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Using FAB Strategies®

“Functionally Alert Behavior” FAB Strategies® is an evidence-based curriculum of environmental adaptation, sensory modulation, positive behavioral support, and physical self-regulation strategies for improving the functional behavior of children, adolescents and young adults with complex behavioral challenges FAB Strategies ERIC document Complex behavioral challenges involve a combination of inter-related mental health, developmental, sensory and environmental challenges. The FAB Strategies® curriculum is individualized by occupational, physical, speech and mental health therapists for coordinated use in conjunction with the client, their family and teachers.  The FAB Strategies®curriculum emphasizes the use of a coordinated multidisciplinary approach that addresses specific goal-directed functional behaviors in the natural environment.

FAB Strategies® is useful for guiding integrated individual, group, and home program intervention by teachers, family members, as well as occupational, physical, speech and mental health therapists. Teachers, therapists and familys face the challenge of helping students develop the behavioral skills that support learning. This challenge has become more difficult given the increasing academic demands and numbers of students with complex behavioral challenges. It is crucial to help students with complex behavioral challenges because their behaviors interfere with these students’ and their classmates learning. The “Functionally Alert Behavior” FAB Strategies® curriculum can improve self-control in students with complex behavioral challenges.

The FAB Strategies Form guides therapists in developing an individualized program for improving the client’s functional behavior fab-stratform Section A environmental adaptations provide the structural foundation for FAB Strategies. The child’s response related to his functional goal guides the use of environmental adaptations. Environmental adaptations include adaptive equipment such as fidgets, visual schedules and adaptive techniques.

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Environmental enrichment through adaptive equipment, visual schedules, and adaptive techniques reduces aggression in children with behavioral challenges and developmental disabilities. When developing environmental adaptations, it is important to consider the dynamic relationship between the child’s behavioral, sensory, cognitive, and environmental challenges. Environmental structure and behavioral demands are interacting variables, with greater sensory demands suggesting the need for more structure. When children show improved self-control or demands are decreased, structure is reduced to promote independence.

Section B sensory modulation strategies help lower stress and enhance self-regulation, with the massage activities included in this section. Sensory modulation includes body awareness, basic mindfulness, touch, and motor self-control strategies. The Pagano FAB Trigger & Coping forms use pictures visually representing common environmental and body triggers as well as sensory coping strategies for children with behavioral, developmental, and sensory challenges.

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Section C positive behavioral control strategies improve behavior and communication skills. Learning social and communication skills significantly improves the behavior of children with developmental and behavioral challenges. Functional communication can be supported and rewarded through socially embedded reinforcers. For example, when a child says or signs “jump”, the therapist takes the child’s hands and jumps with the child. Section C also includes the FAB Turtle Technique, where a child notices his triggers and does his individualized self-calming strategies in the sensory coping area.

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Section D physical sensory strategies promote attention, behavior, and social skills through cardiovascular, dynamic balance, sensory motor, and sequential bilateral tasks. Children with developmental challenges are motivated to participate in sensory activities, making them an effective means for promoting behavioral change. FAB Strategies attend to a child’s arousal level so he can play without becoming overly excited. For example, if a child rates his energy level as “uncomfortably high” following play ground tasks he is assisted in calming down before returning to class.

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“Functionally Alert Behavior” FAB Strategies® offers an evidence-based curriculum of environmental adaptation, sensory modulation, positive behavioral support, and physical self-regulation strategies for improving the functional behavior of children, adolescents and young adults with complex behavioral challenges.  Application of the FAB Strategies®curriculum emphasizes ta coordinated multidisciplinary approach that addresses specific goal-directed functional behaviors in the natural environment.

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PRT Treatment in SLP, OT, & PT

PRT (Pivotal Response Treatment) is an important frame of reference for Speech/Language Pathologists, Occupational Therapists and Physical Therapists. PRT uses applied behavioral analysis principles as well as child choice, reinforcing attempts, varying activities, alternating familiar with challenging activities, and direct natural reinforcers. PRT’s transdisciplinary family-centered approach makes it particularly appropriate for allied health therapists.

