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Behavioral, Sensory & Mindfulness Strategies

Positive Behavioral Support (PBS) interventions are used in many schools to improve student behavior and learning.  PBS interventions involve adapting the classroom environment, teaching basic social skills, and rewarding positive behavior to enhance learning. PBS interventions can be enhanced through integrating them with sensory and mindfulness strategies.  Sensory and mindfulness activities are especially useful when using PBS with classes that include young and special needs students.  As an occupational therapist I have found the Second Step, PATHS, and DECA programs helpful in guiding PBS interventions.

Occupational, Speech/Language, Physical and Mental Health therapists can team with regular and special education teachers to implement PBS, sensory and  mindfulness strategies.  Sensory strategies include environmental adaptations and movement activities that enhance learning.  Mindfulness strategies include body awareness, movement, and breathing activities that enhance student’s abilities to pay attention to learning activities.

PBS, sensory and mindfulness strategies teach students self-control by enabling them to be aware of their environmental and body triggers so they can implement coping strategies to avoid inappropriate behavior.  An extremely useful PBS strategy is the PATHS Turtle Technique, where an upset student notices they are becoming upset, stops and breathes to calm down.   The turtle technique can be adapted for students with special needs using the FAB Turtle Technique.  When the student or teacher notices the student reacting to environmental and body triggers they stop what they are doing and go to a pre-designated sensory coping area in the back of the class.  The student does their individualized coping activities for self-calming until they are sure they will no longer act aggressively.  Later, when they are calm the teacher can assist the student with problem solving.

FABTURTLETech

Combining PBS (Positive Behavioral Support), sensory and mindfulness strategies is particularly useful in inclusive classrooms that integrate regular and special education students.  Below is a description of ways to adapt research proven PBS strategies with sensory and mindfulness activities to provide increase individualized structure for students with special needs.

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Using Sensory Strategies to Improve Behavior

Sensory strategies have a significant impact on the behavior of children and adolescents with developmental, mental health, Post Traumatic Stress Disorder and sensory processing challenges. Deep pressure touch provided by pediatric occupational therapists through massage, brushing, weighted blankets, mat sandwiches and other sensory strategies are described as extremely positive experiences for children and adolescents with developmental, mental health, Post Traumatic Stress Disorder and sensory processing challenges. Finding preferred activities is helpful because motivation can be a significant problem when treating these youngsters.

MatSandwichPropLayondog

A significant relationship was found between sensory and behavioral problems in children with developmental disorders. Research indicated that deep pressure sensory input functioned as positive reinforcement while matched sensory activities reduced repetitive non-purposeful behaviors in children with Autism Spectrum Disorder. Offering opportunities to use sensory strategies for self-regulation significantly reduced behavioral problems as well as the need for restraint and seclusion in adolescent and adult residential treatment centers for psychiatric and trauma challenges.

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The usefulness of offering clients deep pressure sensory strategies as an alternative to aggression and restraint makes sense, as it can replace the use of restraint as reinforcement for aggression with sensory activities to reinforce avoiding physical aggression. School occupational and physical therapists have begun using sensory activities as reinforcement for avoiding aggression to reduce student restraint and seclusion. SchoolOTRedAgg  The functioning of sensory strategies as positive reinforcement makes it important for therapists to avoid using sensory strategies immediately following aggressive or inappropriate behavior. Despite bitter conflicts between behaviorists, pediatricians and therapists clients would greatly benefit from their collaboration.

References

Canfield, J. M. (2008). Sensory dysfunction and problem behavior in children with autism spectrum and  other developmental disorders.

McGinnis, A. A., Blakely, E. Q., Harvey, A. C., & Rickards, J. B. (2013). The behavioral effects of a procedure used by pediatric occupational therapists. Behavioral Interventions, 28(1), 48-57.

O’Hagen, M., Divis, M., & Long, J. (2008). Best practice in the reduction and and elimination of seclusion and restraint; Seclusion: time for change. Aukland: Te Pou Te Whakaaro Nui: The National Center of Mental Health Research, Information and Workforce Development.

Rapp, J. T. (2006). Toward an empirical method for identifying matched stimulation for automatically reinforced behavior: A preliminary investigation. Journal of Applied Behavioral Analysis, 39(1), 137-140.

Sutton, D., Wilson, M., Van Kessel, K., & Vanderpyl, J. (2013). Optimizing arousal to manage aggression: A pilot study of sensory modulation. International Journal of Mental Health Nursing, 22, 500-511.

Warner, E., Spinazzola, J., Westcott, A., Gunn, C. & Hodon, H. (2014). The body can change the score. Journal of Child & Adolescent Trauma, 7(4), 237-246.

