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Sensory-Based Intervention Groups

Sensory-based intervention (SBI) groups can be useful in schools and clinical settings to improve sensory skills, behavior and learning.  SBIs are the guided use of sensory strategies to improve behavior by addressing specific sensory modulation or sensory discrimination challenges.  SBIs are commonly implemented in early intervention, school, and mental health settings through individual, group and consultative interventions. SBIs include directing other professionals in embedding goal-directed sensory activities into a student’s daily routine to improve behavior for learning.

It is important to distinguish occupational therapy utilizing SBIs from Sensory Integration Intervention. While SBIs and Sensory Integration both utilize the theory of sensory integration, they are distinct interventions with unique research efficacy. Sensory integration intervention, also referred to as Ayres Sensory Integration® is a developmental clinic-based, child-led intervention that follows specific core concepts.

SBIs can empower clients to actively substitute the sensory input provided through aggressive, inappropriate and self-injurious behavior with sensory coping strategies and adaptive equipment. SBIs are goal-directed and specifically matched to the client’s needs and preferences. The use of SBIs has been integrated into the evidence-based Greenspan Floortime Approach for Autism Spectrum Disorders, Collaborative Problem Solving Approach for children with oppositional defiant disorder, Dialectical Behavioral Therapy for adolescents with borderline personality disorder, and models for reducing restraint and seclusion in mental health facilities and schools a-reducing-restraint-and-seclusion OTPractSchoolOTRedAgg .

The new ESSA “Every Student Succeeds Acts” (2015) potentially expands the role of school therapists in helping at risk students and consulting with parents and teachers to improve school climate.  Under ESSA occupational, physical, speech/language, and school mental health therapists are designated as Specialized Instructional School Personnel (SISP) and given a role in helping at-risk regular education as well as special education students.  SBI’s can be included in interventions to educate students, staff and parents in enhancing student self-regulation school therapist consultations and group leadership.

Effectively using sensory-based interventions (SBIs) to improve functional behavior is different from the more common practice of randomly distributing adaptive equipment or using a single sensory strategy such as brushing for every student in a class. Using SBI adaptive equipment and sensory strategies to optimally promote functional behavior begins with an occupational therapy assessment, developing an individualized functional behavioral goal, gathering baseline data on the goal, and matching the client with the most appropriate individualized environmental adaptation.  Once a specific environmental adaptation has been implemented consistently for a month in conjunction with other professionals, it’s effectiveness is assessed to determine if the environmental adaptation should be continued, modified, or discontinued.

Sensory modulation is the ability to respond to functionally relevant sensory information while screening out irrelevant input.  Simply helping students understand their sensory modulation and/or sensory discrimination differences is an important first step in SBI.  Therapists can begin by discussing sensory modulation “energy levels” as low, medium and high, to help students identify when their energy levels are too high or low for behaving appropriately and learning.  Consistently using the color codes developed by the Zones of Regulation program can be part of the effort in helping students gain a better understanding of how their arousal levels affect their behavior and emotional regulation.

Once students have modulated their energy level, consider and intervene if sensory discrimination disorders are negatively impacting behavior.  When in the quiet alert state some students can still become dysregulated because of sensory discrimination disorders in which they have difficulty distinguishing, interpreting and organizing the information coming in from all their various senses.  For example, sensory discrimination disorder can involve problems organizing and combining information from the pressure, touch, and movement senses to appropriately print the “b”.

Sensory discrimination disorder can occur in any combination of ones sensory systems: tactile (touch), proprioceptive (muscle force/tension), interoceptive (internal organ states such as hung & pain), olfactory (smell), gustatory (taste), auditory, and visual.   it is most widely described in tactile discrimination disorder. A common assessment item regarding tactile discrimination from the Miller Assessment for Preschoolers involves the therapist having a client identify which finger is touched with eyes closed, with consistently accurate identification expected by age 3. Some high school students who are above grade level who had a trauma history and psychiatric disorder were inconsistently able to do this task. This difficulty alerts me to the need of increasing body awareness. Sensory Discrimination Disorders can involve the sense of: touch, proprioception (body awareness), vestibular (movement), vision, sound, taste, and/or smell. Interventions of sensory discrimination disorder are best done after basic sensory modulation has been addressed.