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PRT shows significantly greater effectiveness for treating Autism Spectrum Disorder than traditional ABA  https://www.autismspeaks.org/sites/default/files/docs/koegel_prt_rancomized_controlled_trial_of_prt.pdf and facilitates neuroplasticity in young children with Autism Spectrum Disorders PRT NeurogenisisArt.  In addition to its usefulness for addressing language and behavioral challenges related to Autism Spectrum Disorders, PRT is a clinically relevant intervention for addressing other developmental and psychiatric challenges (e..g., fragile x syndrome, cognitive deficits, developmental trauma disorder, oppositional defiant disorder, depression, anxiety). Treatment is done with the family across disciplines in the child’s natural environment, so gains in language and motor skills are generalized to improve functioning.

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PRT strategies can be integrated with language, sensory and movement strategies as a component of occupational, speech and physical therapy interventions SensoryBehavior  I have found PRT is a particularly valuable treatment frame of reference for Speech/Language, Occupational and Physical Therapists.

References

Amaral, D. G., Schumann, C. M., & Nordahl, C. W. (2008). Neuroanatomy of Autism. Trends in Neuroscience, 31(3), 137-145.

Voos, A. C., Pelphrey, K. A., Tirrell, J., Bolling, D. Z., Wyk, B. V., Kaiser, M. D., McPartland, J. C., Volkmar, F. R. (2012). Neural mechanisms of improvements in social motivation after pivotal response treatement: Two case studies. Journal of Autism Dev Disord, 43(1), 1683-1689.

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FAB Rainbow Goal Strategy

The FAB Rainbow goal strategy is useful for developing goals and reinforcers that motivate students, while involving staff in supporting the goal and its achievement.  Like the FAB Coping card strategy, the rainbow goal allows clients to visually plan and review their behavioral goals and reinforcement schedule. The student begins by drawing a star at the top of the rainbow representing what they would choose if they could earn anything in the world.  It is presented as the positive opposite of what they say they want to avoid (e.g., being kicked out of their home or school).

Next, the student draws five separately colored rainbows beneath the star describing the steps needed to achieve their goal.  The five rainbows are 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 upon returning to class, and is linked to a sticker chart and tangible reinforcer.

The rainbow goal pictured below was done by a sixth grader with Pervasive Developmental Disorder and Oppositional Defiant Disorder, who hit classmates approximately every ten minutes.  He was initially unable to identify any goals for the future or prizes he wanted. The student reported that his goal was to stay at home, rather than again being sent to a group home or juvenile detention facility.  Using the FAB Rainbow Goal Strategy the therapist guided him in visually representating his goal and the steps for achieving it.

His sequential rainbow steps were organized into positive opposites of his current behaviors: “I can talk to Mom when upset (stop hitting Mom), Stay in control (not hit peers), and Do what Mom asks” (not misbehave).  His final rainbow step was that he would now go back and “Today work hard in school”.  The therapist also learned from his mother that the most effective way to increase his behaviors was to give him items related to toy cars.

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After observing the student and collecting data the student’s greatest current problem was found to be hitting other students, so the positive opposite of keeping safe hands was used to behaviorally describe his current goal: “Today work hard in school”. Since the student was found to hit others on average once every ten minutes the reinforcement schedule was developed that 15 minutes of safe hands (not hitting peers) earned one car sticker.

The student’s rainbow goal picture was laminated to his desk, and he received one car sticker whenever he kept safe hands for fifteen minutes.  If he hit another student before10 minutes the teacher pointed to his rainbow goal and explained she still liked him but could not award him a sticker yet because he was not showing his goal of working hard in class by keeping safe hands for fifteen minutes.  At the end of the day he would cash in all his car stickers for a reward. One sticker earned a racing car card and stick of gum, while six stickers bought a toy race car and an hour with an adult who would help him assemble it.

The FAB Rainbow Goal Strategy is useful for motivating students, staff and families to set a behavioral goal, action plan for achieving it, and follow a reinforcement schedule.  It promotes goal directed positive behaviors such as safe hands, which research shows can decrease the development of long term aggressive behavior.  The FAB Rainbow Goal Strategy empowers students, teachers, therapists and families to develop and visually represent behavioral goals, so they are motivated to achieve them.  It is helpful to pair the students most immediate goal with an observeable behavior and 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 Coping Card Strategy

The FAB Coping card gives clients, teachers and therapists a visual support strategy for achieving their goals. Based on Power Cards, coping cards use the child’s preferred interest to guide goal-directed behavior. Clients use an index card to depict their preferred interest, behavioral goal, coping strategies, and reinforcement schedule. Constructing and displaying the coping card focuses the client and staff on their individual goal, coping strategies, and reinforcement schedule while using their preferred interest to help achieve the goal.

