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FAB Coping Card Strategy

The FAB Coping card gives clients, teachers and therapists a visual support strategy for achieving their goals. Based on Power Cards, coping cards use the child’s preferred interest to guide goal-directed behavior. Clients use an index card to depict their preferred interest, behavioral goal, coping strategies, and reinforcement schedule. Constructing and displaying the coping card focuses the client and staff on their individual goal, coping strategies, and reinforcement schedule while using their preferred interest to help achieve the goal.

For example, a student who frequently bit his hand constructed a coping card by depicting his goal (e.g., keep safe hands by not biting myself when I get upset), preferred interest (e.g., Sponge Bob), coping strategies (e.g., chewy, weighted blanket, and basket ball) and reinforcement schedule (e.g., 10 minutes of safe hands=1 sticker). The goal is written and/or drawn, stickers or drawings depict the preferred interest, and coping strategies are visually represented (colored, cut out, and pasted on an index card using the FAB Trigger & Coping forms).

FAB Coping CardFABTriggerCopingFormsMasterpgno5

 

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On the reverse side of the coping card the reinforcement schedule is written: “Safe hands for 10 consecutive minutes earns one sticker, while five stickers=1 toy car)”.  The index card is laminated and fastened to the desktop or worn as a necklace. Through their process of constructing the coping card clients and staff develop an effective functional goal, preferred interest, coping strategies, and reinforcement schedule.

Making a coping card helps teach clients how to use adaptive equipment to achieve their goal. The process of constructing the coping card focuses the client and staff on the goal and plan for achieving it.  The coping card helps to quickly remind clients and staff of the individualized program for achieving their goal.  Coping cards quickly guide busy teachers and therapists in addressing functional goals of students with significant behavioral challenges. Coping cards also encourage professional collaboration in goal development and implementation.

Reference:

Spencer, V., Simpson, C., Day, M., Buster, E. (2008).  Using the power card strategy to teach social skills to a child with Autism.  Teaching Exceptional Children Plus, 5(1), 1-10.

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My Perspective on Sensory Integration

I frequently use Sensory Integration/Sensory Processing Intervention in my work as an occupational therapist with clients who have severe behavioral, sensory processing and developmental challenges. I get criticism both by professionals who question the validity of sensory processing intervention and those who dislike my integrating it with other treatment approaches. It is time to transcend the polarizing debate about the sensory processing model and put it in perspective.

CoopPlayTheraband chairarm rotation

Like most occupational therapists my treatment grew from my clinical practice and the influence of many gifted teachers. I was introduced to sensory integration intervention in my entry-level occupational therapy training and studied it extensively at the post-graduate level. I spent thousands of dollars on my sensory processing training and although I’m frugal (my son says “a cheap skate”) it was worth every penny.

My sensory processing teachers have had so many students that they wouldn’t even know my name, but they transformed my professional and personal life through their mentoring. Among my most effective sensory processing teachers were the late Ginny Scardinia, Mildred Ross, Winnie Dunn, and Lucy Jane Miller. Each holds a distinct view of sensory processing intervention, is an occupational therapist, master teacher, and base their practice on the teaching of A. Jean Ayres the founder of Sensory Integration.

I first met Mildred Ross as a guest lecturer in my undergraduate occupational therapy class. Using sensory (e.g., touch, movement, smells) strategies she developed individual and group interventions that improve the functioning of individuals with severe psychiatric and developmental challenges. Disagreeing with the “experts” who viewed these clients as “hopelessly regressed psychiatric patients”, Mildred motivated her clients by respecting them as people, caring about them, and beginning at their current developmental level then gradually improving their functional skills. Mildred used a similar approach with occupational therapists, teaching us what an honor it was to help others and motivating us to improve our skills. I remember that the professors and conference leaders who invited Mildred to speak often set an egg timer for one hour before she began, and kept it ringing until she stopped speaking. Although they told me the timer was essential and I usually hate listening to people talk, I always hoped the timer would break so I could listen to her all day.https://www.youtube.com/watch?v=vHuhYaYRIb8

After five years as a school occupational therapist a unique experience introduced me to my next mentor Ginny Scardinia. I was watching my OT student treat a 6-year old girl who had developmental, behavioral, and PTSD challenges using a net swing when the girl suddenly spoke for the first time. I’d been treating that girl for half a year and gotten little response, but after that single half-hour session from my OT student the child was able to consistently speak in school. My OT intern told me that she’d learned sensory integration treatment during her previous affiliation with Ginny Scardinia at the Ayres Clinic. I soon located Ginny, took classes with her, and bugged her to teach me whenever she could from that day on.