Recent research suggests that interoception can be a significant component of sensory discrimination disorders.  Interoception challenges involve confusion regarding internal body sensations such as hunger, thirst, and pain.  Exploring internal sensations through sensory mindfulness activities can help address interoception.  Research supports that mindfulness activities can be helpful interventions for individuals with somatic pain and post-traumatic stress disorder challenges.

mindfulnessSensory discrimination disorder contributes to difficulties with body awareness, embodiment, and organizational skills. Sensory discrimination disorder is more commonly seen in clients who experience early childhood post-traumatic stress disorder. It is hard to teach self-esteem and respecting others personal boundaries when clients don’t have adequate body awareness.

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It is important to help students learn to identify what they are feeling before they yell, hitting others or engage in problematic behavior “because they suddenly feel horrible”.   For students with developmental challenges it can be helpful to combine feeling faces with the color codes from the Zones of Regulation so they can use pictures to identify their negative feelings and arousal level and get assistance with finding self-regulation activities.

SBI involves the use of individualized adaptive equipment to improve specific goal-directed behavior, such as reducing noise and visual distractions with a study carol and noise-canceling headphones to reduce peer conflicts and increase attention.  It can also include massage, mindfulness activities, or embedded classroom tasks involving delivering a box of books for the teacher as a deep pressure movement break.  The most important and often neglected step is to identify and educate students regarding their specific sensory challenges related to behavior, and to reinforce all efforts to self-regulate.

Adaptive Equipment

grpsbi2016 SLIDES

school-therapy SUPPLEMENTAL Therapy in the Schools Slides

 

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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

XMarkstheSpot

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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FAB Strategies® to Improve Self-Control

FAB Strategies® are Functionally Alert Body Strategies that can be used by parents, teachers, as well as Occupational, Speech, Physical, and Mental Health therapists to improve youngster’s functional behavior.  FAB Strategies® were developed to guide transdisciplinary intervention for individuals with developmental, mental health, post traumatic stress disorder, and sensory processing challenges. FAB Strategies® combines developmental, sensory processing, behavioral, touch pressure, mindfulness, movement and neuropsychology interventions to help individuals with complex behavioral challenges.

The four sections of FAB Strategies® are environmental adaptation, sensory modulation, positive behavioral support, and physical self-regulation strategies. While reducing aggression in special needs students FAB Strategies® simultaneously facilitates attention, learning, and parental involvement in typical students. FAB Strategies® can be used for regular class teaching as well as small group and individual intervention sessions. Many typical students lack adequate seated attention, self-control, and sensory-motor skills to master their academic learning requirements. FAB Strategies® are fun active learning tasks that engage students’ musical, visual-spatial, auditory, interpersonal, and bodily-kinesthetic intelligence to improve learning.

FAB Strategies® are guided by the FAB Strategies® to Improve Self-Control form FAB STRATEGIES FORM and FAB Strategies® for Pre-K and Kindergarten form FAB StrategiesPre&KForm. The FAB Strategies® forms list strategies organized into four sections addressing: environmental adaptation, sensory modulation, positive behavioral support, and physical self-regulation strategies. The teachers and therapists develop a functional goal and choose at least one strategy from each section for goal attainment. Strategies chosen are checked and underlined for use across disciplines.

The FAB Strategies® forms can be used as a checklist of helpful activities to consider when developing transdisciplinary interventions for students with behavioral challenges. The FAB Strategies® forms were also designed as an efficient way to develop home programs and provide a list of effective strategies when students transfer to other teachers and therapists. The FAB Strategies form enables teachers and therapists to individualize interventions that improve behavior in response to each student’s developmental level and individual needs.

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School Occupational Therapy for Developmental Trauma

School occupational therapists emphasis on therapeutic relationships, mental health, sensory processing, attachment, development, purposeful activity and self-regulation offer a unique contribution for improving the behavior of students with developmental trauma disorder. School behavioral problems related to developmental trauma are seen in students who have experienced early chronic abuse. Many students with developmental trauma difficulties have significant sensory modulation, emotion regulation, attachment, self-regulation, sensorimotor, somatic, and developmental challenges.  Working in conjunction with school psychologists, social workers, and guidance counselors, occupational therapists can help improve the mental health and behavior of students who have developmental trauma challenges http://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/Fact-Sheets/OT%20%20School%20Mental%20Health%20Fact%20Sheet%20for%20web%20posting%20102109.pdf http://www.aota.org/-/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Reducing-Restraint-and-Seclusion.pdf

Occupational therapy for improving the behavior of students with developmental trauma can include energy level modulate, sensory processing, deep pressure touch, and mindfulness strategies. The energy level modulate strategy involves increasing students’ awareness of their arousal level and teaching them to modulate dysfunctional high or low energy levels to better participate in school learning tasks. It can be introduced by explaining that “some students who have had difficult experiences early in their life can get into trouble by overreacting when they have really big feelings”. The energy level modulate strategy teaches students to identify whether their current energy level feels “High” (hyper, off the wall, with stiff muscles like raw spaghetti), “Medium” (just right and ready to learn) or “Low” (tired, numb, with loose muscles like over cooked spaghetti).

