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Implementing Sensory Strategies in Preschools & Kindergartens

Many excellent discussions debate the best ways to responsibly integrate sensory strategies that help young children. While I don’t have a conclusive answer for this dilemma I have been struggling with this question all of my professional life. The attachments presented in this post describe my FAB Strategies for integrating environmental adaptations, sensory modulation, positive behavioral support, and physical self-regulation strategies in preschool and kindergarten classes.

My hope is to offer an approach for teachers and therapists in the schools to help children both who have and who have not yet been diagnosed with special needs and are having difficulty learning.  The FAB “Functionally Alert Behavior” Preschool & Kindergarten Strategies form can be used by teachers and therapists for children both with and without identified special needs.  It guides home programs, serves as a check list for teachers and therapists of strategies that help children with behavioral and developmental challenges learn, and can be used to guide goal-directed interdisciplinary interventions for children receiving special education services FABPre&KStrategies

I offer small two-day workshops for occupational, speech, physical, and mental health therapists that include direct practice for developing, implementing, and consulting with parents and teachers implementing FAB Strategies (see Schedule of FAB Strategies Workshops Page of this blog). I will be releasing an additional schedule of my 10 larger, one-day workshops in January and March 2014 for teachers, parents, and school therapists.

I have included for teachers, therapists, consultants, and researchers my recently published paper describing my research supported theory of FAB Strategies for preschoolers and kindergarteners.  I am currently conducting research regarding the relationship between children’s behavioral and sensory processing challenges.

FAB STRATEGIES Preschools & K

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Sensory Integration Needs to Evolve

Following its initial development by A. J. Ayres, Sensory Integration Intervention has been slowly evolving.   As a result of this slow evolution, two major problems threaten the sensory integration frame of reference. First is the problematic discrediting of sensory integration research by some behaviorists and pediatricians who favor interventions that are too rigid or medication based to optimally help children.  Second is intervention borrowing sensory integration terminology with out adequate expertise in carrying out the strategies.  Increasing use of “brushing, sensory diets, sensory equipment, and comfort rooms” developed and used by teachers and mental health therapists with out adequate guidance from therapists trained in sensory integration significantly dilute the effectiveness of sensory integration intervention.

Luckily, many well trained therapists continue the evolution of sensory integration intervention.  While these excellent contributions are too vast to cover fully, I want to review three major areas of evolution in sensory integration intervention that serve as a foundation for further expansion.  Related to each evolution I will mention and provide links to clinicians who have built on sensory integration in a way that has been most helpful to me in my intervention as an occupational therapist working with children and adolescents who have behavioral, psychiatric, early trauma, Autism Spectrum Disorders, and other developmental challenges.

The first evolution contributes sound research, theory, and standardized sensory integration terminology to clinical sensory integration intervention.  This evolution is led by Lucy Jane Miller and her colleagues at the Sensory Processing Disorder SPD Network www.spdnetwork.org  While the therapists significantly contributing to the SPD Network are too numerous to mention fully, I want to describe two that greatly contribute to my practice in child and adolescent psychiatry.  Diana Henry www.ateachabout.com offers many helpful clinical intervention strategies.  The late Jane Koomar, Teresa May-Benson and her associates at OTA Watertown www.otawatertown.com and the Spiral Foundation conduct research and teach clinical sensory integration strategies that enhance attachment and the development of children with early trauma challenges.

The second evolution is the brief valid assessment of sensory modulation problems and their treatment through adaptive equipment and techniques.  Winnie Dunn has led this evolution through her research and development of the Sensory Profile and sensory integration based consultation strategies.  Others that have greatly helped my practice through environmental adaptations include Tina Champagne www.ot-innovations.com whose work with sensory coping rooms and adaptive equipment has helped psychiatric hospitals significantly reduce the use of restraint, replacing it with sensory coping rooms and equipment that empowers clients to learn effective coping strategies.  The adaptive sensory strategies developed through the Alert Program by Sherry Shellenberger and Mary Sue Williams www.alertprogram.com have also helped empower children with behavioral challenges to actively learn coping strategies.  Mention also needs to be made of Patricia & Julia Wilbarger’s  development of the sensory diet www.avanti-ed.com  Problems with misuse of the sensory diet by untrained individuals while significant are contrary to how the Wilbarger’s instructed it be used.

