper while drawing/writing 
  • Appears clumsy 
  • Bumps her toes a lot 

10. Vestibular system 

This is the system responsible for balance and postural control and gives us the guts to climb and to explore our environment. 

Kids with limitations here will struggle to perform gross motor tasks, fears climbing/exploring and doesn’t trust their own bodies. 

How will I know if a child has a problem? 

  • Avoids climbing/jungle-gyms/jumping trampoline 
  • Falls easily 
  • The child will rather perform table-top tasks than part-taking in gross-motor tasks 
  • The child doesn’t realize when he places himself in danger e.g. will climb onto The roof of the jungle-gym/onto the roof of the house 
  • Is scared to place his head in the backwards position 
  • Appears clumsy 
  • Doesn’t like it when her feet leave the ground – wants to be on a stable surface 

11. Insufficient concentration 

There are many reasons why a child’s concentration may not be sufficient. 

Some of the skills that show impairment, mentioned above, can be the cause. 

Other reasons include: 

  • Emotional trauma 
  • Tiredness 
  • Hunger 
  • Physical illness/pain 

One of the biggest reasons for insufficient concentration these days are children with insufficient postural control. 

Kids don’t play outside enough anymore and thus the proprioceptive- and vestibular systems doesn’t develop adequately. 

Before a child is taken to a doctor to be diagnosed with possible ADHD, please let an occupational therapist evaluate the child’s postural control before a miss-diagnosis is made. 

10. Other reasons to refer a child for an occupational therapy assessment 

  • The child reacted immature – cries easily, struggles to separate from mom/dad, can’t handle conflict, can’t handle criticism, cannot adapt to the class routine, etc. 
  • If a child struggles to cope with the demands of his current grade i.t.o. reading/spelling/maths 
  • If the child’s progress in his current grade is worrisome 
  • If the child exhibits problematic behaviour e.g. hurts himself/other children, frequently in physical/verbal confrontations, struggles to handle their emotions, gets angry easily, has mood-swings, kids with a poor self-image, kids that struggle with impulse-control, etc. 
  • Kids that struggle to sit still – out ‘busy bees’ 

More info on an occupational therapy assessment 

A full assessment takes approximately 2:30 hours (for kids between age 5 – 12). 

A full report of approximately 7 pages is types and an hour feedback session given to the parents. 

Forms are given to the teacher and parents to complete to determine the child’s functioning in class and at home. In this way a holistic view of the child is seen. 

Sometimes only a home-program is recommended but if the impairment in the child’s life-rolls/class functioning is influenced then therapy would be recommended. 

24 sessions of therapy (1 hour per week) is done after which a full assessment is done again to determine progress. 

The average child is seen in therapy for 48 sessions as we have to go back in development and facilitated the building-blocks that were missed. 

Some children finish after 24 sessions and some needs to continue for more than 48 sessions. It all depends of the severity of the impairment as well as each child’s progress. 

Remember each child has the ability to improve!! 

The younger a child is seen in therapy the easier it is to overcome the impairments. 

All kids are referred for vision-acuity and eye-muscle functioning as well as a hearing test as this will have an immense impact on a child’s functioning if impaired. 

We also refer to speech therapy, play therapy, paediatric neurologist and/or developmental paediatricians if necessary. 

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