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Sensory Strategies in Adolescent Psychiatry

The FAB Sensory Match Strategy uses individualized sensory coping strategies and reinforcement to reduce self-injurious behaviors in adolescents with psychiatric challenges.  Effective treatment approaches for self-injurious behavior such as DBT, CBT, and ARC teach adolescents to use generalized coping strategies to replace self-injurious behaviors.  However, research reports that adolescent self-injurers have significantly increased sensory modulation difficulties and physiological reactivity to stress.  Research suggests their problem is not ignorance about coping strategies but the inability to use selective coping strategies to reduce self-injurious behavior.

Research shows that the function of self-injurious behaviors is automatic negative reinforcement (e.g., pain as an escape from negative thoughts and feelings) and automatic positive reinforcement (e.g., to feel something even if it’s pain when numb).The FAB Sensory Match Strategy combines sensory processing and behavioral intervention to develop individualized sensory coping strategies that adolescents can use as an alternative to self-injurious behaviors, and reinforces them for reducing their incidences of self-injury.  Assessment includes the Adolescent Sensory Profile, a functional behavioral analysis with base line data, and use of the FABTriggerCopingForms

Following assessment several sensory coping strategies are done with the adolescent and they select the strategies they find most helpful in reducing self-injurious behavior.  The most effective strategies are listed along with the Sensory Match Strategy on the FABSTRATEGIES TO PROMOTE SELF-CONTROL form.  Reinforcement is provided when the child uses coping strategies to reduce self-injurious behavior.  The most commonly helpful sensory coping strategies used in the FAB Sensory Match Strategy include: fidgets, comfort box (a box of fidgets and sensory toys), theraplast hand exercises,  craft kits, vibrating bath brush, surgical scrub brushing, massage on request, theraband arm exercises, therapy ball use, and mindfulness activities.

References:

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

Nock, M.K. & Mendes, W.B. (2008).Physiological arousal, stress tolerance, and social problem-solving deficits among adolescent self-injurers.  Journal of Counseling and Clinical Psychology, 76(1), 28-38.

Nock, M.K., Prinstein, MJ., 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.

Smith, S.A., Press, B., Koenig, K.P., Kinnealey, M. (2005).  Effects of sensory integration intervention on self-stimulating and self-injurious behaviours.  American Journal of Occupational Therapy, 59, 418-425.

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FAB Rainbow Goal Strategy

The FAB Rainbow goal strategy is useful for helping children and families develop goals and plans for goal achievement.  The child or family begins by drawing a star at the top of the rainbow by brain storming what they would choose if they could earn anything in the world.   Next, they draw five separately colored rainbows beneath the star that describe the steps needed to earn their goal.  The rainbows describe 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, and is paired with a sticker system and tangible reinforcers.

Rainbow Goal

The rainbow goal shown in the link above was done by a child in middle school with Pervasive Developmental Disorder and Oppositional Defiant Disorder, who demonstrated aggressive behavior.  He was initially unable to list any goals he had for the future and I could find no affective reinforcers for changing his behavior.  This child reported that his goal was to stay at home, rather than again being sent to another group home or juvenile detention facility.  The FAB Rainbow Goal Strategy enabled him to use a fun activity to develop a visual representation of his goal and the steps for achieving it.

His sequential rainbow steps were: “I can talk to Mom when upset, Stay in control , and Do what Mom asks”.  His final rainbow step was that he would now go back and “Today work hard in school”.  I learned from his mother that he loved toy cars, and developed a car sticker system that I paired with his step “Today work hard in school”.

He received one car sticker when I visited his class each time I observed that he was working hard in school.  If he was not working hard (or initially if he was acting aggressively), I pointed to his rainbow goal step and explained I still liked him but could not award him a sticker because he was not working hard in class.  I usually visited his class six times daily, and gave him the opportunity to cash in his stickers for prizes at the end of each day.  One sticker earned a racing car card and stick of gum, six stickers bought a toy race car.

The FAB Rainbow Goal Strategy is useful for motivating children and families to set goals, an action plan, and develop a reinforcement schedule to improve behavior.  It also promotes goal directed behavior, which research significantly correlates with decreased aggression.  The FAB Rainbow Goal Strategy empowers parents, teachers, and therapists to help children and families develop and visually represent their goals, so they are motivated to achieve them.  It is often helpful to pair the immediate goal with a 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 Pressure Touch Strategies

The FAB Pressure Touch Strategies help reduce anxiety, increase communication, and improve behavior with children who have self-control, developmental, and sensory processing challenges. FAB Pressure Touch was developed by adapting and synthesizing evidence-based Massage Techniques, QST, Knickerbocker Sensory Integration strategies, Trager Body Work, and NDT touch strategies to meet the needs of children with developmental, behavioral, and/or early trauma history challenges. However, distinct from the Wilbarger Protocol, massage, and prescribed body work sensory stimulation strategies FAB Pressure Touch Strategies are an individualized goal-directed approach that is a component of the total FAB Strategies program. Strategies that the therapist finds helpful should be taught to interested parents, teachers, and other team members but no minimal amount of intervention is required for results.

