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FAB Trigger & Coping Forms

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The FAB Trigger & Coping Forms are an assessment that can be included in occupational, physical, and speech/language therapy assessments to help students identify their most problematic triggers and most affective coping strategies. The FAB Trigger & Coping Forms are helpful in developing student’s awareness of their triggers for misbehavior, and used in developing affective coping strategies. Students are asked to identify three pictures from each page depicting their biggest environmental triggers, body triggers, and coping strategies for preventing misbehavior.

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The FAB Trigger & Coping Forms are particularly useful for motivating students with complex behavioral problems by building on their existing understanding of the triggers and coping strategies related to their problematic behavior. I have been using them as a component of my occupational therapy evaluation for the past fifteen years and found this assessment motivates students and improves their self-control. Students with complex behavioral challenges can be uncooperative during therapy assessments because they are skeptical that anything can help them. The FAB Trigger & Coping Forms enable therapists to introduce students to new, fun coping strategies at the beginning of the assessment, motivating them to participate in the assessment and therapy. It is made clear that everyone is an individual, and it is up to the student to choose the coping strategies they enjoy and find most useful.

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Special Needs Behavior Plans

Students with complex behavioral problems including cognitive limitations need to be taught to behave appropriately so they can learn in school. An individualized understanding of the student’s developmental level, trauma history, sensory modulation, and effective coping strategies are helpful in developing a behavior plan. It is helpful to develop a trauma informed behavior plan that addresses the student’s feelings and developmental challenges.

Often “big” feelings need to be managed to prevent problematic behaviors. Visual supports help students become aware of their problematic big feelings. Emotional learning follows a developmental sequence with the first feelings learned being sad, mad, glad, tense and relaxed. Once these are learned more complex and combined emotions can be taught. Emphasis is given to current feelings that lead to problematic behavior. Ask student to use different colors to draw all the feelings “in my head”.

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Next, feelings which are always O. K. things to feel need to be distinguished from problematic behaviors like hitting, which are not O. K. in school. Particularly with cognitively impaired students desired results are emphasized not morality. It is also helpful to use a trauma informed approach that repeatedly emphasizes “I will like you no matter what. Some behaviors will be rewarded that will make you successful, while other behaviors will be punished so you don’t have a bad life”. A rainbow goal is a useful art activity is used to help the student plan behavior goals.

RainbowGoal

For cognitively impaired students goal planning emphasizes what they want to do “Be safe” rather than what they won’t do “hit”. Each rainbow beneath the top pot of gold goal is a related step. The student can dictate or write, chooses the color, and draws. Participation is encouraged, rather than just scribbling and saying “done”.

Finally a safety plan is visually depicted with objectively specified behaviors for reaching their rainbow goal. The students favorite sensory coping strategy options for replacing the inappropriate behavior are included. Coping strategies are “non-contingent reinforcement (NCR)”, always immediately available options that do not need to be earned. This transdisciplinary behavior plan was developed by the student’s occupational therapist, social worker, and speech/language pathologist.

Visual Safety Plan

The objective behaviors include a definition of “Be safe” that the student and all teachers and therapists understand clearly “No hitting, threatening, or throwing objects”. A baseline is taken and specific point chart or rewards are given for progress toward the goal. Visual supports and art activities can help students with complex behavioral challenges improve their behavior for learning.

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Sensory-Based Interventions in School Occupational Therapy

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School occupational therapists apply sensory-based interventions (SBIs) providing specific sensory input for improved classroom behavior. SBIs can include school occupational therapy teacher consultation, environmental adaptations, adaptive equipment, and the use of specific sensory activities. It is important to differentiate occupational therapy SBIs using individualized goal-directed sensory strategies and adaptive equipment to objectively improve behavior, from SBIs without occupational therapy involvement using sensory activities or equipment (Watling et al., 2011).

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It is also important to distinguish occupational therapy using sensory-based interventions (SBIs) from Sensory Integration Therapy (SIT). SBIs and SIT are both occupational therapy interventions based on sensory integration theory, but are different interventions that have distinct research support. Sensory Integration therapy (SIT), also referred to as Ayres Sensory Integration® (ASI), is the specific use of individualized child-directed activities that adhere to designated core concepts involving the use of sensory interactions to facilitate an adaptive response (Schaaf & Mailloux, 2015).