Ginny Scardinia was unique in her ability to motivate me to do whatever it took to learn to help children like she could.  I recently learned that Ginny inspired many occupational therapists, and a research study was conducted summarizing her skills as a master mentor  http://www.ncbi.nlm.nih.gov/pubmed/23927618 Over 25 years have past but I still remember that after she first saw me treat she said, “You’re off to a good start, but you need to learn a lot more about neurology and sensory integration and honey, I can teach you”.   I knew that she was right and although I never reached her level as a clinician I am still trying.

Ginny inspired me to take all the sensory integration courses I could and to take motor learning classes at Columbia University T C. The motor learning research taught me that clients have the ability to recover from neurologically based challenges through engaging in developmentally appropriate sensory experiences in their natural environments. My experiences with Ginny and Mildred Ross inspired me to lead a group for children with Autism Spectrum Disorders with the help of occupational therapy students and the children’s parents.

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I met Winnie Dunn and Lucy Jane Miller at an AOTA symposium where they were mentoring new researchers by letting us help with their projects. I remember asking them both why they were developing assessments when new treatments were needed, and they told me that until we learned to measure sensory integration interventions we couldn’t improve and validate our treatments. Winnie Dunn developed the Sensory Profile, a reliable and valid measure of sensory processing abilities www.sensoryprofile.com Dr. Dunn also went on to develop an intervention model that used the sensory profile to coach clients on adapting their sensory modulation styles so they could function more effectively. http://events.jeena.org/media/blog_media/2011/05/13/Sensory_Integration.pdf  While I still do direct and group interventions I always include consultation to the client, family, and teachers regarding how their sensory styles impact their interactions and functioning.

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By taking the Sensory Profile I found I had significant Low Registration and Sensory Sensitivity, at a level where only 2 out of 100 adults my age score. Being low registration influences me to often miss sensory input that others notice. Because I am also sensory sensitive I also frequently get overwhelmed by sensory input I do notice and take a long time to accommodate to touch (e.g., I’m bothered by neck ties, rings and watches).

I’ve learned to stomp my feet and look people in the eye when they are telling me something important, and to take an hour walk when I’m feeling overwhelmed so I don’t yell at anyone. I still can’t wear a tie when I speak but can tolerate wearing shoes rather than sneakers. Knowing my sensory profile helps me accommodate my behavior to the needs of my clients. I tend to talk loudly and quickly, but consciously speak softer and slower when working with clients who have sensory sensitivity and attention deficit hyperactive disorder.

As a new researcher who was a member of Lucy Jane Miller’s team I learned to be a better observer. Although she is arguably one of the most influential leaders in sensory processing intervention (helping to create the term) what inspired me most about her was her honesty. I was putting off getting my Ph.D. because I felt I wasn’t smart enough, but was inspired when Dr. Miller asked me for help changing her flat tire. I figured if someone that smart couldn’t change a tire I could try to get my Ph.D. even though I didn’t feel smart enough.

Dr. Miller has evolved from developing assessment tools to supporting sensory processing intervention research through the Sensory Processing Disorder Network www.spdnetwork.org Her organization presents workshops on sensory processing basic and clinical research. I refer parents and clinicians to her organization because it is both factual and parent friendly.

My clinical experiences have shown me that sensory processing intervention helps clients with severe sensory processing, behavioral and developmental challenges to improve their functional skills. I have discovered the value of sensory processing intervention through individual, group, client/family education, and environmental consultation treatment. My perspective on sensory processing and professional vision wouldn’t have been possible with out my teachers and mentors. To paraphrase Isaac Newton, “If my professional vision has expanded it is because I stand tall on the shoulders of giants”.

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Assessing Sensory & Behavior Challenges

Many clients have interrelated sensory processing and behavior challenges that interfere with their functioning. Sensory processing disorders are distinct from behavior disorders (e.g., Oppositional Defiant, Post Traumatic Stress, Autism Spectrum, and Bipolar Disorder) but clients who have these mental health diagnoses are significantly more likely to have sensory processing challenges as well.

It is important that clients who have both sensory processing and behavior challenges affecting their functioning receive an evaluation that addresses both difficulties. Regardless if the evaluation is done by an occupational and/or mental health therapist (psychologist, social worker, licensed professional counselor, behaviorist) it is important to assess both sensory processing and behavioral functioning. Coordinated assessment by both an occupational and mental health therapist can be extremely helpful.