Individualized pressure touch and weight bearing activities can reduce anxiety and promote social development in children with Pervasive Developmental Disorder, other developmental disabilities, and behavioral problems. Because anxiety can increase children’s behavior problems, pressure touch and weight bearing are used in FAB Pressure Touch Strategies to significantly reduce anxiety in children with developmental disabilities. Behavioral improvement from pressure touch and weight bearing activities appears related to the activation of proprioceptive receptors that can be independently obtained through resistance exercises. If implementation of the FAB Pressure Touch Strategies improves behavior, children are also taught and reinforced for independently engaging in independent pressure touch and resistance exercises.

FAB Pressure Touch strategies include the: Head Crown, Shoulder squeeze, Spine roll, Back protocol tap, Back protocol press, touch on the back, as well as touch and joint compression through the arms, legs, and feet. The FAB Pressure Touch Strategies form can be attached to the FAB Strategies form to provide more detailed touch strategies. In my FAB Strategies workshops for therapists, goal-directed development and implementation of FAB Pressure Touch Strategies is learned as a component of FAB Strategies. An example of me providing intervention utilizing FAB Pressure Touch Strategies with a preschooler who has Asperger’s Syndrome and behavioral challenges is provided at http://www.youtube.com/watch?v=W8fMdJ6l0AM&feature=youtu.be

References
Beider, S., & Moyer, C. (2007). Randomized controlled trials of pediatric massage: A review. Evidence-based Complementary and Alternative Medicine, 4(1), 23-34.
Field, T., Henandez-Reif, M., Diego, M., Schanberg, S., Kuhn, C. (2005). Cortisol decreases and serotonin and dopamine increase following massage therapy. Intern. J. Neuroscience, 115, 1397-1413.
Kaufaman, L.B., & Schilling, D.L. (2007). Implementation of a strength training program for a 5-year-old child with poor body awareness and developmental coordination disorder. Physical Therapy, 87, 455-467.
Silva, L.M. Schalock, M., Gabrielsen, C. (2011). Early intervention for Autism with a parent-delivered qigong massage program: A randomized controlled trial. American Journal of Occupational Therapy, 65(5), 550-559.

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Possible implications of New DSM-5 PDD Diagnosis for OT, PT, and ST

Given the DSM-5 diagnosis of Autism Spectrum Disorder “ASD” as a single diagnosis with differing degrees of severity and a subcategory of restricted repetitive behaviors occupational, speech-language, and physical therapists are uniquely qualified to offer important diagnostic input. ASD is categorized as Level 1 requiring support, Level 2 requiring substantial support, and Level 3 requiring very substantial support. Particularly given their respective expertise regarding functional sensory activities, speech/communication, and movement development occupational, physical, and speech therapist assessments can uniquely inform the diagnosis of PDD.

Occupational, physical, and speech/language therapists offer unique expertise in the areas of functional sensory, speech, and motor development. Their expertise regarding functional sensory, speech/communication, and movement development can enhance comprehensive intervention plans to enhance social skills as well as address repetitive behaviors. For example occupational therapy expertise regarding the development of functional sensory skills can enhance the abilities of children with PDD to learn to play catch, brush their teeth, and engage in many functional sensory tasks that normalize social development in a family context. Occupational, speech-language, and physical therapists are potentially valuable allies for pediatricians, psychiatrists, and mental health therapists in the assessment, treatment, and research of individuals with Pervasive Developmental Disorders.

References
Dunn, W. (2007). Supporting children to participate successfully in everyday life by using sensory processing knowledge. Infants & Young Children, 20(2), 84-101.
Silva, L.M. Schalock, M., Gabrielsen, C. (2011). Early intervention for Autism with a parent-delivered qigong massage program: A randomized controlled trial. American Journal of Occupational Therapy, 65(5), 550-559.
Whitney, R.V. & Miller-Kuhaneck, H. (2012). Diagnostic Statistical Manual 5 changes to the autism spectrum criteria: A critical moment for occupational Therapists. The Open Journal of Occupational Therapy, 1(1), article 7.