The third evolution is the development of touch pressure strategies as an individualized component of Ayres’ Sensory Integration that was initially expanded on by Knickerbocker.  The Wilbarger Protocol (brushing) is brilliant despite problems resulting from its misuse that are contrary with how it was taught by the Wilbargers.  Two other helpful contributions to this evolution are research efficacy of touch pressure through massage from Tiffany Field http://www6.miami.edu/touch-research and Qigong Sensory Treatment (QST) touch pressure based on Tui Na massage.  QST is developed and research validated by Dr. Silva www.qsti.org

QST was found through repeated research to significantly improve behavior and sensory processing in preschoolers with Pervasive Developmental Disorders.  QST research and my clinical experiences suggest the use of QST touch pressure offers great promise as a touch pressure strategy done as a component of Sensory Integration Intervention, particularly for youngsters with Autism Spectrum Disorders and/or an early trauma history.  Research suggests that young children with Autism Spectrum Disorders who are hyper-responsive to touch benefit from sensory processing intervention, while both hyper and hypo-responsive preschoolers with Autism Spectrum Disorders show significantly improved behavior and sensory processing skills following firm pressure touch.  I adapted the work of Knickerbocker, Tiffany Field, and QST to develop FAB Pressure Touch Strategies.   A major difference of FAB Pressure Touch Strategies is that therapists individualize it to reach the child’s functional goals as one component of comprehensive intervention.

The three evolutions of clinical, environmental adaptation, and pressure touch strategies in sensory integration provide a solid foundation for the development of Sensory Integration Intervention, and it is important to stay updated on this clinical and research work. Although proponents of the three evolutions conflict at times, these disagreements are insignificant given the contribution that all these intervention methods offer in conjunction with one another.  Sensory integration is now ready to further evolve into a solid research based frame of reference that is a specialized component of occupational, physical, and speech therapy practice.  Critics of sensory integration have used their objections to this frame of reference to advocate against children receiving occupational therapy services.  Sensory integration intervention is not all of occupational therapy, but is an important frame of reference for the profession.

My development of FAB Strategies offers an example of ways therapists can knowledgeably include sensory integration intervention as one goal directed component of a comprehensive intervention strategy for children and adolescents with behavioral, developmental, and sensory processing challengesFAB Functionally Alert Behavior STRATEGIES While a written format of strategies is described, interventions including the use of touch pressure strategies are individualized by trained therapists to attain their client’s goals.  In FAB Strategies the goal is used to guide development of intervention composed of environmental adaptations, sensory modulation, positive behavioral support, and physical self-regulation strategies.  I urge other occupational therapists to continue the evolution led by Ayres and her initial followers to further help and guide their clients.

References:

Ayres, A. J. (2005). Sensory integration and the child: 25th Anniversary Edition.  Los  Angeles, CA: Western Psychological Services.

Higbee, T.S., Chang, S., Endicott, K. (2005).  Noncontingent access to preferred sensory stimuli as a treatment for automatically reinforced stereotypy.  Behavioral Interventions, 20, 177-184.

Kimball, J. G., Lynch, K. M., Stewart, K. C., Williams, N. E., Thomas, M. A. & Atwood, K. D. (2007).  Using salivary cortisol to measure the effects of a Wilbarger protocol-based procedure on sympathetic arousal: A pilot study.  American Journal of Occupational Therapy, 61(4), 406-413.

McClafferty, H., Sahler, O. J., Wiley, S. E. (2012).  Sensory Integration therapies for children with developmental and behavioral disorders.  Pediatrics, 129(6), 1186-1189.

Schaaf, R.C., & Miller, L.J. (2005).  Occupational therapy using a sensory integrative approach for children with developmental disabilities.  Mental Retardation and Developmental Disabilities Research Reviews, 11, 143-148.

Silva, L. M., Schalock, M. (2013).Prevalence and significance of abnormal tactile responses in young children with Autism.  North American Journal of Medicine and Science, 6(3), 121-127.

