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Teaching Sensory Modulation Improves Behavior

Many children and adolescents with sensory modulation, Autism Spectrum, behavioral, and/or mental health challenges are under-responsive and/or over-responsive to sensory stimulation.  Difficulty maintaining a calm alert state can negatively impact behavioral, mental health, and learning skills.  The FAB energy modulation strategy teaches clients to identify their arousal level before it becomes problematic and use coping strategies to manage it.  While independently managing their arousal level is challenging for children and adolescents practicing this through the FAB energy modulation strategy teaches that self-control is their responsibility.

Children and adolescents with behavioral and sensory modulation disorders often state, “I suddenly feel bad in my skin, then explode when someone tells me no or orders me to do something”.  To manage their energy levels clients must learn to identify their arousal level and notice when it begins becoming uncomfortable and problematic. The FAB energy level strategy involves kids regularly describing their energy level verbally and/or using visual supports such as the energy meter, anger meter, or spazo-meter

EnLevSimp AngerMete

Spaz-O-Meter

The FAB energy level strategy involves rating their energy as low (e.g., “feeling numb and sleepy”), medium (e.g., “calm and alert), or high (“hyper and wired”).  Youngsters are also encouraged to notice whether their energy level feels comfortable or uncomfortable.

By repeatedly modeling and discussing energy levels throughout the day clients gradually become aware of them.  Adapted from the ARC “Attachment, Self-Regulation, and Competency” model for children and adolescents with trauma challenges <www.traumacenter.org> The FAB energy level strategy also helps youngsters with sensory modulation, mental health, and behavioral challenges.  The FAB energy level strategy can be embedded in the school routine before and after low structure and stressful activities (e.g., school lunch room, recess, physical education class, therapy sessions).  If a student identifies his energy level as uncomfortably high after physical education class or recess I urge school staff to send him to occupational therapy for individualized energy modulation strategies (e.g., pushups, mindfulness tasks).  Once the child rates his energy as medium and comfortable he is rewarded and returned to class.

The FAB energy level strategy also encourages youngsters to identify their triggers and coping strategies through drawings or using the FABTrigger & CopingForms  On each page clients select their 3 most problematic environmental triggers, body triggers, and effective coping strategies.  Youngsters can color and paste pictures of their trigger and coping strategies to post in areas where they often experience behavioral problems related to sensory modulation difficulties (e.g., preschool nap area, first grade writing area, math corner).

Coping

The final aspect of the FAB energy modulation strategy is embedding individualized strategies that effectively manage their energy levels into their daily routine.  Practice with coping strategies can begin in the sensory calming area where the environment can be easily managed.  Deep pressure activities with slow linear movement (e.g., going through a Steam Roller Deluxe, wheel barrow walking on hands over a therapy ball, moving mats) are frequently helpful for modulating energy levels.  Daily cardiovascular (e.g., an hour walk, half-hour jog), relaxation (e.g., 30 minute meditation, mindfulness, or yoga activities) and heavy work (lawn mowing, weight lifting, swimming) activities often help clients maintain a quiet alert state.

Rather than prescribing a specific sensory diet individualized FAB Strategies are suggested to provide options for maintaining self-regulation embedded in the daily routine. Strategies for maintaining a quiet alert state can be independently developed by the child or adolescent using the FAB Energy Modulation Wheel  SEnModWheel1

or developed as a home program with his therapist and teachers using the FAB STRATEGIES form. The SensoryLifestyle is a great new approach I was introduced to by occupational therapists in discussions on my blog that conveys the lifelong management of arousal levels that is often needed.  While teaching children and adolescents to manage their arousal level can be a long and challenging process, it is ultimately affective for promoting functional behavior and learning.

References:

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

Dunn, W., Cox, J., Foster, L., Mische-Lawson, L. & Tanquary, J. (2012).  Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: A pretest-posttest repeated-measure design.  American Journal of Occupational Therapy, 66(5), 520-528.

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.

Rodger, S. & Brandenburg, J. (2009).  Cognitive orientation to (daily) occupational performance (CO-OP) with children with Asperger’s syndrome who have motor-based occupational performance goals.  Australian Occupational Therapy Journal, 56(1), 41-50.

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FAB Energy Modulation Wheel

The FAB Energy Modulation Wheel strategy helps teach clients to manage their arousal level for appropriate behavior and learning.  It can be used in groups or individual therapy sessions.  The FAB Energy Modulation Wheel is provided here for personal use by parents, teachers, and therapists guiding clients in developing energy modulation strategies.  FAB Energy ModWheel

The FAB Energy Modulation Wheel is useful for helping children, adolescents, young adults and their parents develop sensory activities they can embed in their daily routines.  It has been successfully used with clients who have sensory modulation, Autism Spectrum, mental health, and learning disorders.  The FAB Energy Modulation Wheel integrates the ARC “Attachment, Self-Regulation and Competency” trauma intervention <www.traumacenter.org>, Sensory Integration, and Life Wheel self-regulation models.