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Light touch and Holding Interventions

Light touch and holding strategies promote body awareness and social-emotional skills in children and adolescents with behavioral challenges. Deep pressure touch is a more common therapeutic intervention. However, light touch and holding are valuable therapeutic options for promoting attention, body awareness and social-emotional skills.

KONICA MINOLTA DIGITAL CAMERA

KONICA MINOLTA DIGITAL CAMERA

Body awareness, stress and somatic pain challenges negatively impact behavior in many children and adolescents with developmental, sensory processing, Post-Traumatic Stress Disorder, internalizing behavioral concerns and other psychiatric disorders.  Attention, body awareness, stress and somatic pain problems can be addressed through the use of light touch and holding strategies.  Light touch and holding strategies are particularly useful for improving and directing functional attention, and provide a valuable option for reducing stress, somatic pain, and social-emotional problems when deep pressure massage is contraindicated.  Particularly for young people experiencing acute pain, edema, taking analgesic medications (e.g., which can decrease pain perception) or taking antidepressant medications (e.g., which can cause light headedness and dizziness) light touch and holding are preferred.

Recent research indicates that positively perceived slow, light touch specifically activates CT afferent fibers connecting to the Insular Cortex that convey social-emotional interactions and our internal sense of self.  FAB Strategies utilizing light touch and holding include: Vibration to the Back, Arms, & Body as well as the Rolling the arm, Back X, Spine crawl, Head crown, and Foot input.  These light touch and holding techniques which are components of FAB Strategies will be described below.

It can be clinically useful to provide extremely irritable children and adolescents who have significant body awareness challenges repeated sensory experiences of the front, back, top and bottom of their bodies. FAB Strategies light touch and holding techniques were developed to provide sensory experiences of the front, back, top and bottom of the body as a foundation for improved body awareness and social-emotional skills.  In addition to the light touch and holding strategies the awareness of the front, back, top and bottom of the body is practiced through several FAB Strategies deep pressure touch and mindful movement activities.

Vibration to the Back, Arms, & Body provide light touch input.  Vibration can also be applied to various body parts with eyes open and closed, to increase body awareness by having clients identify each body part as it is touched (e.g., arm, left ankle).  Light touch can also be provided through the Rolling the arm strategy.  The therapist rolls the arm in a palm open, thumb lateral direction providing relaxation.

Trager and me Original

The Back X involves drawing an X across the back with your fist, while the Spine crawl involves moving up the spine to give awareness of the back. The Back X and Spine Crawl can be done as part of the X Marks the spot light touch game

XMarkstheSpot

The Head Crown involves 10 second holding on the head, first on both sides then on the front and back of the head.

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Foot input involves massage and holding of the feet to provide improved sensory awareness of the feet as the foundation and bottom of the body.  Foot input can be followed by stretching exercises to help decrease the likelihood of habitual toe walking.  Light touch and holding strategies are a valuable intervention to improve attention, body orientation and social-emotional skills through interpersonal touch.  Light touch and holding can also decrease stress, pain, and provide comfort when more intense massage is contraindicated.

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.

Bjornsdotter, M., Loken, L., Olausson, H.., Valbo, A., & Wessberg, J. (2009). Somatotopic organization of gentle touch processing in the posterior insular cortex. The Journal of Neuroscience, 29(29) 9314-9320.

Koester, C. (2012). Movement based learning for children of all abilities. Reno, NV: Movement Based Learning Inc.

McGlone, F., Wessberg, J., & Olausson, H. (2014). Discriminative and affective touch: Sensing and feeling. Neuron, 82(4), 737-755.

Perini, I., & Olausson, H. (2015). Seeking pleasant touch: Neural correlates of behavioral preferences for skin stroking. Frontiers in Behavioral Neuroscience, 9.

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FAB Strategies Mindfulness Movement Activities

I wanted to share this video of my FAB Strategies Mindfulness Movement activities to improve student’s behavior  https://www.facebook.com/educationresourcesinc/videos/943257499082558/ It was recorded by ERI at their Therapy in the Schools Conference.  Mindfulness movement activities are simple to do and can improve attention as well as enhance behavior by reducing student’s anxiety and giving them a break from seated work.

Mindfulness movement activities help all students yet are especially helpful for students with developmental disabilities, anxiety, sensory processing challenges, Post Traumatic Stress Disorder, ADHD, and/or other behavioral challenges.  Brief five minute mindfulness movement activities can help students attend better and promote the processing of academic learning when done between academic subjects (e.g., after math before proceeding to language arts).  Mindfulness movement activities can also be done in conjunction with teaching Positive Behavioral Support Interventions and used as a pre-correction before challenging school activities (e.g., lunch, playground, assemblies, and transitions).