SIT is not considered an appropriate occupational therapy model for use in many school systems. However, medical referrals for SIT can be extremely helpful for student who do well at school but demonstrate inappropriate behavior when they get home. Clinic occupational therapy involving SIT can also be helpful for reducing stress and improving behavior in some students immediately following transitions such as discharge home from a psychiatric hospital.

Sensory-based interventions (SBIs) are a useful component of school occupational therapy practitioners efforts to help reduce the use of seclusion and restraint in school OTPractSchoolOTRedAgg Reducing-Restraint-and-Seclusion SBIs can also help achieve objective behavioral improvement by addressing specific sensory modulation challenges. Sensory modulation is the ability to respond to functionally relevant sensory information while screening out functionally irrelevant information (Watling et al., 2011). Sensory modulation disorders are both distinct from and significantly more likely to co-occur in students with mental health, Post-Traumatic Stress, and Autism Spectrum Disorder.

SBIs can significantly improve self-regulation and reduce distress in students with complex behavioral challenges by teaching them to monitor and regulate their arousal level for improved behavior. Students who have sensory modulation disorders can be taught to notice whether their arousal level is too high (hyper and fidgety interfering with learning) or too low (sleepy and sluggish) for learning, then use coping strategies to change their arousal related behavior to a more functional level. Most students learn best in a quiet alert state rather than when they are overly excited or lethargic. One method for assessing student’s energy level used in the ARC trauma program is depicting where in their body house their energy level is. The drawing below is a teen who was sad depicting that since getting out of bed and coming to OT her energy level has “just left the basement”.

EnergyHouse

Maintaining an appropriate arousal level involves sensory, social and behavioral skills. Using sensory modulation skills for appropriate behavior requires the social skills to understand their current arousal level and the unique expectations of differing school environments (e.g., there are usually higher arousal level expectations in physical education than in reading class). Once a student identifies his current behavior of running around and shouting during reading class as a problem, he must have the sensory and behavioral skills to engage in sensory coping strategies that lower his arousal level. While therapists, teachers and parents initially help students recognize and reward them for modulating their arousal levels for improved behavior, the ultimate goal is to teach students to independently regulate their arousal levels for school learning.

It is helpful for school occupational therapy practitioners using SBIs to consult with teachers, social workers, speech/language pathologists and behaviorists when applying SBIs. Occupational therapy using SBIs can be integrated with school Positive Behavioral Support and the Pivotal Response Training behavioral frame of reference to use sensory coping strategies that are embedded in classroom routines. Pivotal Response Training offers a child-centered behavioral approach that integrates well with occupational therapy using SBIs to improve school behavior. Pivotal Response Training uses applied behavioral analysis to developmentally address motivation, interactions, and generalization of skills. Rather than say “swing” and be given food as a reinforcement, a student would say “swing” and immediately be pushed on the swing (Stahmer et al., 2010).

School occupational therapy practitioners have the unique skills to help students understand and regulate their specific sensory modulation challenges to achieve school goals of improve behavior for learning. SBIs offer occupational therapy practitioners a tool for expanding their role in schools beyond (Tier 3) individual treatment. SBIs can also be provided through (Tier 2) targeted small group and (Tier 1) school wide interventions.

An example of a Tier 1 school wide intervention is an occupational therapy bulletin board developed to introduce occupational therapy and the use of sensory-based interventions for improved self-control to the school. This therapist asked students to identify the “popular kids”, and after getting consistent responses invited these students to volunteer to contribute their hand prints and first name to the occupational therapy bulletin board. The board described wall pushups as a way of modulating high arousal levels that were negatively impacting behavior. With teacher encouragement students were invited when they passed by the occupational therapy bulletin board to do wall pushups in the hands of their favorite “popular kid”.

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Case Study of School Occupational Therapy Using SBIs

School occupational therapy practitioners can help students understand and regulate their unique sensory modulation challenges to achieve school goals of improved behavior for learning. “Robert” was a kindergarten student referred for an occupational therapy evaluation to address his inability to remain seated. His teachers reported that Robert was a motivated student with good intelligence but that his inability to remain seated for five consecutive minutes would interfere with his ability to succeed in first grade, where the teacher expected students to maintain seated attention for a minimum of two consecutive hours.

