Our second client, Toby, is an abused child who has suffered primarily from physical trauma. He has a mild to moderate impairment in balance, both his arms remain in 85 degrees flexion, his hands have decreased function, fine motor coordination, and weak grasp with the hands remaining in a fisted position.

He also suffers from secondary deficits that are a result of the emotional abuse that he received from his biological mother. Although his cognitive abilities are at an age appropriate level, he is hesitant to speak, withdrawn and easily frustrated.

1. Adaptation- Apply hand grips around the drawing utensil

Grading - As the sessions progress, increase the width of the hand grip.

Therapeutic Benefits - By increasing the width of the hand grip, Tobyís fingers that are rested in a flexed/fisted position will be encouraged to extend. By opening up this fisted position, his finger dexterity will increase. Play is an important occupational performance area (productivity) for a child. Increased finger dexterity will further Tobyís productivity level so that he can manipulate cars or action figures with ease.

2. Adaptation - Use a height adjustable chair

Grading - Initially, Toby can draw with his chair adjusted at a height to accommodate his present degree of arm flexion (85 degrees). The height of the chair can then be increased incrementally, as the range of motion in his arms and his functional ability increases.

Therapeutic Benefits - As sessions continue, increase the height of the chair. The higher the chair is, the further Toby will have to extend his arms. By increasing the height of the chair, arm extension is encouraged. As Tobyís range of motion in his arms increases, he can become more independent in self care activities such as brushing his hair, feeding (lifting the spoon to his mouth), putting on his shoes and dressing (putting on his pants). A chest strap should be used to ensure that Toby is indeed extending his arms to complete the activity. This will eliminate the trick movement of flexing his torso forward to reach the paper in front of him. A chest strap will also help Toby maintain balance as his completes the activity.

3. Adaptation - Place drawing supplies in strategic locations in order to encourage Toby to extend his flexed elbows. For example, avoid placing the drawing/coloring utensils directly in front of Toby. To encourage the flexion-extension movement involved in drawing, the materials should be placed to his side. He now will have to extend his arm to extend his arms to retrieve the desired drawing/coloring utensil.

Grading - The drawing supplies can be placed on higher shelves to promote Tobyís arm extension.

Therapeutic Benefit -. As the locations of the drawing/coloring utensils is changed, Toby will be encouraged to extend his arms. The range of motion in his arms increases and slowly will improve his arm function. He will become increasingly functionally independent. The skills acquired during the flexion-extension motion used in drawing the picture can be transferred to his occupational performance area in self-care. For example, the same flexion-extension motions are used in brushing teeth.

The activity of drawing/coloring is a good therapeutic medium to address Tobyís psychological concerns. He is withdrawn, anxious and easily frustrated due to his physical and emotional abuse. This activity can be used as an emotional release for his suppressed feelings. Furthermore, a sense of self worth and increased verbalization should develop as the therapist encourages Toby and he feels satisfied with his completed projects. Not only can drawing/coloring be a therapeutic medium, it is also a play and leisure outlet