In this video I demonstrate Touching the head-shoulders-stomach for sensory body awareness, Belly breathing, Hand opening and stretching to prevent hand cramping from writing (while breathing in) followed by thumb fisting as a mudra for relaxation (while breathing out)

MindfulClk1MindfulClk2

Bird breathing, and Mindful Clock Sitting (righting reactions moving forward-back and laterally).

Mindful clock standing activities can also be used, particularly to help students with sensory irritability gain basic body awareness of the anterior-posterior portions of their body through forward-back balancing movements  

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as well as sensory awareness and stability of the bottom (feet) and top (head) of their body through squatting then moving on their toes.

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I hope more early childhood and special education teachers as well as occupational, physical, speech/language and mental health therapists will begin using basic sensory mindfulness movement activities with their students.  Mindfulness movement activities offer a great opportunity for teachers and therapists to integrate and co-teach the academic and developmental curriculum areas.  As we continue to integrate the regular and special education curriculums, mindfulness movement activities can benefit students while promoting transdisciplinary interactions between teachers and therapists.

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3 Popular Neurologically Based Treatments

Occupational, Physical and Speech/Language therapists often include popular neurologically based approaches in their interventions for students with behavioral and developmental challenges. Brain Gym, Bal-A-Vis-X and Sensory Integration Intervention are three popular neurologically based approaches to promote neurological development for improved functional skills. While many clinicians, parents and families report that these interventions are clinically useful in achieving functional goals, they are criticized for lacking adequate research support.

Given the current emphasis on using evidence-based strategies it is important that therapists using these approaches apply current research to justify their use of these popular neurologically based approaches. A good way to show the efficacy of using these approaches is through goal attainment scaling, which can validate the effectiveness of strategies in achieving the student’s education related goals SIforASDGoal It is also important to consider research related to the components of these methods.

In addition to gathering baseline data and assessing treatment effectiveness through goal attainment scaling, it is important to understand the evidence-based components of these popular neurologically based approaches that can contribute to their effectiveness. First is their emphasis on child motivation through allowing students to choose the treatment activities. Second is their use of cardiovascular and strengthening exercises, and third their implementation of pressure touch strategies.

First, these popular neurologically based approaches facilitate student motivation by involving students in selecting fun and engaging activities. While sometimes criticized for being popular “only because students enjoy them”, the importance of activities that motivate children cannot be over-emphasized.   PRT (Pivotal Response Treatment) is a behavioral intervention that emphasizes the importance of student motivation. PRT was found to be highly effective in improving communication and behavior skills in children with Autism Spectrum Disorder.   The emphasis of PRT on facilitating motivation is a major reason for this success. Client motivation is facilitated in PRT by emphasizing child choice in activity selection and reinforcing attempts. In addition to its developmental efficacy in improving communication and behavior, recent research suggests PRT promotes more normalized neurological functioning.

The second component of these popular neurologically based approaches is their use of aerobic and strengthening exercises. Participation in aerobic exercise has been repeatedly associated in research with improved attention, learning and neurological development. Regular moderate exercise for 30 minutes daily appears to promote neurological development of the hippocampus for learning in both typical students (Cramer et al., 2011) and students with neurological challenges (Ploughman, 2008).

The third evidence based component of these popular neurologically based approaches is their use of pressure touch through massage and brushing. Massage has consistently been found through repeated research to decrease pediatric stress, which can help reduce behavior and learning challenges. More specifically, Asian massage strategies were found to improve behavior and communication skills in preschoolers with Autism Spectrum Disorders (Piravij et al., 2009; Silva & Schalock, 2013) www.qsti.org

While caution should be used in applying these popular neurologically based approaches to school therapy interventions, these techniques can be useful for attaining school goals. It is important to gather baseline data and use progress toward school related goals in judging the effectiveness of these strategies. It is also important to consider research supporting the specific strategies used, as well their research supported components of student motivation, aerobic exercise, strengthening exercise, and touch pressure   Reduce Problematic Reflexes:Hab

References:

Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65(1), 76-85.

Piravej, K., Tangtrongchitr, P., Parichawan, C., Paothong, L., Sukprasong, S. (2009). Effects of Thai traditional massage on Autistic children’s behavior. Journal of Alternative and Complementary Medicine, 15(12), 1355-1361.

Ploughman, M. (2008). Exercise is brain food: the effects of physical activity on cognitive function. Developmental Neurorehabilitation, 11 (3), 236-240.

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.

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Role of school OT’s, PT’s, SLP’s in Behavior Intervention

School Occupational, Physical and Speech Therapists play a significant role in improving student behavior. While traditionally viewed exclusively as the role of school social workers, psychologists, and behaviorists the complex problems of students with interrelated behavioral and developmental challenges can be helped by the contribution of school therapists.  The relationship between behavioral problems, the occupation of students, communication/language abilities, and gross motor skills supports the role of school occupational, speech/language and physical therapists as members of school teams helping students with behavioral and developmental challenges.