The Short Sensory Profile 2 (Dunn, 2014) rated by the kindergarten teacher, was included as a component of Robert’s occupational therapy evaluation. His scores indicated much more than others Sensitivity, Registration, and Sensory as well as just like the majority of others Seeking, Avoiding, and Behavioral. Based on the Short Sensory Profile 2 as well as other evaluation findings, school occupational therapy services including SBIs was recommended to address the goal of maintaining seated attention for fifteen consecutive minutes.

Occupational therapy services included both direct intervention and consultation with the teacher and Robert to increase awareness of strategies to increase seated attention. The visual support shown below was used to guide their understanding of Robert’s sensory modulation challenges and guide strategies for using SBIs to improve seated school attention. Consultation was initially directed at identifying whether Robert’s arousal level was in the quiet alert state, too hyper or too hypo-responsive for appropriate seated attention.

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When Robert or his teacher noticed he was too hypo or hyper-responsive to stay seated they would decrease, then if needed sequentially increase sensory input until he could resume sitting. This visually supported decrease, then if needed gradually increase sensory input to maintain a quiet alert state strategy can be useful for guiding teachers and students in adjusting arousal levels for learning. During individual occupational therapy specific SBIs were tried, and those that helped Robert maintain seated attention were taught to him and his teacher.

When Robert became too hyper or hypo-responsive to remain seated the environmental stimuli was initially reduced (e.g., by lowering extraneous classroom noise levels and having Robert wear noise canceling headphones). If a quiet alert state was not adequately achieved for him to resume sitting, sensory input was incrementally increased from this lowered level until he could resume sitting (e.g.. the teacher used color lined paper for reading then placed Theraband on Robert’s chair legs so he could get deep pressure input by kicking).

Chairleg Theraband

The specific SBIs described above were tried based on clinical reasoning during individual occupational therapy sessions and found to improve seated attention. Clinical reasoning that led to lowering extraneous classroom noise levels and using noise cancelling headphone was based on research suggesting that students with sensory sensitivity were significantly more distracted by auditory input due to decreased neurological habituation (Green et al., 2015) and showed improved learning given reduced noise distractions (Kinnealey et al., 2012). The use of color lined paper was tried based on research suggesting that adding colored cues can enhance reading (Zentall et al., 2013). Finally, the SBI of tying Theraband to the legs of the chair was based on sensory integration theory suggesting that providing proprioceptive input helps organize behavior (Schaaf & Mailloux, 2015).

School occupational therapy practitioners can apply specific goal-directed SBIs to improve student behavior. SBIs can be used not only in individual occupational therapy intervention, but in small group and school wide interventions as well. It is important to give school staff an understanding of occupational therapy using SBIs to improve behavior for participation in classroom learning tasks (Watling et al., 2011).

References

Dunn, W. (2014). Sensory Profile 2. Bloomington, MN: Pearson.

Green, S. A., Hernandez, L., Bookheimer, S. Y., & Dapretto, M. (2016). Salience network connectivity in autism is related to brain and behavioral markers of sensory overresponsivity. Journal of the American Academy of Child & Adolescent Psychiatry, 55(7), 618-626.

Green, S. A., Hernandez, L., Tottenham, N., Krasileva, K., Bookheimer, S. Y., & Dapretto, M. (2015). Neurobiology of sensory overresponsivity in youth with autism spectrum disorders.

Kinnealey, M., Pfeiffer, B., Miller, J., Roan, C., Shoener, R., & Ellner, M. L. (2012). Effect of classroom modification on attention and engagement of students with autism or dyspraxia. American Journal of Occupational Therapy, 66, 511–519.

Schaaf, R. C. & Mailloux, Z. (2015). Clinician’s guide for implementing Ayres Sensory Integration: promoting participation for children with autism. Bethesda, MD: AOTA Press.

Stahmer, A. C., Suhrheinrich, J., Reed, S., Bolduc, C., & Schreibman, L. (2010). Pivotal response teaching in the classroom setting. Preventing School Failure: Alternative Education for Children and Youth, 54(4), 265-274.

