Facilitating Adaptive Behavioral Responses

Occupational therapy uses specific child-directed sensory activities to achieve adaptive behavioral responses. To achieve adaptive responses specific support is provided to assure that the behavioral demands are challenging but not too difficult to achieve. Sensory coping strategies and sensory coping areas can be used to obtain the right combination of challenges and supports for adaptive behavioral responses.




While occupational therapy sensory activities are often criticized as being “fun but too frivolous for school”, students must be willing to actively participate in activities in order to learn from them. Discovering students’ interests is crucial for developing activities they will actively engage in to improve their adaptive behavioral responses. Once students are willingly engaging in activities the tasks can be gradually modified to promote their goal-directed adaptive behavioral responses (e.g., frustration tolerance, attention, seated attention, direction following, keeping safe hands).   An individualized program of sensory copying strategies that promote self-control can be developed using the FAB STRATEGIES Form COLOR





Once therapists and teachers find engaging activities it is important to continuously modify the tasks so they are at a level that is not too hard or easy for the student. Students with behavioral, developmental, trauma history, and/or sensory processing challenges frequently show poor motivation and school behavioral problems because their developmental level and interests do not match the classroom curriculum. A preschooler at a six month developmental level obviously needs modifications in the typical preschool curriculum developed for four to five year olds. A more complicated challenge is the student with behavioral, developmental, trauma history, and/or sensory processing challenges who functions at significantly different levels in various developmental areas, requiring diverse challenges in different developmental areas (e.g., two year old social and six year old reading skills).

Because of delayed behavioral skills many children benefit from a sensory coping area they can use when they begin reacting negatively to environmental triggers (e.g., “being told what to do, being told no”) or showing body triggers (e.g., “acting hyper, hand fisting”).   Sensory coping areas can vary from a special desk in the back of the class where the student can take a break to a designated room where the child can go with a teacher to do their self-calming activities.  It is helpful to record the activities used and affects of the sensory coping room using the FAB Sensory Coping Area Log Occupational therapy directed sensory coping strategies and sensory coping areas are helpful ways of promoting child-directed sensory activities that promote students’ adaptive behavioral responses.


Stackhouse, T. M. (2014). The adaptive response to the just-right challenge: Essential components of sensory integration intervention. Sensory Integration Special Interest Section Quarterly, 37(2).  


Coping With Hearing Voices

Hearing voices that others don’t perceive is a challenging difficulty for a small but significant number of children, adolescents, and adults. While some people who hear voices do not experience functional problems, many do.  Medications help some but not all people who have functional difficulties involving hearing voices, but do not always eliminate the problem. In addition unlike cardiac disease, people who hear voices also have to deal with being discriminated against and uncomfortable discussing their experiences, something medication does not address.

My experience of working with children, adolescents, and adults with functional problems related to hearing voices got me to research non-medication interventions that could help. While little non-medication research is done in the United States, support groups and coping strategies are used extensively in England to help people with functional problems related to hearing voices. Recently, the Connecticut Department of Mental Health offered a workshop by Rachel Waddingham http://www.behindthelabel.co.uk a United Kingdom interventionist whose work I’d read about. Ms. Waddingham described how support groups, mindfulness activities, and the use of coping strategies can help children and adults who hear voices as a component of their intervention.

As an occupational therapist working in psychiatry I use purposeful activities and coping strategies extensively with some children, adolescents, and young adults who have functional problems related to hearing voices. I sometimes use propelling scooter boards, exercise, taking clients to therapeutic horse back riding, mindfulness activities, and other coping strategies as part of a comprehensive treatment program to help individuals who hear voices.

Engaging in meaningful activities helps assess and promote functional skills. To help youth and adults with functional difficulties related to hearing voices find meaningful coping strategies, I ask them to select 3 from each page of the PaganoFABTriggerCopingForms copy It is helpful to build on the coping strategies the individual is already using affectively to help them better manage their biggest environmental and body triggers.

As a school occupational therapist in a psychiatric hospital school I use partial sentences to simultaneously address writing and provide opportunities to express feelings. In the following example using partial sentences a student expressed her fear of hearing voices and loneliness of not seeing her mom.