The FAB Energy Wheel strategy emphasizes that therapists can guide the client and family in developing sensory modulation strategies, but it is the client’s responsibility to implement them.  Following individual and/or group therapy sessions using sensory modulation strategies the client and parents choose 8 activities to do daily, labeling and drawing them in varied colors on the FAB Energy Modulation Wheel.  An adolescent with a sensory modulation and Autism Spectrum disorder whose goal is “managing my energy level to keep safe hands” developed the FAB Energy Modulation Wheel below.

SEnModWheel1

The teachers and therapists reinforce this adolescent and his parents for completing the FAB Energy Modulation Wheel activities daily and progressing toward his goal.

Clients with behavioral and sensory modulation challenges need sensory activities to replace their current dysfunctional “coping” strategies for managing uncomfortable energy levels (e.g., cutting themselves, head banging).  Motor learning research suggests it is easiest to stop dysfunctional behaviors by repeatedly replacing them with new activities embedded in daily routines.  These new strategies help clients manage their sensory modulation and behavioral challenges.  Sensory diets effectively manage client’s sensory modulation needs but often fail because they are not implemented regularly.  Involving clients and their parents in developing their sensory modulation strategies makes it more likely they’ll do the activities daily. My next blog post “Clients can develop their sensory diets” will further discuss ways of helping clients develop FAB Energy Modulation Strategies that improve their sensory modulation skills.

 References:

Dunn, W., Cox, J., Foster, L., Mische-Lawson, L. & Tanquary, J. (2012).  Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: A pretest-posttest repeated-measure design.  American Journal of Occupational Therapy, 66(5), 520-528.

Rodger, S. & Brandenburg, J. (2009).  Cognitive orientation to (daily) occupational performance (CO-OP) with children with Asperger’s syndrome who have motor-based occupational performance goals.  Australian Occupational Therapy Journal, 56(1), 41-50.

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FAB Strategies to Improve Body Scheme

FAB “Functionally Alert Behavior” Strategies promoting body scheme can improve behavior in children and adolescents with sensory processing, developmental, learning, and mental health challenges.  Improving body scheme is particularly important for children and adolescents because it impacts the development of their behavior and learning.  Improving body scheme can also promote self-esteem, organization, and motor planning skills.

Body scheme difficulties can negatively impact behavior and learning skills.  Although body scheme difficulties are commonly described in children and adolescents with trauma histories, inappropriate behavior, and psychiatric disorders limited attention is given to body scheme by mental health therapists.  The sensory integration frame of reference provides body scheme assessment and intervention strategies (see Sensory Discrimination and Praxis Disorders in my previous blog post Making Sense out of Sensory Integration).  Sensory Integration, pressure touch, and basic mindfulness are combined in FAB “Functionally Alert Behavior” Strategies to improve body scheme.

Sensory integration intervention is not a school service, so any use of the sensory integration frame of reference by school occupational, speech, or physical therapists must be directed toward school goals required for the child to benefit from their learning program.  An examples of a school occupational therapy goal for a first grader that includes intervention to improve body scheme is: Given repeated verbal prompts as needed the student will maintain a seated position for ten consecutive minutes on 4 out of 5 occasions (e.g., will not fall or get out of their seat with out permission).  It is important to measure the child’s baseline skills so achievement of school therapy goals shows the child’s improved learning and behavioral functioning.

The following pictures were taken of a group of kindergarten age children with a diagnosis of Pervasive Developmental Disorder who had body scheme and motor planning challenges.  I led the group assisted by the children’s wonderful parents as well as undergraduate occupational therapy students.  Fun activities were included involving child-directed movement combining graded touch (tactile), deep pressure (proprioception), and vestibular (movement) sensory input.

AirMatFun

Strategies for repeated use at home and school are particularly helpful to improve body scheme.  FAB Strategies that promote body scheme include: Touch vibration on the Back and Arms, FAB Pressure Touch, Back X, Spine crawl, Nose breathe, Mindful clock, Bird, Tense & relax, Focus on feet, Body scan, Focus on palms, and Wall pushups. The picture below shows an elementary student using my occupational therapy bulletin board to feel his palms while doing wall pushups.

WallPushup

FAB Strategies intervention including Sensory Integration, Pressure Touch, and Mindfulness activities can improve body scheme for improved behavioral, self-esteem, organizational, and motor planning skills.

References:

Ayres, A. J. (1985).  Developmental dyspraxia and adult-onset apraxia.  Torrance, CA: Sensory Integration International.

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, 70-95.