Visual chart for rating arousal level and if it feels comfortable

Visual chart for rating arousal level and if it feels comfortable

The energy level modulate strategy is extremely useful in school settings for students with sensory modulation difficulties who become aggressive following activities that raise their energy levels extremely high. While many students can use the energy level modulate strategy with teacher encouragement, some students with sensory modulation difficulties and developmental trauma need assistance. For example, a student receiving occupational therapy attended a wild physical education class where the students ran, screamed and threw balls at each other. His classmates behaved appropriately upon returning to class. However, this student who had significant sensory sensitivity and developmental trauma challenges was unable to sit down upon returning to class and threw a chair.

Following this experience the occupational therapist taught the school physical education teachers and mental health therapists the energy level modulate strategy so students could rate their energy levels before returning to class. The teacher or therapist would bring students who rated their energy level as uncomfortably high to a designated staff member (e.g., occupational therapist, speech therapist, principle, resource room teacher) who would help the student do pushups or other individualized sensory coping strategies to lower their energy level before returning to class.

The most effective strategies for normalizing energy levels involve deep pressure through the joints with slow linear movements. Activities such as regular or wall pushups, moving furniture, moving mats, delivering messages or boxes of books throughout the school, or wheelbarrow walking on your hands over a therapy ball can help achieve this.

Wallpushups

Special consideration can be given in the energy level modulate strategy for students with both sensory modulation and developmental trauma challenges who have become use to maintaining a high energy level that interferes with appropriate attention and behavior for school functioning. This difficulty can be indicated by students who describe their energy level as “Hyper and comfortable” and students who actively resist efforts by their teachers and therapists to calm down to a functional energy level where they can pay attention to classroom activities. For students who resist regulating their energy to a functional level it is helpful for the therapist to begin by matching the student’s initial energy level, then support the student during individual sessions to gradually modulate their energy level.  http://www.traumacenter.org/products/pdf_files/Body_Change_Score_W0001.pdf 

Individual OT sessions using sensory processing, deep pressure touch, and sensory mindfulness strategies help students with self-regulation and developmental trauma challenges improve their attention, seated attention, and behavior for participation in school learning tasks.

ComicCopingMindfulClock1ChairlegsTheraband

These interventions emphasize child-focused activities that optimally challenge students to discover activities that will enable them to modulate dysfunctional arousal levels for improved school functioning. Sensory processing interventions promote attachment relationships combining child-directed activities at their optimal level of challenge with an attitude of PACE (playfulness, acceptance, curiosity and empathy). Offered respectfully with choices to decline, firm pressure touch strategies can enhance attachment, relationships, and self-control in students with behavioral and developmental trauma challenges. Attached is a link showing integrated use of behavioral, sensory processing, PACE, and FAB Pressure Touch strategies. While this treatment was done with a preschooler who had Asperger’s syndrome, a similar approach is often also helpful for students with behavioral and developmental trauma challenges https://www.youtube.com/watch?v=W8fMdJ6l0AM

References

Beider, S., Mahrer, N. E., Gold, J. I. (2007). Pediatric massage therapy: An overview for clinicians. Pediatric Clinics of North America, 54(6), 1025-1041.

Engel-Yeger, B., Palgy-Levin, D., & Lev-Wiesel, R. (2013). The Sensory Profile of People With Post-Traumatic Stress Symptoms. Occupational Therapy in Mental Health, 29(3), 266-278.

Hanson, J. L., Chung, M. K., Avants, B. B., Shirtcliff, E. A., Gee, J. C., Davidson, R. J., & Pollak, S. D. (2010). Early stress is associated with alterations in the orbitofrontal cortex: a tensor-based morphometry investigation of brain structure and behavioral risk. The Journal of neuroscience30(22), 7466-7472.

http://www.jneurosci.org/content/30/22/7466.long

Hughes, D. A. (2011). Attachment-focused family therapy workbook. New York, NY: W. W. Norton & Co.

Warner, E., Koomar, J., Lary, B., & Cook, A. (2013). Can the body change the score? Application of sensory modulation principles in the treatment of traumatized adolescents in residential settings. Journal of Family Violence, 28(7), 729-738.

