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Pediatric Sensory & Psychiatry Research

My recent research with Quinnipiac University found that over half the children and adolescents referred for occupational therapy at my pediatric psychiatry hospital had significant sensory processing difficulties.  The most common difficulties were auditory filtering in three quarters, under-responsive/seeks sensation (60%), and tactile sensitivity in half the sample.   Sensory Processing difficulties were found through definite differences on the Short Sensory Profile (where only 2% of individuals would score).  Three separate studies similarly found over one-third of preschoolers and 40% of elementary school students with significant sensory processing difficulties had psychiatric diagnoses. Sensory processing disorders occur at significantly higher rates in children and adolescents with psychiatric diagnoses.

The findings that sensory processing problems are significantly higher in children and adolescents with behavioral and psychiatric challenges can guide therapists in their clinical interventions.  First, it is important to assess and if needed address sensory processing disorders in youngsters with behavioral and psychiatric difficulties.  Difficulty with sensory over-responsivity, the most common sensory processing problem, is extremely important to address in individuals with behavioral and psychiatric challenges.  Several FAB strategies include environmental adaptations and sensory modulation strategies that help children and adolescents maintain a quiet alert state.  A simple but effective strategy is to first decrease, then if needed incrementally increase sensory stimulation, until a quiet alert state is achieved.

Additionally, the high incidence of difficulties with tactile sensitivity and auditory filtering are particularly relevant.  The high frequency of problems with tactile sensitivity in my psychiatric patients referred to occupational therapy suggests why the use of restraint in pediatric psychiatry has been so problematic and the need for FAB pressure touch strategies as a component of intervention.  The high incidence of auditory filtering difficulties is also extremely relevant given that verbal counseling and coaching intervention is so extensively used.  It is important to distinguish when children and adolescents don’t follow verbal directions because they can’t understand them.  Children and adolescents with auditory processing and behavioral challenges could benefit from the strategic use of visual supports to convey counseling and coaching instructions.

The fields of occupational, speech-language, and physical therapy and our use of sensory processing interventions is criticized by pediatricians and behaviorists as an absurd fad despite our repeated clinical success.  It is time to publicize the extensive research and clinical evidence that shows sensory considerations are crucial in intervention with children and adolescents who have behavioral and psychiatric challenges.  The biases against occupational, physical, and speech therapists using appropriate caring touch and strategic visual supports is depriving young people of important intervention for improving their functional behavior.

References:

Carter, A.S., Ben-Sasson, A., & Briggs-Gowan, M. J. (2011).  Sensory over-responsivity, psychopathology, and family impairment in school-aged children.  Journal of the American Academy of Child & Adolescent Psychiatry, 50(12), 1210-1219.Gourley, L., Wind, C.,

Henninger, E. M. & Chinitz, S. (2012).  Sensory processing difficulties, behavioral problems, and parental stress in a clinical population of young children.  Journal of Child and Family Studies, 1-10.

Gouze, K.R., Hopkins, J., LeBailly, S.A., & Lavigne, J.V. (2009).  Re-examining the epidemiology of sensory dysfunction and comorbid psychopathology. Journal of Abnormal Child Psychology, 37(8), 1077-1087.

1079-1085.

Van Hulle, C.A., Schmidt, N.L., Goldsmith, H.H. (2012).  Is sensory over-responsivity distinguishable from childhood behavior problems? A phenotypic and genetic analysis.  Journal of Child Psychology and Psychiatry, 53(1), 64-72.

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Improving Functional Movement & Behavior

Addressing functional movement skills is important in children and adolescents with functional movement and behavioral challenges.  The FAB Goal-Plan-Review strategy promotes functional movement, behavioral, developmental, and learning skills.  Teaching children and adolescents to use adaptive strategies and equipment addressing dyspraxia (e.g., direction following, organizational, printing, cursive writing, keyboarding, and/or shoe tying difficulties) can improve behavior by reducing confusion and frustration.  Dyspraxia is now often referred to outside of the United States as DCD (“Developmental Coordination Disorder”).

The FAB Goal-Plan-Review strategy is adapted from the CO-OP (Cognitive Orientation to daily Occupational Performance), Ayres Sensory Integration, and Tools of the Mind approach.  These functional movement approaches span three decades and nations.  Research suggests that the CO-OP, Ayres Sensory Integration, and Tools of the Mind approach significantly improve functional skills but they appear most clinically effective when combined.  The FAB organizational strategies (see preceding Planning strategies improve behavior blog post) and FAB Goal-Plan-Review strategy integrate these three approaches to improve youngster’s functional movement and behavior.