By teaming with occupational, speech/language and physical therapists, teachers and school mental health specialists can enhance their school positive behavioral support programs with expanded use of visual supports, mindfulness, music, exercise, and sensory-motor activities (Patten et al., 2013; Schaaf et al., 2014).  There is emerging evidence that cardiovascular and resistance exercise enhances body awareness, attention, as well as functional strength and endurance for improved participation in school learning tasks http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208137/pdf/nihms297861.pdf

School therapists can utilize evidence based mindfulness strategies as movement breaks that improve attention, and integrate behavioral strategies into their school therapy to enhance student’s school behavior.  Behavior for Therapists Slides The picture below describes the FAB Strategies adaptation of the PATHS PBS Turtle Technique to help students with special needs learn to calm down and avoid aggression.

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The AOTA supports the role of school occupational therapy in helping to improve student’s behavior (Cahill & Pagano, 2015).  The following Occupational Therapy article describes clinical school occupational therapy strategies that can be used to reduce student aggression  (Click on highlighted, then double click on lower heading) SchoolOTRedAgg

References

Cahill, S. M. & Pagano, J. L. (2015). Reducing restraint and seclusion: The benefit and role of occupational therapy. AOTA School Mental Health Toolkit. http://www.aota.org/-/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Reducing-Restraint-and-Seclusion.pdf

Flook, L., Smalley, S., Kitil, M., Galla, B., Kaiser-Greenland, S., Locke, J., Ishijima, E., Kasari, C. (2010). Effects of mindful awareness practices on executive functions in elementary school children. Journal of Applied School Psychology, 26(1), 70-95. http://skolenforoverskud.dk/Artikler%20-%20mindfulness/Flook-Effects-of-Mindful-Awareness-Practices-on-Executive-Function-1.pdf

Kazdin, A. E. (2008). The Kazdin Method for parenting the Defiant Child. NY, NY: Mariner Books.

Laugeson, E. A. (2014). The PEERS curriculum for school-based professionals: Social skills training for adolescents with autism spectrum disorder. Routledge.

Mahammadzaheri, F., Koegel, L. K., Rezaee, M., Rafiee, S. M. (2014). A randomized clinical trial comparison between pivotal response treatment (PRT) and structured applied behavioral analysis (ABA) intervention for children with autism. Journal of autism and developmental disorders, 44(11), 2769-2777.

Schaaf, R. C., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., van Hooydonk, E., … & Sendecki, J. (2014). An intervention for sensory difficulties in children with Autism: A randomized trial. Journal of autism and developmental disorders, 44(7), 1493-1506.

Warner, E., Spinazzola, J., Westcott, A., Gunn, C. & Hodon, H. (2014). The body can change the score. Journal of Child & Adolescent Trauma, 7(4), 237-246.

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PRT Treatment in SLP, OT, & PT

PRT (Pivotal Response Treatment) is an important frame of reference for Speech/Language Pathologists, Occupational Therapists and Physical Therapists. PRT uses applied behavioral analysis principles as well as child choice, reinforcing attempts, varying activities, alternating familiar with challenging activities, and direct natural reinforcers. PRT’s transdisciplinary family-centered approach makes it particularly appropriate for allied health therapists.

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PRT shows significantly greater effectiveness for treating Autism Spectrum Disorder than traditional ABA  https://www.autismspeaks.org/sites/default/files/docs/koegel_prt_rancomized_controlled_trial_of_prt.pdf and facilitates neuroplasticity in young children with Autism Spectrum Disorders PRT NeurogenisisArt.  In addition to its usefulness for addressing language and behavioral challenges related to Autism Spectrum Disorders, PRT is a clinically relevant intervention for addressing other developmental and psychiatric challenges (e..g., fragile x syndrome, cognitive deficits, developmental trauma disorder, oppositional defiant disorder, depression, anxiety). Treatment is done with the family across disciplines in the child’s natural environment, so gains in language and motor skills are generalized to improve functioning.

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PRT strategies can be integrated with language, sensory and movement strategies as a component of occupational, speech and physical therapy interventions SensoryBehavior  I have found PRT is a particularly valuable treatment frame of reference for Speech/Language, Occupational and Physical Therapists.

References

Amaral, D. G., Schumann, C. M., & Nordahl, C. W. (2008). Neuroanatomy of Autism. Trends in Neuroscience, 31(3), 137-145.

Voos, A. C., Pelphrey, K. A., Tirrell, J., Bolling, D. Z., Wyk, B. V., Kaiser, M. D., McPartland, J. C., Volkmar, F. R. (2012). Neural mechanisms of improvements in social motivation after pivotal response treatement: Two case studies. Journal of Autism Dev Disord, 43(1), 1683-1689.