Coping cards are index cards that are constructed to address the student’s functional goal.  Using an index card a student uses pictures or words to describe their functional goal, preferred interest, reinforcement schedule, and most affective coping strategies.  This reminds students and staff of their individual goal and coping strategies for achieving the goal.


Public school occupational therapy bulletin boards are another way of teaching about coping strategies while showing that occupational therapy can be useful for all students. It helps address the bias some students have that occupational therapy is “only for mentally retarded and crazy kids”, and teachers are always willing to let me have one of their bulletin boards.


The needs of individuals who hear voices is inadequately addressed in the United States because of the fear and biases related to this problem and it is time we professionals address it. Coping strategies have been a useful component of my interventions for individuals with functional difficulties related to hearing voices.



Farhall, J., Greenwood, K. M., & Jackson, H. J. (2007). Coping with hallucinated voices in schizophrenia: A review of self-initiated strategies and therapeutic interventions. Clinical Psychology Review, 27(4), 476-493.

Kovacs, M. & Lopez-Duran, N. (2012). Contextual emotion regulation therapy: A developmentally-based intervention for pediatric depression. Child and adolescent psychiatric clinics of North America, 21(2), 327.




Improving Sensory Integration, Emotion Regulation, & Learning

Occupational, Speech/Language, and mental health therapists can work in conjunction with teachers to integrate sensory integration and mindfulness activities with positive behavioral support preventive interventions. Sensory Integration can help enhance emotion regulation and behavior. Synthesizing sensory integration with positive behavioral support strategies comprehensively addresses the development of sensory seeking, novelty seeking, and impulsive behaviors associated with conduct disorder behaviors. The synthesis of sensory integration and behavioral strategies has been extremely affective for my students with behavioral, psychiatric, sensory processing, and learning challenges.

Occupational therapists using sensory integration benefit from synthesizing the Sensory Integration and Positive Behavioral Support frames of reference to improve student’s occupational performance at home and school. It is important to work with teachers, families, as well as Speech/language and mental health therapists in schools to comprehensively address the learning needs of children with behavioral, sensory processing, and learning challenges. While schools tend to delegate the students needs (e.g., cognitive, psychological, physical, social) to diverse professionals they come to school as whole unique individuals.

The DECA and PATHS positive behavioral support programs work well in conjunction with occupational, speech/language, and mental health therapy intervention. The DECA assessment address the resiliency skills of attachment, initiative, and self-control while also screening for internalizing and externalizing behavior concerns. If a child has difficulties in self-control (e.g., never listen to or respect others) this goal area can be comprehensively addressed to improve learning. Examples of sensory integration classroom modifications that help address this goal are a sensory quiet area for use when becoming upset, a study carol to limit distractions, and a wall pushup bulletin board.



Infusing mindfulness movement activities into the PATHS positive behavioral support program can help hyper-reactive students pay attention.



The PATHS program includes lessons regarding understanding feelings, respecting others, and providing reinforcement for respecting others. Too often school staff members are so busy dealing with problem behaviors that we forget to reinforce the behaviors we want.  Collaboration between teachers and occupational, speech/language and mental health therapists in the schools can enhance positive behavioral support programs and student behavior.


Fishbein, D. & Tarter, R. (2009). Infusing neuroscience into the study and prevention of drug misuse and co-occurring aggressive behavior. Substance Use & Misuse, 44,1204-1235.

Greenberg, M.T. (2006). Promoting resilience in children and youth: Preventive interventions and their interface with neuroscience. Ann. N.Y. Acad. Sci., 1094; 139-150.


Occupational Therapy for Autism

Occupational therapy improves the functioning of individuals with Autism Spectrum Disorder (ASD), behavioral, and sensory processing challenges. Inclusion of sensory symptoms (e.g., over or under-responsive to or atypical interest in sensory stimuli) in the new DSM-5 ASD diagnosis has the potential to further promote the use of occupational therapy (OT) interventions for Autism. Research currently supports the relationship between sensory symptoms and functional behavior problems affecting individuals with ASD. However, the contribution of occupational therapists has been limited by a lack of attention to the interrelated sensory, behavioral, and developmental challenges of many individuals with ASD.