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Brain Based Emotion Regulation Strategies

Brain based therapy applies current neuropsychology to developing emotion regulation strategies. Emotion regulation involves learning to non-aggressively express strong feelings. People initially process anger and other negative emotions unconsciously in the right cerebral hemisphere, but require cross-hemispheric communication involving the left cerebral hemisphere for conscious awareness, verbal expression and emotion regulation (Riggs et al., 2006; Shobe, 2014). The Switch hands toss, ball bouncing, and drumming strategies were developed to help link movement activities with the verbal expression of feelings.

Research suggests that communicating negative feelings between the brain hemispheres for emotion regulation can be particularly difficult for students with complex behavioral disorders, including diagnoses of Autism Spectrum (Anderson et al., 2010) and/or Post Traumatic Stress Disorder (Pechtel & Pizzagalli, 2011), who have significantly reduced neurological communication between the cerebral hemispheres. Many of these students, as well as those with ADHD or neurological immaturity, also resist remaining seated and discussing their feelings and behaviors. Because expressing feelings is difficult for students with complex behavioral challenges, they tend to avoid practicing it.

The Switch hands toss, ball bouncing, and drumming strategies were developed to use movement games to promote the verbal expression of feelings in students with complex behavioral challenges. The Switch hands toss strategies combine passing a beanbag with the verbal expression of preferences, feelings, values, and choices. The ball bouncing and drumming strategy similarly combine two hand sequential activities with the verbal expression of feelings. Building on Positive Behavioral Support activities that teach emotions and express feelings, the switch hands toss, ball bouncing, and drumming strategies are fun interactive tasks that can be done individually with students and in groups. Both the movement and expression of feeling are developmentally individualized to improve emotion regulation and verbal skills.

Drumming

Current brain research suggests that most students initially process anger and other negative emotions unconsciously in the right cerebral hemisphere, but require cross-hemispheric communication involving the left cerebral hemisphere for conscious awareness, verbal expression and emotion regulation (Riggs et al., 2006; Shobe, 2014). This can be particularly challenging for students with complex behavioral challenges. Research indicates significantly greater difficulties with neurological communication between the left and right cerebral hemispheres in students with a diagnosis of Autism Spectrum and/or Post Traumatic Stress Disorder.  The picture below shows the corpus callosum (marked as number 1 in black) a major network of nerves connecting the cerebral hemispheres.

LimbicSystem

The switch hands toss, ball bouncing, and drumming strategies combine sequential two handed movement activities with the expression of feelings. These strategies combine movement with the verbal expression of feelings to promote functional communication between both cerebral hemispheres. The switch hands toss, ball bouncing, and drumming strategies are easily graded by matching the specific movement and verbal expression to the student or group’s level.

The switch hands toss, ball bouncing, and drumming strategies address the verbal expression of: favorites (e.g., color, team, quality in a friend), best coping strategy, guessing the feeling or degree of feeling expressed by the therapist or peers, right now I feel _____, and I messages (e.g., when you yell at me, I feel sad, so please speak to me politely). These strategies enable students to express their feelings with out needing to be seated or the center of attention. The switch hands toss, ball bouncing, and drumming strategies offer fun Positive Behavioral Support activities to improve emotional awareness and the verbal expression of feelings.

References:

Anderson, J. S., Druzgal, T. J., Froehlich, A., DuBray, M. B., Lange, N., Alexander, A. L., & Lainhart, J. E. (2010). Decreased interhemispheric functional connectivity in autism. Cerebral cortex, 190.

Bengtsson, S.L., Nagy, Z., Skare, S., Forsman, L., Forssberg, H., Ullen, F. (2005). Extensive piano practicing has regionally specific effects on white matter development. Nature Neuroscience, 8, 1148-1150.

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

Pechtel, P., & Pizzagalli, D. A. (2011). Effects of early life stress on cognitive and affective function: an integrated review of human literature. Psychopharmacology, 214(1), 55-70.

Riggs, N. R., Greenberg, M. T., Kusche, C. A., Pentz, M. A. (2006). The mediational role of neurocognition in the behavioral outcomes of a social-emotional prevention program in elementary school students: Effects of the PATHS curriculum.   Prevention Science, 7(1), 91-102.

Shobe, E. R. (2014). Independent and collaborative contributions of the cerebral hemispheres to emotional processing. Frontiers in human neuroscience, 8.

Sun, F. T., Miller, L. M., Rao, A. A., Esposito, M. D. (2007). Functional connectivity of cortical networks involved in bimanual motor sequence learning. Cerebral Cortex, 17(5), 1227-1234.

