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School Occupational Therapy for Developmental Trauma

School occupational therapists emphasis on therapeutic relationships, mental health, sensory processing, attachment, development, purposeful activity and self-regulation offer a unique contribution for improving the behavior of students with developmental trauma disorder. School behavioral problems related to developmental trauma are seen in students who have experienced early chronic abuse. Many students with developmental trauma difficulties have significant sensory modulation, emotion regulation, attachment, self-regulation, sensorimotor, somatic, and developmental challenges.  Working in conjunction with school psychologists, social workers, and guidance counselors, occupational therapists can help improve the mental health and behavior of students who have developmental trauma challenges http://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/Fact-Sheets/OT%20%20School%20Mental%20Health%20Fact%20Sheet%20for%20web%20posting%20102109.pdf http://www.aota.org/-/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Reducing-Restraint-and-Seclusion.pdf

Occupational therapy for improving the behavior of students with developmental trauma can include energy level modulate, sensory processing, deep pressure touch, and mindfulness strategies. The energy level modulate strategy involves increasing students’ awareness of their arousal level and teaching them to modulate dysfunctional high or low energy levels to better participate in school learning tasks. It can be introduced by explaining that “some students who have had difficult experiences early in their life can get into trouble by overreacting when they have really big feelings”. The energy level modulate strategy teaches students to identify whether their current energy level feels “High” (hyper, off the wall, with stiff muscles like raw spaghetti), “Medium” (just right and ready to learn) or “Low” (tired, numb, with loose muscles like over cooked spaghetti).

Visual chart for rating arousal level and if it feels comfortable

Visual chart for rating arousal level and if it feels comfortable

The energy level modulate strategy is extremely useful in school settings for students with sensory modulation difficulties who become aggressive following activities that raise their energy levels extremely high. While many students can use the energy level modulate strategy with teacher encouragement, some students with sensory modulation difficulties and developmental trauma need assistance. For example, a student receiving occupational therapy attended a wild physical education class where the students ran, screamed and threw balls at each other. His classmates behaved appropriately upon returning to class. However, this student who had significant sensory sensitivity and developmental trauma challenges was unable to sit down upon returning to class and threw a chair.

Following this experience the occupational therapist taught the school physical education teachers and mental health therapists the energy level modulate strategy so students could rate their energy levels before returning to class. The teacher or therapist would bring students who rated their energy level as uncomfortably high to a designated staff member (e.g., occupational therapist, speech therapist, principle, resource room teacher) who would help the student do pushups or other individualized sensory coping strategies to lower their energy level before returning to class.

The most effective strategies for normalizing energy levels involve deep pressure through the joints with slow linear movements. Activities such as regular or wall pushups, moving furniture, moving mats, delivering messages or boxes of books throughout the school, or wheelbarrow walking on your hands over a therapy ball can help achieve this.

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Special consideration can be given in the energy level modulate strategy for students with both sensory modulation and developmental trauma challenges who have become use to maintaining a high energy level that interferes with appropriate attention and behavior for school functioning. This difficulty can be indicated by students who describe their energy level as “Hyper and comfortable” and students who actively resist efforts by their teachers and therapists to calm down to a functional energy level where they can pay attention to classroom activities. For students who resist regulating their energy to a functional level it is helpful for the therapist to begin by matching the student’s initial energy level, then support the student during individual sessions to gradually modulate their energy level.  http://www.traumacenter.org/products/pdf_files/Body_Change_Score_W0001.pdf 

Individual OT sessions using sensory processing, deep pressure touch, and sensory mindfulness strategies help students with self-regulation and developmental trauma challenges improve their attention, seated attention, and behavior for participation in school learning tasks.