OT uses the sensory integration and behavioral frames of reference to improve functioning in daily activities. The Sensory Profile www.sensoryprofile.com ; PaganoFABTriggerCopingForms ,activity analysis, and clinical observations can be useful components of an OT Evaluation. The OT Evaluation helps determine the most important functional goals related to sensory and behavioral challenges.

Functional goals for clients with ASD can include increasing seated behavior, attention, and keeping safe hands (e.g., eliminating physical aggression towards ones self and others). Objective baseline data is used in developing the functional goal and monitoring progress. Examples of baseline data may include: client currently sits a maximum of 10 consecutive minutes, attends to teacher selected tasks for an average of 5 minutes, or keeps safe hands (e.g., does not hit others) for ten consecutive minutes.

Occupational therapy sensory interventions related to functional goals in ASD include psycho-education, environmental adaptations, sensory diet activities, and direct therapeutic intervention. Psycho-education involves teaching clients with ASD how their sensory processing, emotion regulation, and behavior challenges affect their functioning. A related intervention is coaching clients, families and professionals to develop environmental adaptations that enhance participation in daily activities.

Environmental adaptations include the use of adaptive equipment and techniques that enhance daily functioning. Commonly used adaptive equipment for ASD include noise canceling headphones, fidget toys, chewey tubes, and theraputty. Frequently used adaptive sensory strategies for clients with ASD include initially reducing then if needed incrementally increasing sensory input in a socially acceptable manner, choosing one activity and doing it for a set period of time beginning another task, and using a sensory coping area to improve self-control.

Clients with ASD, sensory processing, behavior, and social skill challenges may receive direct occupational therapy services including sensory and behavioral interventions. Given the strong relationship between tactile sensory processing and behavioral problems in ASD, touch intervention appears important. Examples of direct intervention activities for clients with ASD include massage, scrub brushing, vibration, mindfulness, yoga, and movement planning tasks.

By combining sensory and behavioral strategies as part of a transdisciplinary team, OTs can achieve functional goals that enhance the daily life of individuals with ASD (e.g., increased attention, improved social interactions, decreased self-injurious behaviors). Pivotal Response Therapy (PRT) http://education.ucsb.edu/autism is an evidence-based behavioral strategy that can be used in conjunction with sensory strategies. PRT provides developmental transdisciplinary interventions addressing effort, communication, and social interactions. Developed by a psychologist with expertise in Applied Behavioral Analysis and a Speech/Language Pathologist, PRT is a practical intervention that is useful for teachers, parents, as well as occupational, speech, and physical therapists.

For example, a behaviorist and I provided services to a kindergarten girl who had ASD, sensory seeking, and behavior challenges. Her repeated hand mouthing was interfering with learning and damaging the skin on her fingers. Our transdisciplinary assessments included a FAB Sensory Functional Behavioral Analysis (FBA), Sensory Profile, and observations.  The FAB Sensory FBA adds sensory environment antecedents (e.g., loudness, crowding, transitions) to traditional FBA data for greater focus on antecedents (what happens before problematic behavior that could be changed to improve functioning).

The evaluation suggested she was sucking her hands to receive sensory input in her mouth and wetness on her hands. Using a Preference Assessment and Activity Analysis, her favorite activities matching the sensory input she got from hand sucking were mouthing a chewey tube and playing in a water table. Intervention involved allowing use of the chewey tube and water table as well as rewarding her for going progressively longer periods with out sucking her hands.



This example shows how sensory and behavioral strategies can be combined to improve functioning in individuals with ASD.  Transdisciplinary use of sensory and behavioral strategies is especially helpful for improving functioning in individuals with ASD, sensory processing, and behavior challenges. It is time for the conflicts to end so all professionals are working together to help our clients. Hopefully, recognition of sensory challenges in the new ASD diagnosis will encourage transdisciplinary sensory and functional behavioral interventions.


Dunn, W., Cox, J., Foster, L., Mische-Lawson, L. & Tanquary, J. (2012). Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: A pretest-posttest repeated-measure design. American Journal of Occupational Therapy, 66(5), 520-528.