For example, a student who frequently bit his hand constructed a coping card by depicting his goal (e.g., keep safe hands by not biting myself when I get upset), preferred interest (e.g., Sponge Bob), coping strategies (e.g., chewy, weighted blanket, and basket ball) and reinforcement schedule (e.g., 10 minutes of safe hands=1 sticker). The goal is written and/or drawn, stickers or drawings depict the preferred interest, and coping strategies are visually represented (colored, cut out, and pasted on an index card using the FAB Trigger & Coping forms).

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On the reverse side of the coping card the reinforcement schedule is written: “Safe hands for 10 consecutive minutes earns one sticker, while five stickers=1 toy car)”.  The index card is laminated and fastened to the desktop or worn as a necklace. Through their process of constructing the coping card clients and staff develop an effective functional goal, preferred interest, coping strategies, and reinforcement schedule.

Making a coping card helps teach clients how to use adaptive equipment to achieve their goal. The process of constructing the coping card focuses the client and staff on the goal and plan for achieving it.  The coping card helps to quickly remind clients and staff of the individualized program for achieving their goal.  Coping cards quickly guide busy teachers and therapists in addressing functional goals of students with significant behavioral challenges. Coping cards also encourage professional collaboration in goal development and implementation.

Reference:

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.

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Self-Injury is a Bad Habit

A lot of occupational therapy referrals at my psychiatric hospital are for adolescents and young adults with mental health, trauma history, developmental, and/or sensory processing challenges who repeatedly injure themselves. Individuals with trauma history and developmental challenges have greater incidences of neurological, sensory processing, and self-injury challenges. Clients with these complex difficulties benefit from integrated intervention addressing their specific triggers, coping strategies, mindfulness activities, and sensory input needs to reduce self-injurious behavior.

Long-standing self-injurious behavior has often become a bad habit. Reducing this “bad habit” can be helped by first recognizing the triggers. Research shows that the brain (Striatum at the center of the subcortical basal ganglia) forms habits by chunking behavior into a single automatic memory package. However, through planning and mindfulness the brain (Neocortex) can interrupt or stop the habit. The habitual aspects of self-injurious behavior can be address by recognizing the triggers, then replacing the bad habit of self-injury with the good habit of coping strategies that include mindfulness and sensory activities.

Recognizing the environmental triggers (e.g., “being told no”) and body triggers (e.g., “crying”) that precede self-injurious behavior empowers clients.  Research shows many adolescents and adults report their motivational triggers for injuring themselves are to: “distract myself from negative thoughts and feelings, feel something when I feel numb, get social attention, and/or get out of unwanted social situations”. An understanding of their early motivational, environmental, and body triggers empowers people who self-injure to discover and use effective coping strategies.

A useful self-assessment I developed for clients with self-injurious behavior is the PaganoFABTriggerCopingForms copyClients choose the three environmental and body triggers that most often precede their self-injurious behavior. Their triggers can serve as early warning signs that they need to use coping strategies. On each of the coping strategies pages the client selects their 3 most effective coping strategies. Their selections remind clients of their most common triggers and effective coping strategies related to self-injury. When introducing the coping forms the therapist demonstrates any unfamiliar mindfulness and sensory coping strategies. behindthelabel.co.uk

It is helpful to review the trigger and coping strategies the client determines are most relevant to their self-injurious behaviors, building on their most effective coping strategies. The most helpful new coping strategies to try are usually physical activities, rather than strategies such as talking to a friend. Commonly effective new physical coping strategies for reducing self-injury include hobbies (e.g., art), mindfulness movement (e.g., opening their hand while breathing in, then closing their hands by breathing out), and sensory strategies (e.g., focusing on the bottom of their feet or palms of their hands).