The FAB Goal-Plan-Review strategy adapts the CO-OP (Cognitive Orientation to daily Occupational Performance) task-oriented approach by having clients develop a goal, plan a task, do the task, and review their performance.  The CO-OP approach is based on current motor learning research addressing dyspraxia by guiding clients in actively discovering adaptive techniques and generalizing them across functional motor tasks.  After doing the movement task clients review it with their therapist and revise strategies for improved performance.

The FAB Goal-Plan-Review strategy also adapts Ayres Sensory Integration by considering three components of functional movement (explained in parenthesis using the example of building with Playdoh).  The first component “IDEATION” is developing a physical movement goal (e.g., I want to build a snowman). The second component “MOTOR PLANNING” is developing a sequential movement plan (e.g., a. Make a large ball and place it on the bottom for a foundation, place a medium ball on top, then a small ball on the medium ball for the head; b. Make 3 tiny balls and place them vertically on the center ball for buttons; c. Finally on the head place two tiny balls horizontally on top for eyes, another tiny ball centered below for a nose, then several tiny balls in a concave circle below for a mouth).  The third component “EXECUTION” is the physical actions (e.g., building the snow man).

This ideation, motor planning, and execution framework enables therapists to observe whether a clients’ dyspraxia results from difficulties with ideation, motor planning, or both. To address ideation difficulties it is helpful to treat any related sensory discrimination and body image difficulties.  It is often also helpful to use touch prompts and/or massage strategies immediately before beginning motor tasks.  If the difficulty is in motor planning discussing, writing, and drawing the motor plan can be helpful.  The client can also try different motor plans and decide which works best.

Activities combining linear movement with deep pressure input can also promote motor planning and praxis skills.  Repetition of these movements in the functional environment is important for motor learning.  FAB Strategies involving slow linear movement and deep pressure that are embedded in regular school and home environments include: setting table, moving mats, moving tables, passing out books, and playground activities.

FAB Strategies also adapt the Tools of the Mind approach visual supports and modeling to teach self-regulation during functional movement tasks.  The Tools of the Mind approach, developed by a pediatric neuropsychologist to promote development of inhibitory control and planning skills, helped inspire the FAB: Goal-Plan-Review, List, Picture schedule, Praxis comic, 3 Comic, Schedule story, Rainbow goal, and Coping card strategies. The Tools of the Mind use of visual supports, self-talk, and modeling is particularly valuable for improving functional movement and behavior in children and adolescents with developmental challenges.

BEST Prax

Modern neurological and motor learning research suggests that repeated active practice in the natural environment as implemented in the FAB Goal-Plan-Review strategy is essential for learning.  A clinical example of the FAB Goal-Plan-Review strategy helps clarify its use with children and adolescents who have behavioral, praxis, and developmental challenges.  I worked with an adolescent girl who was low registration and had dyspraxia and Asperger’s Syndrome.  She repeatedly got injured while skate boarding and was upset that her parents would not let her go skate boarding by herself.  Her goal was to skateboard safely and independently.

While initially planning a skateboard obstacle course in the clinic, the adolescent seriously proposed skate boarding on the roof of the clinic.  I guided her with her parents assistance to ask and answer out loud the question “is that safe?” during ideation and motor planning of skate boarding and related movement tasks.  She was repeatedly reinforced for independently considering safety during her ideation and motor planning for skate boarding, and her parents eventually let her skate board independently without concern about her safety.  She gradually learned to transfer this questioning strategy “is that safe?” across her movement tasks.  In this way, the FAB Goal-Plan-Review and planning strategies help children and adolescents to improve their functional movement and behavioral skills.

References:

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

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.

Hillier, S. (2007).  Intervention for children with developmental coordination disorder: A systematic review.  The Internet Journal of Allied Health Sciences and Practice, 5(3).

Polatajko, H.J., & Cantin, N. (2006).  Developmental coordination disorder (dyspraxia): An overview of the state of the art.  Seminars in Pediatric Neurology,12(4), 250-258.

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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Planning Strategies Improve Behavior

The FAB List, Picture schedule, Praxis comic, 3-Comic, Schedule story, and Coping card strategies describe planning with visual supports to improve self-control.  These FAB planning strategies improve behavior in children and adolescents with sensory processing, developmental, trauma history, and mental health challenges.  Learning routines, rules, and structure enhance self-control.