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These interventions emphasize child-focused activities that optimally challenge students to discover activities that will enable them to modulate dysfunctional arousal levels for improved school functioning. Sensory processing interventions promote attachment relationships combining child-directed activities at their optimal level of challenge with an attitude of PACE (playfulness, acceptance, curiosity and empathy). Offered respectfully with choices to decline, firm pressure touch strategies can enhance attachment, relationships, and self-control in students with behavioral and developmental trauma challenges. Attached is a link showing integrated use of behavioral, sensory processing, PACE, and FAB Pressure Touch strategies. While this treatment was done with a preschooler who had Asperger’s syndrome, a similar approach is often also helpful for students with behavioral and developmental trauma challenges https://www.youtube.com/watch?v=W8fMdJ6l0AM

References

Beider, S., Mahrer, N. E., Gold, J. I. (2007). Pediatric massage therapy: An overview for clinicians. Pediatric Clinics of North America, 54(6), 1025-1041.

Engel-Yeger, B., Palgy-Levin, D., & Lev-Wiesel, R. (2013). The Sensory Profile of People With Post-Traumatic Stress Symptoms. Occupational Therapy in Mental Health, 29(3), 266-278.

Hanson, J. L., Chung, M. K., Avants, B. B., Shirtcliff, E. A., Gee, J. C., Davidson, R. J., & Pollak, S. D. (2010). Early stress is associated with alterations in the orbitofrontal cortex: a tensor-based morphometry investigation of brain structure and behavioral risk. The Journal of neuroscience30(22), 7466-7472.

http://www.jneurosci.org/content/30/22/7466.long

Hughes, D. A. (2011). Attachment-focused family therapy workbook. New York, NY: W. W. Norton & Co.

Warner, E., Koomar, J., Lary, B., & Cook, A. (2013). Can the body change the score? Application of sensory modulation principles in the treatment of traumatized adolescents in residential settings. Journal of Family Violence, 28(7), 729-738.

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Brain Based Emotion Regulation Strategies

Brain based therapy applies current neuropsychology to developing emotion regulation strategies. Emotion regulation involves learning to non-aggressively express strong feelings. People initially process anger and other negative emotions unconsciously in the right cerebral hemisphere, but require cross-hemispheric communication involving the left cerebral hemisphere for conscious awareness, verbal expression and emotion regulation (Riggs et al., 2006; Shobe, 2014). The Switch hands toss, ball bouncing, and drumming strategies were developed to help link movement activities with the verbal expression of feelings.

Research suggests that communicating negative feelings between the brain hemispheres for emotion regulation can be particularly difficult for students with complex behavioral disorders, including diagnoses of Autism Spectrum (Anderson et al., 2010) and/or Post Traumatic Stress Disorder (Pechtel & Pizzagalli, 2011), who have significantly reduced neurological communication between the cerebral hemispheres. Many of these students, as well as those with ADHD or neurological immaturity, also resist remaining seated and discussing their feelings and behaviors. Because expressing feelings is difficult for students with complex behavioral challenges, they tend to avoid practicing it.

The Switch hands toss, ball bouncing, and drumming strategies were developed to use movement games to promote the verbal expression of feelings in students with complex behavioral challenges. The Switch hands toss strategies combine passing a beanbag with the verbal expression of preferences, feelings, values, and choices. The ball bouncing and drumming strategy similarly combine two hand sequential activities with the verbal expression of feelings. Building on Positive Behavioral Support activities that teach emotions and express feelings, the switch hands toss, ball bouncing, and drumming strategies are fun interactive tasks that can be done individually with students and in groups. Both the movement and expression of feeling are developmentally individualized to improve emotion regulation and verbal skills.

Drumming

Current brain research suggests that most students initially process anger and other negative emotions unconsciously in the right cerebral hemisphere, but require cross-hemispheric communication involving the left cerebral hemisphere for conscious awareness, verbal expression and emotion regulation (Riggs et al., 2006; Shobe, 2014). This can be particularly challenging for students with complex behavioral challenges. Research indicates significantly greater difficulties with neurological communication between the left and right cerebral hemispheres in students with a diagnosis of Autism Spectrum and/or Post Traumatic Stress Disorder.  The picture below shows the corpus callosum (marked as number 1 in black) a major network of nerves connecting the cerebral hemispheres.