Watling, R., Koenig, K., Davies, P. & Schaaf, R. (2011). Occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration. Bethesda, MD: AOTA Press.

Zentall, S. S., Tom-Wright, K., & Lee, J. (2013). Psychostimulant and sensory stimulation interventions that target the reading and math deficits of students with ADHD. Journal of attention disorders, 17(4), 308-329.

 

 

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Enhancing the Behavior of Students with Autism & Sensory Over-responsivity

Over half of students with Autism Spectrum Disorders have sensory over-responsivity to tactile and auditory stimulation with reduced sensory limbic habituation (Green et al., 2015).  Their lack of habituation makes it physiologically more likely they will become distracted and have difficulty learning. Significant sensory modulation difficulties were related to attention and academic achievement challenges in children with Autism Spectrum Disorders. Students with Autism Spectrum Disorders and significant sensory modulation difficulties benefit from learning to use coping strategies that improve their attention, learning and behavior in the classroom. Among SBIs (sensory-based interventions) tactile massage intervention a minimum of 15 minutes, twice weekly for 3 months has the greatest research support for improving student behavior and learning (Wan Yunus et al., 2015).

Sensory coping strategies for students with Autism Spectrum Disorders who have sensory over-responsivity begin with teaching students to monitor their energy levels to determine if they are high, medium or low and whether their energy levels are OK for learning.

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Next, evidence-based environmental adaptations should be tried to minimize auditory (sound absorbing walls, noise canceling headphones, carpeting), visual (halogen lighting, study carols), and tactile distractions (specific seating so they will not accidentally touch peers). Finally, teachers and therapists should try to reduce the pace and volume as well as increase the salience of instructions, and use visual supports as indicated (Ashburner et al., 2008; Kinnealey et al., 2012). Breaks from learning involving deep pressure and linear movement (Murray et al., 2009), such as by having the student pass out books or deliver messages, can also promote learning. Given that over half of students with Autism Spectrum Disorders also demonstrate significant sensory over-responsivity, it is important to teach coping strategies that will maximize their learning. speechaudnevhandouts  ERI2017SBISupplement

References:

Ashburner, J., Ziviani, J., & Rodger, S. (2008). Sensory processing and classroom emotional, behavioral, and educational outcomes in children with autism spectrum disorder. American Journal of Occupational Therapy, 62, 564–573.    

Green, S. A., Hernandez, L., Tottenham, N., Krasileva, K., Bookheimer, S. Y., & Dapretto, M. (2015). Neurobiology of sensory overresponsivity in youth with autism spectrum disorders. JAMA psychiatry, 72(8), 778-786.

Kinnealey, M., Pfeiffer, B., Miller, J., Roan, C., Shoener, R., & Ellner, M. L. (2012). Effect of classroom modification on attention and engagement of students with autism or dyspraxia. American Journal of Occupational Therapy, 66, 511–519.

Murray, M., Baker, P. H., Murray-Slutsky, C., & Paris, B. (2009). Strategies for supporting the sensory-based learner. Preventing School Failure: Alternative Education for Children and Youth53(4), 245-252.

Wan-Yunus, F. W., Liu, K. P., Bissett, M., & Penkala, S. (2015). Sensory-based intervention for children with behavioral problems: a systematic review. Journal of autism and developmental disorders, 45(11), 3565-3579.

 

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Sensory-Based Interventions (SBIs) Improve Behavior

Occupational therapists use sensory-based interventions (SBIs) to improve the behavior of children, adolescents and adults with developmental and sensory processing challenges. SBIs are the guided use of sensory coping strategies and adaptive equipment to improve sensory modulation skills and behavior. Emerging evidence suggests that SBIs can significantly reduce distress and promote attention.