The FAB List strategy helps organize children and adolescents who move rapidly throughout the class or therapy room making a mess and getting more disorganized. The therapist or teacher keeps all materials locked up then has the child make a sequential list of up to six activities they want to do that day.  They are then given access to the first activity, and must clean up and check it off the list before beginning the second task.

A similar strategy for students who learn best through visual prompts is the FAB Picture schedule strategy.

VisSchedSelfCont

This FAB Picture schedule strategy was individually developed by this student’s speech-language pathologist and occupational therapist using board maker.  The child’s individualized picture schedule helps the student identify when he is angry and/or mad (the feelings that most often precede his aggressive behavior), then choose one of his three most effective coping strategies to stay in control.  The picture schedule also designates that the student will be rewarded with an extra fifteen minutes long session with John (his occupational therapist) if he uses coping strategies.

The FAB Praxis comic strategy guides children and adolescents in understanding and sequentially following multiple step activities.  Below is the 4-part FAB Praxis comic created and used by a small occupational therapy group.  Group members are guided to describe, draw, and color 4 comic strips depicting the sequential components of every group. 

GroupComic

The students dictate and write the captions of the group sequence, (with the sensory purpose of the activities described here in parenthesis): 1. Move the chairs (e.g., specifically involving slow linear movement combined with deep pressure through the joints to facilitate self-regulation) 2. Throw the ball underhand (a sequential movement task that is combined with the verbal expression of feelings). 3. Sit (a calming activity during which students construct a feeling wheel or coping card, given the environmental structure of a seated position) 4.Play Frisbee ending the group (e.g., the final routine regularly done as a transition before moving the chairs back to end the group). Another FAB Praxis Comic is presented that is used in groups and individual sessions with adolescents learning to cook.

PraxComCook

For these students hand washing before cooking and sitting to plan the cooking were major steps they needed to remember.  For other students I stress other steps of cooking like a reminder to shut off the stove when done cooking.

The FAB 3 Comic is used to help children understand the trigger and consequences of their problematic behavior.  3 comic strips are constructed using drawings and captions.  The child begins by drawing comic 2 depicting the problematic behavior, draws comic 1 next showing the antecedent trigger, and finally comic 3 illustrating the consequences.

3 Comic Chain

It can be done with the child when they are calm following the problematic behavior, and be reviewed repeatedly.

The FAB Schedule story helps children understand and follow structure, and is particularly useful for promoting self-control during transitions and situations with little external structure.  The first example was done to assist a girl I worked with Autism Spectrum Disorder to leave the class for her speech language and occupational therapy sessions.

ScdlStry

The second schedule story was constructed with a small group who had difficulty independently selecting and carrying out free time activities.  INSERT  The children dictated the captions and drew the picture of their favorite free time activities.  For example, the teacher posted the Build Model picture on top of the cabinet where the models were kept.  When it was free time the student who liked model building would get the schedule story, select the picture Build Models, match the picture to the same picture on the cabinet where the models were kept, and play with the models.

SchedStryFreetime

The FAB Coping card strategy concisely integrates on a laminated index card the child’s preferred interest, behavioral goal (selected to be incompatible with aggression), coping strategies and equipment, and reinforcement schedule.

Copingcard

For example, a student who frequently bit his own hand when peers teased him helped construct a coping card with a drawing of his preferred interest Sponge Bob, coping pictures of his chewy, weighted blanket, and listening to music (colored, cut out, and pasted on an index card from the FAB Trigger & Coping forms), with the written caption: “Keep safe hands don’t hurt myself when I get upset”.  On the reverse side of the coping card was his reinforcement plan: “Safe hands for one 10 minute activity earns one sticker (five stickers= 1 toy car)”. The coping card is worn or posted on the desk to remind the child and all staff of the child’s behavioral goal, preferred interest, coping strategies, and reinforcement schedule.

The FAB List, Picture schedule, Praxis comic, 3 Comic, Schedule story, and Coping card strategies assist planning with visual supports to improve self-control.  These FAB strategies involve students in developing organizational strategies that improve their behavior.  These FAB  planning strategies can be individualized to best meet each child’s needs and integrated into their daily routines.

References:

Diamond, A. & Lee, K. (2011).  Interventions shown to aid executive function development in children 4-12 years old.  Science, 33(6045), 959-964.

Gray, C. A., & Atkins, T. (2010).  The new social story book. Arlington, TX: Future Horizons.

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

Spencer, V., Simpson, C., Day, M., Buster, E. (2008).  Using the power card strategy to teach social skills to a child with Autism.  Teaching Exceptional Children Plus, 5(1), 1-10.