It is helpful if the sensory processing and behavior assessment include observations and a norm-referenced, reliable and valid measurement tool. The sensory processing clinical observations can describe whether the client becomes overly excited during movement activities, is able to pay attention in loud environments, touches people and objects more frequently than others his age, is easily distracted, and the length of attention span for both preferred and adult directed activities. Standardized assessments include the Short Sensory Profile sensoryprofile.com and Sensory Processing Measure http://www.wpspublish.com/store/p/2991/sensory-processing-measure-spm

Behavior observations can include the frequency of inappropriate behaviors (e.g., yelling, screaming, swearing, hitting, biting, spitting) as well as the most common setting events, antecedents, and consequences related to them. Standardized behavior assessments include the Devereux Behavior Rating Scale-School Form and the Ages and Stages Questionnaire: Social Emotional.

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Whenever clients present with interrelated sensory processing and behavioral concerns related to their functioning both issues need to be comprehensively addressed. The assessment needs to include functional base lines data, prioritize functional goals, and recommend needed intervention. Comprehensively assessing the client’s interrelated sensory processing and behavior concerns guides affective intervention for both problems.

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Sensory Strategies For Teens With PTSD

Adolescents with PTSD and sensory processing challenges can benefit from sensory strategies to improve their behavior. Sensory strategies are particularly helpful for improving attention and decreasing aggression. While too seldom used for PTSD I have found that deep pressure touch sensory strategies can be particularly effective for reducing aggression and improving attention in teenagers with PTSD.

Therapists can help help teens understand that past traumatic stress experiences can lead them to overreact to stress. I tell teens “some people who have experienced bad things in the past overreact and get into trouble when they have really big feelings, and benefit from noticing when they first start having big feelings so they can use coping strategies to be successful”. The energy level meter strategy can help teens identify whether their current energy level feels “High”, “Medium” or “Low” and whether they feel “OK and Comfortable” or “Not OK Uncomfortable”. If a teen is too hyper to behave appropriately but rates his current energy as “High Energy and O. K. Comfortable” then the therapist is alerted that the teen is use to having a high energy state. The therapist would try to gradually modulate down the teen’s energy level by beginning with quick and intense tasks then gradually decreasing the speed and intensity in a structured way.    http://www.traumacenter.org/

Visual chart for rating arousal level and if it feels comfortable

Visual chart for rating arousal level and if it feels comfortable

Other teens find it more helpful to use an anger meter that monitors how angry they are feeling so they can leave the situation or use coping strategies to avoid aggressive and self-injurious behavior.

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Many teens are helped by using movement and deep pressure activities rather than only talk therapy as a coping strategy. This is because our joint receptors (e.g., muscle spindle fibers and Golgi Tendon Organs) convey deep pressure touch input that is typically calming and nurturing, like when a parent calms an upset child by hugging them. An example of input from our joint receptors is that we can identify our index finger with out looking at it, and our experience when walking down stairs in total darkness of feeling off balance because we thought there was another step but we were at the bottom of the stairs. It is important for teens with PTSD to understand that experiencing PTSD as a child can interfere with typical neurological development, the development of body awareness, and functional attention skills http://fabstrategies.org/2013/07/06/sensory-strategies-for-childhood-trauma/

Activities combining deep pressure input (through our body weight as well as lifting or pushing heavy objects) with linear movement can be an extremely effective coping strategies for improving self-control. Teenagers can use pushups, wall pushups, and isometric exercises as coping strategies to avoid aggression and help maintain attention.

Wallpushups http://www.traumacenter.org/products/pdf_files/Can%20the%20Body%20Change%20the%20Score_Sensory%20Modulation_SMART_Adolescent%20Residential%20Trauma%20Treatment_Warner.pdf

It is also helpful to teach teenagers to incorporate deep pressure and linear movement into their daily routines to maintain attention at school (e.g., moving tables, passing out books) and home (e.g., weight training, lawn mowing, vacuuming).  Research supports the use of occupational therapist guided sensory processing strategies to improve self-control of teens with PTSD challenges http://www.traumacenter.org/products/pdf_files/Body_Change_Score_W0001.pdf

Although it is considered a taboo by some mental health professionals I have also found that offering touch, brushing, vibration and massage with FAB Touch Pressure Strategies http://www.youtube.com/watch?v=W8fMdJ6l0AM is a powerful sensory strategy for teenagers with PTSD. Particularly with teens who did not receive nurturing touch growing up and show significant differences in sensory processing on the Sensory Profile sensoryprofile.com I have found FAB Pressure Touch Strategies useful in improving their self-control. It is extremely important to first teach about personal boundaries and always get the parent and teens permission before using touch, but with these guidelines I have found this an extremely effective intervention.