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Movement for Mindfulness

Mindfulness is the process of paying attention to what you are currently doing and feeling. Attention is a vital skill that is too often underemphasized, particularly when teaching young and developmentally challenged individuals. Movement strategies are useful for teaching mindfulness, self-control, and attention. Several useful movement strategies are listed below that can help young and developmentally challenged people to be mindful and pay attention better.

Standing Mindful Clock: A movement activity to promote mindfulness and body awareness, especially with people who lack the coordination to use deep breathing for relaxation. It involves verbalizing specific words (designated in bold print) while moving in a specific sequence (described in italics) to promote basic awareness of the front, back, top and bottom of the body. The entire sequence is done 3 times.

Tic squat Tock stand on toes Like a squat Clock stand on toes
‘Till we squat Find our stand on toes Center assume a centered standing position
Tic lean forward Tock lean back Like a lean forward Clock lean back
‘Till we lean forward Find our lean back Center assume a centered standing position

MindfulClk3MindfulClk4

Tense & relax muscles: A brief progressive relaxation strategy involving the muscles people often tense up when their anxious. Participants tense their muscles for 3 seconds then relax 5-10 seconds, doing each numbered section 3 times.

1) Tense; then relax all the muscles of your face and jaw.
2) Elevate both shoulders towards your ears; then drop and relax both shoulders.
3) Fist hands tightly; then completely relax both wrists, hands & fingers.

Bird: A strategy that uses simple movement to teach deep breathing for relaxation. Gradually lift both arms (from the sides like a jumping jack or straight up vertically) while breathing in and expanding your belly. Then at a slower rate lower both arms while breathing out.

Nose Breathe: A strategy that combines hand stretching with deep breathing for relaxation. The nose breathe strategy is especially helpful for students whose hands feel tense or spasm from handwriting or who have difficulty using breathing for relaxation. The fingers are extended and separated for relaxation, then the thumb is fisted in a mudra hand posture that promotes relaxation. It is done three to six times after the hand motions are learned.
1) Breathe in through your nose (making your belly go out) while opening your hands wide, extending and separating your fingers.
2) At a slower rate breathe out while bringing your thumb inside your hands making fists.

MindfulClk1MindfulClk2

Focus on Feet: Eyes closed feel one big toe, the smaller toe next to it, center toe, second smallest toe, and little toe. Feel your toes, bend them, notice if you have socks on and whether there are holes in your socks. Move back to feel the ball of your foot, back further and feel the arch of your foot and notice if it hits the ground. Move back again to feel your heel. Finally, feel or press down on the entire bottom of your foot.

Focus on Palms: Put your open hands in Dali Lama prayer position and push them together as hard as possible for 10 seconds doing an isometric contraction. Then position your hands palms up and close your eyes. Feel your thumb, pointer, middle, ring, and little finger. Then feel the palms of your hands for 5-10 seconds.

References:
Brain Gym International http://www.braingym.org
Greenland, S. K. The Mindful Child. http://www.susankaisergreenland.com/
Koester, Ceci http://www.movementbasedlearning.com

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Movement Enhances Emotional Expression

Strategies combining movement with expressing feelings motivates students to improve their self-regulation skills. Movement activities that involve emotion expression are especially helpful for motivating students who have behavioral, developmental, trauma history and/or sensory processing challenges. Movement activities are fun and can easily be integrated into strategies to encourage the expression and understanding of feelings.

A strategy for young students that integrates movement with expressing feelings is Feelings Goose. This is a modification of duck-duck-goose in which the student who is “it” touches each peer on the head with alternating hands, while naming a feeling (e.g., sad). When the student touches a child on the head while expressing the opposite feeling (e.g. glad) he is chased as he attempts to run to the other student’s spot.

FeelingGoose

A strategy that has several variations for progressively older students is switch hands toss. The switch hands toss “favorites” strategy involves students passing a beanbag while expressing their favorite: sport, color, ice cream, team, vacation place, coping strategy, quality in picking a friend, what makes them a good friend, and other favorite categories. Students can pick a favorite category to lead if they are willing to go first in expressing their favorite. The “I feel” strategy involves expressing how they currently feel. In “Guess the feeling” a student acts out a feeling using their face and body and the student they throw the beanbag to guesses what they are feeling.

The most challenging switch hands toss strategy is the “I message”. An I message is a DBT statement in which a student describes an action that others do, how they feel in response, and what the behavior they want others to do. The student says “When people ______, I feel _________, so please. A positive example is “When people say hi to me, I feel happy, so please say hi when you see me”. An example of a complaint would be “When people call me Shortie, I feel angry, so please call me John”. Combining movement with expressing their feelings motivates students to actively express feelings and improves self-control.