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SBIs empower clients to actively substitute the sensory input provided through aggressive and self-injurious behavior with sensory coping strategies and adaptive equipment. However, SBI intervention needs to be goal-directed and specifically matched to the client’s needs and preferences. The use of SBIs has been included in the research supported Greenspan Floortime Approach for children with Autism Spectrum Disorders, Collaborative & Proactive Solutions Approach for children and adolescents with Oppositional Defiant Disorder, and treatment models for reducing restraint and seclusion in pediatric and adult mental health facilities as well as schools OTPractSchoolOTRedAgg Reducing-Restraint-and-Seclusion  Continue reading

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Body Awareness Intervention Improves Behavior

Many adolescents and young adults with behavioral disorders (e.g., Autism Spectrum, Post Traumatic Stress, Oppositional Defiant Disorder, Anorexia Nervosa) have body image challenges that negatively impact their behavior and social relationships. This is especially true for individuals who have developmental, mental health, and/or sensory processing challenges. Adolescents and young adults with body awareness challenges can be helped to improve their social skills with body awareness interventions.

Developmentally appropriate body awareness intervention involving massage, touch, movement, relaxation and mindfulness activities can take place within their work, school, home and community recreation activities. Body awareness provides the foundation for mindfulness, meditation and other calming activities that have been shown to decrease depression, anxiety, distress, aggression and addiction. Developmentally individualized body awareness tasks promote the emerging development of self-control using individual and group trauma-informed mindfulness, yoga, relaxation, visualization, massage, sensory processing, and movement activities.

Regardless of their chronological body awareness activities must match the adolescent or adult’s developmental level to be effective. The most developmentally basic and clinically effective experiences of embodiment, based on brain gym activities for special needs www.movementbasedlearning.com www.braingym.org , provide sensory awareness of the front, back, top and bottom of the body. Two activities for providing this experience is the X Marks the Spot movement game

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A second basic body orientation activity is the Roll therapyball on client core progression Strategy, in which a therapist specifically rolls a therapyball sequentially over the center, front, back, top and bottom of the body  https://www.youtube.com/watch?v=LCD9JeFviKY  

Sensory body awareness experiences help develop adolescent and young adults awareness of their body and understanding of body based triggers for early identification of the need for coping strategies.

References

Frank, J. L., Bose, B., & Schrobenhauser-Clonan, A. (2014). Effectiveness of a school-based yoga program on adolescent mental health, stress coping strategies, and attitudes toward violence: Fingdings from a high-risk sample. Journal of Applied School Psychology, 30, 29-49.

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

Silva, L. M., Schalock, M., & Gabrielsen, K. R. (2015). About face: Evaluating and managing tactile impairment at the time of Autism diagnosis. Autism research and treatment, 2015.

Taylor, S. E., & Stanton, A. L. (2007). Coping resources, coping processes, and mental health. Ann. Rev. Clin. Psychol., 3, 377-401.

 

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Behavioral, Sensory & Mindfulness Strategies

Positive Behavioral Support (PBS) interventions are used in many schools to improve student behavior and learning.  PBS interventions involve adapting the classroom environment, teaching basic social skills, and rewarding positive behavior to enhance learning. PBS interventions can be enhanced through integrating them with sensory and mindfulness strategies.  Sensory and mindfulness activities are especially useful when using PBS with classes that include young and special needs students.  As an occupational therapist I have found the Second Step, PATHS, and DECA programs helpful in guiding PBS interventions.

Occupational, Speech/Language, Physical and Mental Health therapists can team with regular and special education teachers to implement PBS, sensory and  mindfulness strategies.  Sensory strategies include environmental adaptations and movement activities that enhance learning.  Mindfulness strategies include body awareness, movement, and breathing activities that enhance student’s abilities to pay attention to learning activities.

PBS, sensory and mindfulness strategies teach students self-control by enabling them to be aware of their environmental and body triggers so they can implement coping strategies to avoid inappropriate behavior.  An extremely useful PBS strategy is the PATHS Turtle Technique, where an upset student notices they are becoming upset, stops and breathes to calm down.   The turtle technique can be adapted for students with special needs using the FAB Turtle Technique.  When the student or teacher notices the student reacting to environmental and body triggers they stop what they are doing and go to a pre-designated sensory coping area in the back of the class.  The student does their individualized coping activities for self-calming until they are sure they will no longer act aggressively.  Later, when they are calm the teacher can assist the student with problem solving.

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Combining PBS (Positive Behavioral Support), sensory and mindfulness strategies is particularly useful in inclusive classrooms that integrate regular and special education students.  Below is a description of ways to adapt research proven PBS strategies with sensory and mindfulness activities to provide increase individualized structure for students with special needs.

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