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The switch hands toss, ball bouncing, and drumming strategies combine sequential two handed movement activities with the expression of feelings. These strategies combine movement with the verbal expression of feelings to promote functional communication between both cerebral hemispheres. The switch hands toss, ball bouncing, and drumming strategies are easily graded by matching the specific movement and verbal expression to the student or group’s level.

The switch hands toss, ball bouncing, and drumming strategies address the verbal expression of: favorites (e.g., color, team, quality in a friend), best coping strategy, guessing the feeling or degree of feeling expressed by the therapist or peers, right now I feel _____, and I messages (e.g., when you yell at me, I feel sad, so please speak to me politely). These strategies enable students to express their feelings with out needing to be seated or the center of attention. The switch hands toss, ball bouncing, and drumming strategies offer fun Positive Behavioral Support activities to improve emotional awareness and the verbal expression of feelings.

References:

Anderson, J. S., Druzgal, T. J., Froehlich, A., DuBray, M. B., Lange, N., Alexander, A. L., & Lainhart, J. E. (2010). Decreased interhemispheric functional connectivity in autism. Cerebral cortex, 190.

Bengtsson, S.L., Nagy, Z., Skare, S., Forsman, L., Forssberg, H., Ullen, F. (2005). Extensive piano practicing has regionally specific effects on white matter development. Nature Neuroscience, 8, 1148-1150.

Miller, A. L., Rathus, J. H. & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. NY, NY: The Guilford Press.

Pechtel, P., & Pizzagalli, D. A. (2011). Effects of early life stress on cognitive and affective function: an integrated review of human literature. Psychopharmacology, 214(1), 55-70.

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.

Shobe, E. R. (2014). Independent and collaborative contributions of the cerebral hemispheres to emotional processing. Frontiers in human neuroscience, 8.

Sun, F. T., Miller, L. M., Rao, A. A., Esposito, M. D. (2007). Functional connectivity of cortical networks involved in bimanual motor sequence learning. Cerebral Cortex, 17(5), 1227-1234.

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Environmental Adaptations for Improved Behavior

Environmental adaptations are an important yet underutilized way of helping individuals with behavioral, developmental, and sensory modulation challenges. While environmental adaptations are often included in positive behavioral support and relaxation programs, they are not given sufficient attention. A third of children with significant sensory modulation differences were found to have major psychiatric diagnoses http://www.fyiliving.com/wp-content/uploads/2010/09/re-examiningsensoryregulation.pdf Individualizing and teaching clients to use sensory environmental adaptations can significantly improve their behavior and decrease stress at school, work and home.

Environmental adaptations can provide structure and offer coping strategies that significantly reduce anxiety and improve behavior. Environmental adaptations include both the generalized and specific use of adaptive equipment and techniques. Generalized adaptive equipment and techniques such as assigned seats, reduced noise levels, posted rules and coping strategy bulletin boards provide structure for improved behavior.

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An important guideline is to increase environmental structure before increasing behavioral demands, such as beginning more academically challenging learning activities. Likewise, reducing behavioral demands can be helpful in less structured environments. When clients first begin showing anxiety or behavioral difficulties, assess if the environmental supports match the demands being made and adjust environmental adaptations accordingly.

Some clients with significant behavioral, developmental, and sensory processing challenges benefit from individualized adaptive equipment and techniques such as study carols, noise canceling head phones, and being directed to do one activity for a minimum of five minutes before cleaning up and selecting another task. Research shows that adaptive equipment helps all children feel more comfortable in stressful environments, but the effects were significantly greater for children with developmental disabilities http://www.aamse.us/sites/default/files/Influence_Adapted.pdf

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Specific environmental adaptations are most effective when they are individualized to meet the client’s behavioral goals and sensory needs. It is helpful to introduce environmental adaptations one at a time for a two-week period after practicing their use for goal achievement.