Foss-Feig, J. H., Heacock, J. L., & Cascio, C. J. (2012). Tactile responsiveness patterns and their association with core features in autism spectrum disorders. Research in autism spectrum disorders, 6(1), 337-344.

Silva, L., & Schalock, M. (2013). Treatment of tactile impairment in young children with Autism: Results with qigong massage. International Journal of Therapeutic Massage & Bodywork, 6(4), 12-20.

Stahmer, A., Suhrheinrich, J., Reed, S., Schreibman, L., Bolduc, C. (2011). Classroom Pivotal Response Teaching for children with Autism. New York, NY: Guilford Press.

Mazefsky, C. A., Herrington, J., Siegel, M., Scarpa, A., Maddox, B. B., Scahill, L.& White, S. W. (2013). The role of emotion regulation in Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 52(7), 679-688.



Sensory Interventions for Autism

The new DSM-5 Autism Spectrum Disorders diagnostic criteria finally include sensory symptoms (e.g., over or under-responsiveness to or atypical interest in sensory stimuli) as part of the diagnosis and treatment of Autism. This inclusion of sensory symptoms under the domain “restricted repetitive behaviors” (RRB) will expand sensory processing evaluation, research, and interventions related to the functional difficulties of people with Autism. Individuals with Autism and their families have long realized the practical benefits of sensory strategies on daily life, despite the criticisms of this approach by some pediatricians, behaviorists, and researchers.   The DSM-5 eliminates the diagnoses of Asperger’s and Pervasive Developmental Disorder, combining them under the diagnosis of Autism Spectrum Disorders (ASD). ASD is now categorized as Level 1 requiring support, Level 2 requiring substantial support, and Level 3 requiring very substantial support.

Occupational therapists, physicians, and other professionals can consider the affects of sensory processing on behavior, social skills, and activities of daily living when determining the level of support needed. Assessment of sensory processing problems impacting daily functioning can be done efficiently by combining reliable, valid evaluations with observations of the individuals functioning in various settings. There are many types of interrelated sensory processing challenges, so it is important to have a comprehensive assessment of functional skills and sensory processing . http://www.spdnetwork.com


Sensory processing problems in the area of Sensory Modulation (e.g., over or under-responsiveness to or atypical interest in sensory stimuli) are emphasized in the new DSM-5 Autism Diagnosis. http://www.sensoryprofile.com A reliable, valid self-report measure of sensory modulation and its impact on behavior and daily functioning is the Sensory Profile The Sensory Profile includes versions that assess all ages, allowing for assessment of how the sensory styles of individuals with Autism and their family members, teachers and co-workers affect functional interactions (e.g., allowing parent coaching regarding functional interaction strategies if both children with Autism and their parents are extremely Sensory Sensitive).


My next blog post will further discuss interventions for individuals with Autism Spectrum Disorders.


Hazen, E.P., Stornelli, J. L., O’Rourke, J. A., Koesterer, K., McDougle, C. J., (2014). Sensory symptoms in Autism Spectrum Disorders. Harvard Review of Psychiatry, 22(2), 112-124.

Silva, L.M. & Schalock, M. (2013). Prevalence and significance of abnormal responses in young children with Autism. North American Journal of Medicine and Science, 6(3), 121-127.

Volkmar, F. R., Reichow, B., McPartland, J. (2012). Classification of autism and related conditions: progress, challenges, and opportunities. Dialogues in Clinical Neuroscience, 14(3), 229-237.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3513678/pdf/DialoguesClinNeurosci-14-229.pdf

Whitney, R.V. & Miller-Kuhaneck, H. (2012). Diagnostic Statistical Manual 5 changes to the autism spectrum criteria: A critical moment for occupational Therapists. The Open Journal of Occupational Therapy, 1(1), article 7.



Behavioral & Sensory Strategies for Young Students

Theraband chairarm rotation

Integrated sensory processing and behavioral strategies improve the behavior of pre-school and kindergarten students. Combining Positive Behavioral Support and sensory processing adaptive equipment and techniques can help regular and special education students behave better, pay attention, and learn. A helpful initial resource for pre-school and kindergarten teachers is www.pbisworld.com which suggests behavioral strategies and classroom adaptations.


