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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.

AngerMete

 

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

MindfulClk3MindfulClk4

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.

MindfulClk1MindfulClk2

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.

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School Sensory Modulation Strategies

Sensory modulation strategies, a component of sensory integration intervention, help improve behavior and reduce the need for harsh discipline in schools. Sensory modulation strategies teach students to be aware of and regulate their arousal levels for appropriate behavior and learning.  Sensory modulation strategies are particularly useful for students with behavioral, mental health, trauma history, developmental, and/or sensory processing challenges.

Sensory modulation strategies help students adjust their arousal level for improved self-control. They learn to notice whether their arousal level is low (they feel numb), medium (just right for learning) or high (too hyper to pay attention) and use coping strategies to adjust their energy level.

EnergyLevBasicAngerMeter

Most students learn best when they’re in a quiet alert state rather than overly relaxed or excited.

VolumeMeter

Maintaining appropriate arousal levels also involves social skills, as different levels of arousal are expected during class and at recess.  Occupational and mental health therapists can team with teachers to use sensory modulation strategies with students who have self-control challenges. Clinical research shows that sensory modulation strategies can improve behavior and reduce the need for restraints and other harsh discipline methods.

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

Sensory modulation strategies are especially affective for students with severe behavioral, mental health, trauma history, developmental, and/or sensory processing challenges.  Students are taught to identify when they begin experiencing environmental and body triggers to use their most affective sensory coping strategies http://www.sensoryconnectionprogram.com/what_helps_poster_activity.pdf

 

ModReinfDon'tBiteHandPowerCardVisSchedSelfCont

If sensory modulation or behavioral interventions alone are not working, combining both strategies using picture reminders can be helpful.

Busy teachers may sometimes attend to disruptive and ignore appropriate behavior, and reversing this can make a huge difference. For some students, individual sessions with an occupational and/or mental health therapist are used to teach sensory modulation, while others learn sensory modulation strategies by therapists working with the teacher or leading groups. Sensory modulation strategies can include teaching students to do pushups for self calming when they’re hyper or going to a quiet area for a few minutes to calm down so they won’t misbehave and are able to learn. Therapists need to try various strategies with students to find what works best.  Sensory modulation strategies in schools may involve the use of a quiet area in the class room,

SensoryCopingRm

a sensory coping room

 

Therabandfeet

adaptive equipment

ElemSchWalPushOTCopingBoard

or bulletin boards reminding students of class rules  and sensory coping strategies.  Working together therapists and teachers can use sensory modulation strategies to improve their students’ behavior and learning.

Reference:

Chalmers, A., Harrison, S., Mollison, K., Molloy, N., & Gray, K. (2012). Establishing sensory-based approaches in mental health inpatient care: a multidisciplinary approach. Australasian Psychiatry, 20(1), 35-39. www.rompa.com/media/free-resources/establishing_sensory-based_approaches_in_mental_health.pdf

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Self-Injury is a Bad Habit

A lot of occupational therapy referrals at my psychiatric hospital are for adolescents and young adults with mental health, trauma history, developmental, and/or sensory processing challenges who repeatedly injure themselves. Individuals with trauma history and developmental challenges have greater incidences of neurological, sensory processing, and self-injury challenges. Clients with these complex difficulties benefit from integrated intervention addressing their specific triggers, coping strategies, mindfulness activities, and sensory input needs to reduce self-injurious behavior.

Long-standing self-injurious behavior has often become a bad habit. Reducing this “bad habit” can be helped by first recognizing the triggers. Research shows that the brain (Striatum at the center of the subcortical basal ganglia) forms habits by chunking behavior into a single automatic memory package. However, through planning and mindfulness the brain (Neocortex) can interrupt or stop the habit. The habitual aspects of self-injurious behavior can be address by recognizing the triggers, then replacing the bad habit of self-injury with the good habit of coping strategies that include mindfulness and sensory activities.

Recognizing the environmental triggers (e.g., “being told no”) and body triggers (e.g., “crying”) that precede self-injurious behavior empowers clients.  Research shows many adolescents and adults report their motivational triggers for injuring themselves are to: “distract myself from negative thoughts and feelings, feel something when I feel numb, get social attention, and/or get out of unwanted social situations”. An understanding of their early motivational, environmental, and body triggers empowers people who self-injure to discover and use effective coping strategies.

A useful self-assessment I developed for clients with self-injurious behavior is the PaganoFABTriggerCopingForms copyClients choose the three environmental and body triggers that most often precede their self-injurious behavior. Their triggers can serve as early warning signs that they need to use coping strategies. On each of the coping strategies pages the client selects their 3 most effective coping strategies. Their selections remind clients of their most common triggers and effective coping strategies related to self-injury. When introducing the coping forms the therapist demonstrates any unfamiliar mindfulness and sensory coping strategies. behindthelabel.co.uk

It is helpful to review the trigger and coping strategies the client determines are most relevant to their self-injurious behaviors, building on their most effective coping strategies. The most helpful new coping strategies to try are usually physical activities, rather than strategies such as talking to a friend. Commonly effective new physical coping strategies for reducing self-injury include hobbies (e.g., art), mindfulness movement (e.g., opening their hand while breathing in, then closing their hands by breathing out), and sensory strategies (e.g., focusing on the bottom of their feet or palms of their hands).

FAB Basic Mindfulness Movement

For clients who appear to have sensory processing challenges, it is helpful to have them self-assess using the Sensory Profile http://www.sensoryprofile.com  For example, if a client has significantly different tactile sensitivity and self-cuts, using a vibrating bath brush may be useful as a sensory replacement for habitual self-cutting. It is important to be sure that brushing does not cause skin irritation and that clients never brush over open wounds. To interrupt the self-cutting habit the brush can be located where they most frequently engage in self-injury (such as their bedroom) to facilitate the use of self-brushing as replacing the habit of cutting with a less dysfunctional habit (brushing).

Finally, because self-injury may already be established as a habit, reinforcement is helpful (e.g., being given praise and a vibrating bath brush following two weeks of safe behavior). A helpful tool for clients with sensory modulation difficulties is rating their energy level and planning activities to keep a medium energy level and prevent self-harm using the Energy Modulation Wheel.

FABEnergModWheelTemplateFABEnergyModulationWheel

 

A helpful tool for individuals with sensory and developmental challenges is using a laminated index card that reminds clients of their goal, hero, and coping strategies for preventing self-injurious behavior using a COPING CARD

NoSelfHarmCopingcardDon'tBiteHandPowerCard

Reference: Gaybiel, A. M. & Smith, K. S. (2014). Good habits, bad habits. Scientific American, 310(6), 38-43. Nock, M. K., Prinstein, M. J., Sterba, S. K. (2009). Revealing the form and function of self-injurious thoughts and behaviors: A real-time ecological assessment study among adolescents and young adults. Journal of Abnormal Psychology, 118(4), 816-827. http://dash.harvard.edu/bitstream/handle/1/4134406/Nock_FormFunction.pdf

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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.

 

Playground

 

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

 

 

CoopPlay

 

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.

Reference:

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).