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For clients who appear to have sensory processing challenges, it is helpful to have them self-assess using the Sensory Profile http://www.sensoryprofile.com  For example, if a client has significantly different tactile sensitivity and self-cuts, using a vibrating bath brush may be useful as a sensory replacement for habitual self-cutting. It is important to be sure that brushing does not cause skin irritation and that clients never brush over open wounds. To interrupt the self-cutting habit the brush can be located where they most frequently engage in self-injury (such as their bedroom) to facilitate the use of self-brushing as replacing the habit of cutting with a less dysfunctional habit (brushing).

Finally, because self-injury may already be established as a habit, reinforcement is helpful (e.g., being given praise and a vibrating bath brush following two weeks of safe behavior). A helpful tool for clients with sensory modulation difficulties is rating their energy level and planning activities to keep a medium energy level and prevent self-harm using the Energy Modulation Wheel.

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A helpful tool for individuals with sensory and developmental challenges is using a laminated index card that reminds clients of their goal, hero, and coping strategies for preventing self-injurious behavior using a COPING CARD

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Reference: Gaybiel, A. M. & Smith, K. S. (2014). Good habits, bad habits. Scientific American, 310(6), 38-43. Nock, M. K., Prinstein, M. J., 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. http://dash.harvard.edu/bitstream/handle/1/4134406/Nock_FormFunction.pdf

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Coping With Hearing Voices

Hearing voices that others don’t perceive is a challenging difficulty for a small but significant number of children, adolescents, and adults. While some people who hear voices do not experience functional problems, many do.  Medications help some but not all people who have functional difficulties involving hearing voices, but do not always eliminate the problem. In addition unlike cardiac disease, people who hear voices also have to deal with being discriminated against and uncomfortable discussing their experiences, something medication does not address.

My experience of working with children, adolescents, and adults with functional problems related to hearing voices got me to research non-medication interventions that could help. While little non-medication research is done in the United States, support groups and coping strategies are used extensively in England to help people with functional problems related to hearing voices. Recently, the Connecticut Department of Mental Health offered a workshop by Rachel Waddingham http://www.behindthelabel.co.uk a United Kingdom interventionist whose work I’d read about. Ms. Waddingham described how support groups, mindfulness activities, and the use of coping strategies can help children and adults who hear voices as a component of their intervention.

As an occupational therapist working in psychiatry I use purposeful activities and coping strategies extensively with some children, adolescents, and young adults who have functional problems related to hearing voices. I sometimes use propelling scooter boards, exercise, taking clients to therapeutic horse back riding, mindfulness activities, and other coping strategies as part of a comprehensive treatment program to help individuals who hear voices.

Engaging in meaningful activities helps assess and promote functional skills. To help youth and adults with functional difficulties related to hearing voices find meaningful coping strategies, I ask them to select 3 from each page of the PaganoFABTriggerCopingForms copy It is helpful to build on the coping strategies the individual is already using affectively to help them better manage their biggest environmental and body triggers.

As a school occupational therapist in a psychiatric hospital school I use partial sentences to simultaneously address writing and provide opportunities to express feelings. In the following example using partial sentences a student expressed her fear of hearing voices and loneliness of not seeing her mom.

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Coping cards are index cards that are constructed to address the student’s functional goal.  Using an index card a student uses pictures or words to describe their functional goal, preferred interest, reinforcement schedule, and most affective coping strategies.  This reminds students and staff of their individual goal and coping strategies for achieving the goal.

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Public school occupational therapy bulletin boards are another way of teaching about coping strategies while showing that occupational therapy can be useful for all students. It helps address the bias some students have that occupational therapy is “only for mentally retarded and crazy kids”, and teachers are always willing to let me have one of their bulletin boards.

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The needs of individuals who hear voices is inadequately addressed in the United States because of the fear and biases related to this problem and it is time we professionals address it. Coping strategies have been a useful component of my interventions for individuals with functional difficulties related to hearing voices.

 

References:

Farhall, J., Greenwood, K. M., & Jackson, H. J. (2007). Coping with hallucinated voices in schizophrenia: A review of self-initiated strategies and therapeutic interventions. Clinical Psychology Review, 27(4), 476-493.

Kovacs, M. & Lopez-Duran, N. (2012). Contextual emotion regulation therapy: A developmentally-based intervention for pediatric depression. Child and adolescent psychiatric clinics of North America, 21(2), 327.