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Touch Intervention to Improve Child & Adolescent Behavior

Evidence based touch strategies are an important part of my occupational therapy interventions for children and adolescents with behavioral, psychiatric, developmental, and sensory processing challenges. Although touch is a component of typical attachment and development, many excellent mental health therapists do not include touch in their interventions with children and adolescents, and warned me against using touch when I began working in pediatric psychiatry 30 years ago.   I include touch as part of my psychiatric interventions with children and adolescents based on research showing its efficacy for improving mental health and social skills in children and adolescents with Autism Spectrum Disorders, psychiatric disorders, behavioral problems, early trauma challenges, and sensory processing challenges.

Specific guidelines are needed when using touch with children and adolescents with mental health challenges, because these youngsters may have past experiences of physical abuse, sexual abuse or child neglect that make touch problematic.  I always provide touch only after getting permission from the parent and child, repeatedly urging the youngster to let me know and any time if they want me to stop immediately, and in conjunction with their mental health therapist.  Implementing touch in this manner, I have only had one incident of a child demonstrating distress as a result of being touched during my 20 years of full time practice, and have seen a dramatic reduction in physical and verbal aggression with improvements in behavior, social skills, and attention span.

My use of pressure touch in FAB “Functionally Alert Behavior” Strategies differs from traditional massage and brushing protocols.  There is evidence for massage as an intervention to improve social skills with children who have Autism Spectrum Disorders and clinical experiences of scrub brushing improving behavior in children with sensory processing challenges, but both of these methods are sensory stimulation techniques that are implemented in a prescribed manner.  In FAB Strategies pressure touch is included in the sensory modulation section as one component of an interdisciplinary program to achieve specific behavioral objectives.  The touch is individually developed and modified by the therapist to achieve the child’s goals.

Touch pressure in FAB Strategies is provided through equipment, independent exercises, brushing, massage, or joint compression strategies.  The touch pressure strategies are individualized and modified to achieve the child or adolescent’s specific behavioral goals (e.g., reduced physical aggression, reduced verbal aggression, improved communication, increased social skills).   Equipment and exercises used to provide pressure touch in FAB Strategies include: theraband exercises, wall pushups, theraplast, playdoh, hugging a stuffed animal, a weighted blanket, a pressure or weighted vest, and a body sock.  Pictures of the exercises and equipment touch strategies are identified on the FAB Coping Forms, and can be reviewed during the initial evaluation.

FABCopingForms WallpushupsProneTherapyballfar

All of these strategies provide pressure through the joints. An advantage of the exercise and equipment touch pressure strategies is that they are controlled by the child or adolescent and can be done independently as a coping strategy.  We have pressure receptors in our body (e.g., enabling us to point to our wrist with out looking) and exercises, equipment, or direct touch that activates these receptors provides youngsters with a calming sensation (e.g., like when a mother hugs her child) that can be a useful coping strategy.

Pressure touch can also be provided directly by therapists, parents, and teachers as a coping strategy using the FAB Pressure Touch Strategies.  The FAB Pressure Touch Strategies (taught in my workshops) include the: head crown, shoulders squeeze, spine roll, back protocol, back, arm, legs, feet, and face strategies. Direct touch FAB Strategies listed on the FAB Coping Forms above include get a hug and FAB Pressure Touch (a variety of massage and brushing strategies begun with touch on the back).  Direct touch may reduce physical and verbal aggression when no other strategies are affective, and can be beneficial to improve attachment and relationships.  While some of the FAB Pressure Touch Strategies are currently used by physical and occupational therapists in FAB Strategies emphasis is given to how touch “feels” in the body, affects the child or adolescent’s energy level and tension, and enables them to achieve their behavioral goals.  The link below shows the direct FAB Pressure Touch Strategies being done as a component of FAB Strategies with a preschooler who has Asperger’s Syndrome and behavior challenges http://www.youtube.com/watch?v=W8fMdJ6l0AM&feature=youtu.be

References:

Blaustein, M.E. & Kinniburgh, K.M. (2010).  Treating Traumatic Stress in Children and Adolescents.  NY, NY: The Guilford Press.

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.

Mass. Dept. of Mental Health Safety Tool. (2006).  MacLachlan, J. & Stromberg, N. Safety Tools.

Silva, L. M., Schalock, M. (2013).Prevalence and significance of abnormal tactile responses in young children with   Autism.  North American Journal of Medicine and Science, 6(3), 121-127.