The PBIS World website helps pre-school and kindergarten teachers identify the most problematic student behaviors. PBIS World then provides a menu of appropriate Tier 1 regular classroom, Tier 2 small group, and Tier 3 individual interventions to choose from for improving behavior. Free data tracking forms are also provided for monitoring the effectiveness of the selected behavioral interventions.


Special education teachers as well as occupational, speech-language, or mental health therapists can assist teachers in identifying the best Tier 1 interventions for a specific student, and can assist the teacher by providing Tier 2 or Tier 3 interventions within and outside the classroom. It is important for team members to provide consistency between Tier 1, 2, and 3 interventions so students are not confused by varied rules and procedures.  Tier 1 Preschool and Kindergarten classroom interventions combining sensory processing and positive behavioral support are suggested using the FAB Strategies Form.


While some special education faculty, behaviorists, pediatricians, and occupational therapists object to combining behavioral and sensory strategies it makes sense to combine these clinically proven interventions before using medications.


Turtle Teaches Self-Control

The turtle technique is a practical evidence-based method of teaching self-control to pre-school and kindergarten students. The turtle technique is a component of the PATHS positive behavioral support program using classroom routines, rewards, stories, puppets, crafts, and activities. The turtle technique is based on Tucker Turtle, who learns to control his aggression when he feels angry so he doesn’t upset his friends. Preschool and kindergarten teachers around the world use this technique to promote self-control, with free resources available at http://www.challengingbehavior.org/do/resources/teaching_tools/ttyc_toc.htm#turtle .

In addition to its usefulness with typical preschool and kindergarten students, the turtle technique can be modified to teach self-control to pre-school through fifth grade students with special needs (e.g., emotional, trauma history, developmental, and/or sensory processing challenges). Free resources for students with special needs are offered using the FAB Turtle Strategy.


The FAB turtle strategy modifies the turtle technique as: 1) Stop immediately after noticing your environmental and body triggers 2) Go to the classroom sensory calming area 3) Do your individualized coping strategies in the sensory calming area 4) When you are sure you will not act aggressively return to your seat 5) Later the teacher will guide you in problem solving and reward you for doing the turtle strategy to avoid aggression.

The FAB turtle strategy modifies the turtle technique going into your shell by putting your shirt over your head when angry to going to the sensory calming area (e.g., designated area in the back of the classroom that other students can not enter). The turtle technique 3 deep breaths to calm down are substituted with the student’s individualized coping strategy (e.g., pushups, mindfulness activities). Emphasis is placed on the student not leaving the sensory calming area until they are certain they won’t act aggressively, and delaying as long as necessary before problem solving as students with special needs may need longer periods of time to calm down. While the student might need to be reminded of the initial conflict, this additional time provides the calmness needed for problem solving.

The FAB turtle strategy individualizes the turtle technique for students with special needs by building on the original turtle technique curriculum and resources.



TurtlePuppetPATHS Conference 2014

The FAB turtle strategy can be used to individualize the turtle technique for children with special needs in inclusive classrooms. Teachers can also begin by using the FAB turtle strategy for students with special needs, then transition them to the turtle technique and other positive behavioral support strategies.

Domitrovich, C. E., Cortes, R. C., & Greenberg, M. T. (2007). Improving young children’s social and emotional competence: A randomized trial of the preschool “PATHS” curriculum. The Journal of Primary Prevention, 28(2), 67-91.
Pagano, J. L. (2005). Functionally approached body strategies for young children who have behavioral and sensory processing challenges. Available online at http://www.eric.ed.gov search by ERIC # ED490718 http://eric.ed.gov/?q=John+Pagano+2005&id=ED490718
Riggs, N.R., Greenberg, M.T., Kusche, C.A., Pentz, M.A. (2006). The mediational role of neurocognition in the behavioral outcomes of a social-emotional prevention program in elementary school students: Effects of the PATHS curriculum. Prevention Science, 7(1), 91-102.