How to Make and Use a “First and Then” Visual Board


Written By:  Elizabeth McMahon, MA, CCC-SLP
Speech-Language Pathologist

Visual boards are a great way to help children learn and complete targeted activities.  Sometimes, children may need to have a visual board to help them understand “first we do this” and “then we do that.”  For example, in the picture above, “first we string beads” and “then we play ball.”   There are some apps available that work on visual boards, but I find that children have responded better to using objects and picture cards that are more concrete and hands-on.  Here are some easy ways to make and use a “first and then” visual board.

  1. Draw a line down the middle of a piece of paper or cardstock.  Then, laminate it.  I like to use cardstock because it’s a little sturdier and doesn’t bend as easily.   You can find a basic laminator at any craft store.  I found one at Costco and it works really well.  If you don’t have a laminator, you could use contact paper.  Contact paper can be found at stores like Wal-Mart or Target and is usually in the kitchen liner section.
  2. Place a square of Velcro on each side of the line on the laminated cardstock.   This is your visual board.
  3. Find pictures to use as the activity you are requiring them to complete and then those you are using as a reinforcing object.  This is something that your child will work for.  What do they like?  What’s their favorite toy, food or activity?  You can find pictures online or take a picture of the object with your camera.  If your child is working with a speech pathologist, they may have the computer program called Boardmaker and can print some pictures for you.
  4. Laminate the pictures and add Velcro to the back.
  5. Introduce the “first and then” board to your child.
    • Provide your child a few objects and find out which one is motivating to them.  Then, place that picture on the right hand side of the board (e.g. ball).
    • Place a picture of the targeted activity on the left hand side of the board (e.g. stringing beads).
    • Tell your child “first we string beads and then we play ball.”  Show them the visual board and point to each picture as you give this instruction.
    • Provide the activity on the left (e.g. stringing beads).
    • Once this activity is completed, tell them, “all done stringing beads” and have your child take the picture off the board.
    • Then say, “now it’s time for ball” and immediately give them the desired object and let them play with it for a few minutes.

The “first and then” visual board can be used throughout the day at home, during therapy sessions and in the classroom.  You will need to change the desired object in order to have something motivating for your child.

Now It’s Your Turn:  Have you used a “first and then” visual board with your child?  How did it go?


Do’s and Don’ts for Protecting Your Child’s Joints


Written By:  Hannah Taylor, DPT
Brightsong, LLC Physical Therapist

Joint protection is important for children in order to prevent damage to their growing bones.  A joint is defined as the point where 2 bones are attached in order to permit body parts to move.  So, joints include the elbow, wrist, etc.   Here are some tips to protect your child’s joints.


  • Don’t pull on your child’s arms when assisting them from lying flat on their back to sitting.
  • Don’t swing your child by his or her arms, this can cause shoulder or elbow dislocation.
  • Do use proper hand placement to assist your child to sitting from lying flat or side lying (i.e. place hands behind head, back or on hips).
  • Do hold your child at their waist or trunk when lifting them up from surface or ground.


  • Don’t allow “W” sitting (i.e. when child sits on floor and knees are bent and out to either side of body).  “W” sitting places increased pressure and stretching on hips, knees and ankles.
  • Don’t pull on their legs, knees or ankles aggressively during dressing or play to prevent hip or knee dislocation.
  • Do provide good support of ankles and feet with proper shoe wear.
  • Do encourage proper sitting habits and posture.
  • Do monitor your child’s hips, knees and ankles in standing.  Are their knees hyperextended? Do their legs rotate in or out?
  • Do call your doctor if your child complains of pain in joints.


  • Don’t allow your child to participate in high impact sports activities or intense jumping without asking their doctor. This is especially true for children with Down syndrome – they are at risk for increased laxity in neck and vertebrae.
  • Do provide proper seating positions for your child. Make sure that chair is appropriate height for child; if needed place small stool or stack of books under child’s feet for proper support.

With proper care, we can help ensure that your child’s joints are protected in order to promote good growth and development. If your child complains about joint pain or if you have concerns about their posture, gait, balance or coordination – please talk to your child’s pediatrician.  They might need to see a physical therapist for an evaluation.

5 Ways to Help Make a Trip to the Dentist a Positive Experience


Photo Courtesy:  ClipArt

A trip to the dentist can be an uncomfortable experience for many people.  For children, a visit to the dentist can be scary.  Here are 5 ways you can make a trip to the dentist a positive experience in order to establish good oral health habits.

1.  Find a dentist with pediatric experience.  Working with adults is not the same as working with children and working with children with special needs can be different than working with other children.  Ask your pediatrician for a referral to a pediatric dentist.  Or, if you have a local parent group or play group, ask other families for recommendations.  Some dentists have extra credentials and training for working with children with anxiety or behavioral needs.  Do your research and find someone recommended by other families and professionals.

2.  Ask for a tour and a “meet and greet” before your child’s first appointment.  Some dental offices will give you and your child a tour of the office before your child’s first visit.  During the tour, ask if your child can see the room, sit in the chair, look at the instruments, meet the dentist, etc.  Taking a tour of the office and meeting the dental office staff before their first appointment may help ease your child’s anxiety.

3.  Schedule your child’s appointment when they’re not busy.   Many children have difficulty waiting.  Schedule your child’s appointment during a slow time at the office in order to decrease the amount of time your child has to wait.

4.  Complete the paperwork and provide information to the dental staff before the first visit.  Be prepared to share information about your child’s medical history, , special needs and/or behavior or sensory issues.  Discuss any problems with chewing, gum or tooth pain, toothbrushing, etc.  Also, provide information about your child’s diet, allergies and medications.

5.  Praise and use positive reinforcement with your child.  Ask the dental staff if your child can bring a comfort item with them during the appointment.  A lovey, blanket, toy or favorite music may help keep them calm and decrease their anxiety during the visit.  After the appointment, praise your child for how well they did and offer reinforcers as needed.  Some children may benefit from a “first and then” visual board.

It’s important to establish good oral health habits early in life.  Depending on your child’s specific medical needs, there may be additional dental visits and procedures.  For more information about working with your child’s dentist, please check out the Oral Health for Families with Special Needs Booklet.