FAB Strategies John Pagano, Ph.D., OTR/L

Interoception Intervention for Adolescents with Complex Behavioral Challenges

To develop interventions that help improve interoceptive awareness in adolescents with complex behavioral challenges I recently completed the MABT (Mindful Awareness in Body-Oriented Therapy) Level 1 training and interoception research. Sensory processing and interoception are atypical in adolescents with Autism Spectrum Disorder (DuBois et al., 2016) and mental health challenges (Khalsa et al., 2018). Recent research suggests the need for new multi-disciplinary interventions and a revision of sensory processing theory for adolescents with Autism Spectrum Disorder, PTSD, and mental health challenges (DuBois et al., 2017; Khalsa et al., 2018).

MABT is an individual, voluntary intervention combining massage, self-touch, and psycho-education to improve interoceptive awareness. MABT significantly improves substance abuse recovery, PTSD symptoms, interoceptive awareness, and physiological measures of emotion regulation in comparison to health education treatment both immediately and six months after MABT intervention. Participants in MABT are given home assignments that they report increase their mindfulness even after the treatment is over (Price et al., 2019; Price & Herting, 2013; Price & Mehling, 2016).

MABT and other interoception interventions require significant modification for use with adolescents who have complex behavioral challenges. Promising clinical interoceptive awareness treatments specifically for adolescent with Autism Spectrum Disorder have been developed, but lack adequate research support (Miller & Collins, 2012; Mahler, 2017). Out of necessity I developed clinically applicable interventions for adolescents with developmental, behavioral, Post-Traumatic Stress, mental health and sensory processing challenges that are lacking reliable research support.

In developing clinical treatments to improve interoceptive awareness in adolescents with complex behavioral challenges I began with trauma-informed therapy. Trauma-informed therapy assumes all clients may have a history of trauma and universally applies strategies so intervention will not be harmful if they do. By providing choices that offer but do not push the use of massage adolescents are given choices that reduce the possibility of their being re-traumatized by touch interventions.

Occupational therapists are among a very limited number of professionals who include touch interventions and mental health training in their scope of practice. The sensory processing model includes but does not require the use of a variety of touch interventions as a component of goal-directed therapy. Massage, scrub brushing, self-brushing, vibration, self-touch, mindfulness and adaptive equipment are multiple options that can be offered by occupational therapists for improving interoceptive awareness.

The other modification of MABT and interoceptive awareness is greatly simplifying the initial development of body awareness. The first sequential step in teaching interoceptive awareness to adolescents with complex behavioral challenges is to assure  they have proprioceptive awareness of the front and back of their body. Next they are oriented to their head at the top of their body and feet at the bottom grounding them. Finally, they are taught that they have two separate sides. This body orientation can be enhanced through touch or by using forward-back, down-up (squatting then toes), and side to side movements (Koester, 2012).

MABT progressively teaches the ability to identify, access, then engage mindfully with internal body sensations (Price & Hooven, 2018). A helpful strategy adapted from MABT as an alternative to massage that provides basic body awareness is the body scan. Adolescents who want massage can initially experience the body scan by having the therapist press sequentially on specific areas of their body. For clients who do not want to be touched they can do the body scan through self-touch. Clients can imitate the therapist’s sequential self-touch.

The body scan involves sequentially touching: top of the head, forehead, cheek, other cheek, chin, volar side on top of the shoulder, on top of the elbow, palm, then stomach. The adolescent can progress from (or avoid it if they dislike self-touch) by doing the body scan wizard hand, in which they follow the same body scan progression holding their hand a few inches above each body part (Mahler, 2017). The final progression is to do the body scan by imaging a gold bird lands sequentially on each body part, emitting white light that relaxes and energizes their body. The body scan provides basic body awareness through touch on the “front” of the body.

For adolescents who would benefit from deep pressure touch and basic body awareness but dislike massage and self-touch therapists can offer touch with equipment through the Roll a therapy ball: core progression strategy Roll therapy ball: Core progression Strategy A therapy ball is rolled on the client giving calming deep pressure as well as proprioceptive input developmentally sequenced to orient them first to the front and back, next to the top and bottom, and finally to the sides of their body. Once clients are aware of the basic orientation of their body they can be oriented to the class room having front and back, top and bottom, as well as two sides. Finally, special markings can be used to orient them to the front and back, top and bottom, and two sides of their paper for reading and writing (Koester, 2012; Burpee, 2019).

The MABT course and interoceptive awareness research has provided many new clinical resources for expanding interventions to improve self-control in adolescents with complex behavioral challenges. It has also raised questions regarding the role of interoceptive awareness assessments and the research efficacy for new body awareness intervention strategies. I’m hoping occupational therapists will continue to pursue this new area of interoceptive awareness and participate in multidisciplinary collaborations.

References:

Burpee J. Sensory Integration Workbook Presentation. 2019.

DuBois D, Lymer E, Gibson BE, Desarkar P, Nalder E. Assessing sensory processing dysfunction in adults and adolescents with autism spectrum disorder: a scoping review. Brain sciences. 2017

DuBois D, Ameis SH, Lai MC, Casanova MF, Desarkar P. Interoception in autism spectrum disorder: A review. International Journal of Developmental Neuroscience. 2016 Aug 1;52:104-11.

Koester, C. Movement based learning: For children of all abilities. 2012.

Mahler, K. Interoception: The eighth sensory system. 2017.

Miller LJ, Collins, B. Sensory discrimination disorder. Autism Digest. 2012 Nov.-Dec;32-33.

Price CJ, Thompson EA, Crowell S, Pike K. Longitudinal effects of interoceptive awareness training through mindful awareness in body-oriented therapy (MABT) as an adjunct to women’s substance use disorder treatment: A randomized controlled trial. Drug and alcohol dependence. 2019 May 1;198:140-9.

Price CJ, Herting JR. Changes in post-traumatic stress symptoms among women in substance use disorder treatment: the mediating role of bodily dissociation and emotion regulation. Substance abuse: research and treatment. 2013 Jan;7:SART-12426.

Price CJ, Hooven C. Interoceptive awareness skills for emotion regulation: Theory and approach of mindful awareness in body-oriented therapy (MABT). Frontiers in psychology. 2018;9.

Khalsa SS, Adolphs R, Cameron OG, Critchley HD, Davenport PW, Feinstein JS, Feusner JD, Garfinkel SN, Lane RD, Mehling WE, Meuret AE. Interoception and mental health: a roadmap. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging. 2018 Jun 1;3(6):501-13.