 

 

 

 

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Movement for Mindfulness

Mindfulness is the process of paying attention to what you are currently doing and feeling. Attention is a vital skill that is too often underemphasized, particularly when teaching young and developmentally challenged individuals. Movement strategies are useful for teaching mindfulness, self-control, and attention. Several useful movement strategies are listed below that can help young and developmentally challenged people to be mindful and pay attention better.

Standing Mindful Clock: A movement activity to promote mindfulness and body awareness, especially with people who lack the coordination to use deep breathing for relaxation. It involves verbalizing specific words (designated in bold print) while moving in a specific sequence (described in italics) to promote basic awareness of the front, back, top and bottom of the body. The entire sequence is done 3 times.

Tic squat Tock stand on toes Like a squat Clock stand on toes
‘Till we squat Find our stand on toes Center assume a centered standing position
Tic lean forward Tock lean back Like a lean forward Clock lean back
‘Till we lean forward Find our lean back Center assume a centered standing position

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Tense & relax muscles: A brief progressive relaxation strategy involving the muscles people often tense up when their anxious. Participants tense their muscles for 3 seconds then relax 5-10 seconds, doing each numbered section 3 times.

1) Tense; then relax all the muscles of your face and jaw.
2) Elevate both shoulders towards your ears; then drop and relax both shoulders.
3) Fist hands tightly; then completely relax both wrists, hands & fingers.

Bird: A strategy that uses simple movement to teach deep breathing for relaxation. Gradually lift both arms (from the sides like a jumping jack or straight up vertically) while breathing in and expanding your belly. Then at a slower rate lower both arms while breathing out.

Nose Breathe: A strategy that combines hand stretching with deep breathing for relaxation. The nose breathe strategy is especially helpful for students whose hands feel tense or spasm from handwriting or who have difficulty using breathing for relaxation. The fingers are extended and separated for relaxation, then the thumb is fisted in a mudra hand posture that promotes relaxation. It is done three to six times after the hand motions are learned.
1) Breathe in through your nose (making your belly go out) while opening your hands wide, extending and separating your fingers.
2) At a slower rate breathe out while bringing your thumb inside your hands making fists.

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Focus on Feet: Eyes closed feel one big toe, the smaller toe next to it, center toe, second smallest toe, and little toe. Feel your toes, bend them, notice if you have socks on and whether there are holes in your socks. Move back to feel the ball of your foot, back further and feel the arch of your foot and notice if it hits the ground. Move back again to feel your heel. Finally, feel or press down on the entire bottom of your foot.

Focus on Palms: Put your open hands in Dali Lama prayer position and push them together as hard as possible for 10 seconds doing an isometric contraction. Then position your hands palms up and close your eyes. Feel your thumb, pointer, middle, ring, and little finger. Then feel the palms of your hands for 5-10 seconds.

References:
Brain Gym International http://www.braingym.org
Greenland, S. K. The Mindful Child. http://www.susankaisergreenland.com/
Koester, Ceci http://www.movementbasedlearning.com

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Movement Enhances Emotional Expression

Strategies combining movement with expressing feelings motivates students to improve their self-regulation skills. Movement activities that involve emotion expression are especially helpful for motivating students who have behavioral, developmental, trauma history and/or sensory processing challenges. Movement activities are fun and can easily be integrated into strategies to encourage the expression and understanding of feelings.

A strategy for young students that integrates movement with expressing feelings is Feelings Goose. This is a modification of duck-duck-goose in which the student who is “it” touches each peer on the head with alternating hands, while naming a feeling (e.g., sad). When the student touches a child on the head while expressing the opposite feeling (e.g. glad) he is chased as he attempts to run to the other student’s spot.

FeelingGoose

A strategy that has several variations for progressively older students is switch hands toss. The switch hands toss “favorites” strategy involves students passing a beanbag while expressing their favorite: sport, color, ice cream, team, vacation place, coping strategy, quality in picking a friend, what makes them a good friend, and other favorite categories. Students can pick a favorite category to lead if they are willing to go first in expressing their favorite. The “I feel” strategy involves expressing how they currently feel. In “Guess the feeling” a student acts out a feeling using their face and body and the student they throw the beanbag to guesses what they are feeling.

The most challenging switch hands toss strategy is the “I message”. An I message is a DBT statement in which a student describes an action that others do, how they feel in response, and what the behavior they want others to do. The student says “When people ______, I feel _________, so please. A positive example is “When people say hi to me, I feel happy, so please say hi when you see me”. An example of a complaint would be “When people call me Shortie, I feel angry, so please call me John”. Combining movement with expressing their feelings motivates students to actively express feelings and improves self-control.