A Sensory Functional Behavioral Analysis, FAB Trigger & Coping forms, Sensory Profile, and goal-related base line data can be useful for finding the most effective environmental adaptations and tracking their effectiveness.

FABTriggerCopingFormsMasterpgno3FABTriggerCopingFormsMasterPg4FABTriggerCopingFormsMasterpgno5         It is important to clearly explain the rules for continued access to environmental adaptations before introducing them (e.g., gum chewing will be allowed only if students consistently throw their gum in the garbage when they are finished with it). Specifically considering and teaching clients to use environmental adaptations significantly improves their effectiveness for individuals with behavioral, sensory processing and developmental challenges.

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FAB Rainbow Goal Strategy

The FAB Rainbow goal strategy is useful for developing goals and reinforcers that motivate students, while involving staff in supporting the goal and its achievement.  Like the FAB Coping card strategy, the rainbow goal allows clients to visually plan and review their behavioral goals and reinforcement schedule. The student begins by drawing a star at the top of the rainbow representing what they would choose if they could earn anything in the world.  It is presented as the positive opposite of what they say they want to avoid (e.g., being kicked out of their home or school).

Next, the student draws five separately colored rainbows beneath the star describing the steps needed to achieve their goal.  The five rainbows are the specific steps they need to take to achieve their goal, described positively as what they need to do rather than what they need to avoid doing.  The final rainbow is what they need to do immediately upon returning to class, and is linked to a sticker chart and tangible reinforcer.

The rainbow goal pictured below was done by a sixth grader with Pervasive Developmental Disorder and Oppositional Defiant Disorder, who hit classmates approximately every ten minutes.  He was initially unable to identify any goals for the future or prizes he wanted. The student reported that his goal was to stay at home, rather than again being sent to a group home or juvenile detention facility.  Using the FAB Rainbow Goal Strategy the therapist guided him in visually representating his goal and the steps for achieving it.

His sequential rainbow steps were organized into positive opposites of his current behaviors: “I can talk to Mom when upset (stop hitting Mom), Stay in control (not hit peers), and Do what Mom asks” (not misbehave).  His final rainbow step was that he would now go back and “Today work hard in school”.  The therapist also learned from his mother that the most effective way to increase his behaviors was to give him items related to toy cars.

Rainbow Goal Strategy

After observing the student and collecting data the student’s greatest current problem was found to be hitting other students, so the positive opposite of keeping safe hands was used to behaviorally describe his current goal: “Today work hard in school”. Since the student was found to hit others on average once every ten minutes the reinforcement schedule was developed that 15 minutes of safe hands (not hitting peers) earned one car sticker.

The student’s rainbow goal picture was laminated to his desk, and he received one car sticker whenever he kept safe hands for fifteen minutes.  If he hit another student before10 minutes the teacher pointed to his rainbow goal and explained she still liked him but could not award him a sticker yet because he was not showing his goal of working hard in class by keeping safe hands for fifteen minutes.  At the end of the day he would cash in all his car stickers for a reward. One sticker earned a racing car card and stick of gum, while six stickers bought a toy race car and an hour with an adult who would help him assemble it.

The FAB Rainbow Goal Strategy is useful for motivating students, staff and families to set a behavioral goal, action plan for achieving it, and follow a reinforcement schedule.  It promotes goal directed positive behaviors such as safe hands, which research shows can decrease the development of long term aggressive behavior.  The FAB Rainbow Goal Strategy empowers students, teachers, therapists and families to develop and visually represent behavioral goals, so they are motivated to achieve them.  It is helpful to pair the students most immediate goal with an observeable behavior and tangible reinforcer.

References:

Kazdin, A. E. (2008).  The Kazdin Method for parenting the Defiant Child.  NY, NY: Mariner Books. http://childconductclinic.yale.edu/

Seifert, K. (2011).  CARE-2 Assessment: Chronic Violent Behavior and Treatment Needs.  Boston, MA: Acanthus Publishing.  www.drkathyseifert.com

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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.