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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Making Sense out of Sensory Integration

After 30 years as an occupational therapist treating sensory integration difficulties to improve functional skills in children and adolescents, I still find understanding and explaining sensory integration disorders challenging.  Clearly describing and explaining sensory integration disorders promotes sensory integration intervention.  This blog post provides a basic understanding of sensory integration disorders as a foundation for my next several blog posts, which will discuss how specific Sensory Processing Disorders affect mental health and describe sensory integration intervention strategies. 

Sensory Integration difficulties are currently referred to as Sensory Processing Disorders and consist of 3 major categories of disorders.  An understanding of the differences, similarities, and relationship between the 3 major categories of Sensory Integration difficulties guides assessment and intervention.  The 3 major categories of Sensory Processing Disorders are Sensory Modulation, Sensory Discrimination, and Sensory Based Motor Disorders.  

Sensory Modulation is the most commonly assessed and treated category of Sensory Processing Disorder, and is often wrongly thought of as the only category of Sensory Integration assessment and intervention.  Quick, accurate assessment of Sensory Modulation Disorders can be done using the Sensory Profile, and research has shown that Sensory Modulation Disorders exist and relate to functional challenges.  Sensory Modulation Disorders include: Sensory Overresponsivity (significantly more than typical noticing of sensory input), Sensory Underresponsivity (significantly less than typical noticing of sensory input), and Sensory Seeking (a significantly greater than typical tendency to seek out sensory input).  The types of Sensory Modulation Disorder can be distinct, but some individuals demonstrate Sensory Overresponsivity, Underresponsivity, and Seeking.

 

SensModDisSensModLev

Sensory Discrimination Disorders are an important but less understood category of sensory processing dysfunction that involve difficulties locating, differentiating, and using sensory stimuli functionally.  This can contribute to difficulties with body awareness, body scheme, disorganization, and difficulty learning.  The design below was done by a third grader with Sensory Discrimination Disorder who was asked to cut out body parts and assemble them into a picture of a girl.  This student was bright but showed an inability to identify which of her fingers I was touching with out using her vision, and her picture shows her disorganization in body scheme. Sensory Discrimination Disorders can involve the sense of: touch, proprioception (pressure touch and body awareness), vestibular (movement), vision, sound, taste, and/or smell.

 

SensDiscDisSensDiscDis

The Sensory Based Motor Disorders category includes both Postural Disorders and Dyspraxia.  Postural disorders involve subtle balance difficulties and clumsiness. Dyspraxia, emphasized by the developer of Sensory Integration A. Jean Ayres, is difficulty initially learning new skills (e.g., such as shoe tying, printing, and typing). Dyspraxia can involve difficulties in ideation, motor planning, and/or execution, which are the three components in learning unfamiliar skills.

Ideation is understanding and deciding what to do with an object.  I like to describe the components of praxis by imagining you give playdoh to a child who has not used it much before.  The first thing the child would need to do involves ideation, deciding: “I want to make a snowman”.  Children with ideation problems  have difficulty choosing and beginning an action. 

Once the child decides to make a snowman he would do motor planning.  Motor planning a snowman involves identifying the sequential steps needed (first I’ll make a big ball and put it on the bottom, next put a medium ball on the bottom ball for a body, then a smaller ball on top of the middle ball for the head; after that I put 2 tiny balls on the upper sides of the top ball for eyes, a tiny ball below them in the middle for a nose, and 6 tiny balls in a half circle centered below the nose for a mouth).  The final process is execution, actually building the snowman out of playdoh.

SensBasedMotDisPraxis

Understanding that Sensory Processing Disorders can involve difficulties with Sensory Modulation, Sensory Discrimination, and/or Sensory Based Motor Disorders guides evaluation and treatment.  It helps with identifying an individual’s sensory integration challenges that negatively impact their functional skills.  Research suggests that the categories of sensory processing problems may occur individually or overlap, as shown by the final diagrams.

My next blog posts will discuss the affects of Sensory Discrimination and Motor Based Sensory Disorders in Child & Adolescent Mental Health and describe Sensory Integration intervention strategies.

SensProcDisCatOverlapSPDTypes

References:

Ayres, A. J. (1985).  Developmental dyspraxia and adult-onset apraxia.  Torrance, CA: Sensory Integration International.

Ben-Sasson, A., Cermak, S.A., Orsmond, G.I., Tager-Flusberg, H., Carter, A.S., Kadlec, M.B., Dunn, W. (2007).  Extreme sensory modulation behaviors in toddlers with Autism Spectrum Disorders.  American Journal of Occupational Therapy, 61, 584-592.

Miller, L.J., Anzalone, M. E., Lane, S. J., Cermak, S. A., Osten, E. T. (2007).  Concept evolution in sensory integration: A proposed nosology for diagnosis.  American Journal of Occupational Therapy, 61(2), 135-140.

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., 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.