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Sensory-Based Interventions in School Occupational Therapy

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 used by school occupational therapy practitioners to 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.

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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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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FAB Strategies Mindfulness Movement Activities

I wanted to share this video of my FAB Strategies Mindfulness Movement activities to improve student’s behavior  https://www.facebook.com/educationresourcesinc/videos/943257499082558/ It was recorded by ERI at their Therapy in the Schools Conference.  Mindfulness movement activities are simple to do and can improve attention as well as enhance behavior by reducing student’s anxiety and giving them a break from seated work.

Mindfulness movement activities help all students yet are especially helpful for students with developmental disabilities, anxiety, sensory processing challenges, Post Traumatic Stress Disorder, ADHD, and/or other behavioral challenges.  Brief five minute mindfulness movement activities can help students attend better and promote the processing of academic learning when done between academic subjects (e.g., after math before proceeding to language arts).  Mindfulness movement activities can also be done in conjunction with teaching Positive Behavioral Support Interventions and used as a pre-correction before challenging school activities (e.g., lunch, playground, assemblies, and transitions).

In this video I demonstrate Touching the head-shoulders-stomach for sensory body awareness, Belly breathing, Hand opening and stretching to prevent hand cramping from writing (while breathing in) followed by thumb fisting as a mudra for relaxation (while breathing out)

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Bird breathing, and Mindful Clock Sitting (righting reactions moving forward-back and laterally).

Mindful clock standing activities can also be used, particularly to help students with sensory irritability gain basic body awareness of the anterior-posterior portions of their body through forward-back balancing movements  

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as well as sensory awareness and stability of the bottom (feet) and top (head) of their body through squatting then moving on their toes.

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I hope more early childhood and special education teachers as well as occupational, physical, speech/language and mental health therapists will begin using basic sensory mindfulness movement activities with their students.  Mindfulness movement activities offer a great opportunity for teachers and therapists to integrate and co-teach the academic and developmental curriculum areas.  As we continue to integrate the regular and special education curriculums, mindfulness movement activities can benefit students while promoting transdisciplinary interactions between teachers and therapists.

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Role of school OT’s, PT’s, SLP’s in Behavior Intervention

School Occupational, Physical and Speech Therapists play a significant role in improving student behavior. While traditionally viewed exclusively as the role of school social workers, psychologists, and behaviorists the complex problems of students with interrelated behavioral and developmental challenges can be helped by the contribution of school therapists.  The relationship between behavioral problems, the occupation of students, communication/language abilities, and gross motor skills supports the role of school occupational, speech/language and physical therapists as members of school teams helping students with behavioral and developmental challenges.

By teaming with occupational, speech/language and physical therapists, teachers and school mental health specialists can enhance their school positive behavioral support programs with expanded use of visual supports, mindfulness, music, exercise, and sensory-motor activities (Patten et al., 2013; Schaaf et al., 2014).  There is emerging evidence that cardiovascular and resistance exercise enhances body awareness, attention, as well as functional strength and endurance for improved participation in school learning tasks http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208137/pdf/nihms297861.pdf

School therapists can utilize evidence based mindfulness strategies as movement breaks that improve attention, and integrate behavioral strategies into their school therapy to enhance student’s school behavior.  Behavior for Therapists Slides The picture below describes the FAB Strategies adaptation of the PATHS PBS Turtle Technique to help students with special needs learn to calm down and avoid aggression.

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The AOTA supports the role of school occupational therapy in helping to improve student’s behavior (Cahill & Pagano, 2015).  The following Occupational Therapy article describes clinical school occupational therapy strategies that can be used to reduce student aggression  (Click on highlighted, then double click on lower heading) SchoolOTRedAgg

References

Cahill, S. M. & Pagano, J. L. (2015). Reducing restraint and seclusion: The benefit and role of occupational therapy. AOTA School Mental Health Toolkit. http://www.aota.org/-/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Reducing-Restraint-and-Seclusion.pdf

Flook, L., Smalley, S., Kitil, M., Galla, B., Kaiser-Greenland, S., Locke, J., Ishijima, E., Kasari, C. (2010). Effects of mindful awareness practices on executive functions in elementary school children. Journal of Applied School Psychology, 26(1), 70-95. http://skolenforoverskud.dk/Artikler%20-%20mindfulness/Flook-Effects-of-Mindful-Awareness-Practices-on-Executive-Function-1.pdf

Kazdin, A. E. (2008). The Kazdin Method for parenting the Defiant Child. NY, NY: Mariner Books.

Laugeson, E. A. (2014). The PEERS curriculum for school-based professionals: Social skills training for adolescents with autism spectrum disorder. Routledge.

Mahammadzaheri, F., Koegel, L. K., Rezaee, M., Rafiee, S. M. (2014). A randomized clinical trial comparison between pivotal response treatment (PRT) and structured applied behavioral analysis (ABA) intervention for children with autism. Journal of autism and developmental disorders, 44(11), 2769-2777.

Schaaf, R. C., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., van Hooydonk, E., … & Sendecki, J. (2014). An intervention for sensory difficulties in children with Autism: A randomized trial. Journal of autism and developmental disorders, 44(7), 1493-1506.

Warner, E., Spinazzola, J., Westcott, A., Gunn, C. & Hodon, H. (2014). The body can change the score. Journal of Child & Adolescent Trauma, 7(4), 237-246.

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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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Environmental Adaptations for Improved Behavior

Environmental adaptations are an important yet underutilized way of helping individuals with behavioral, developmental, and sensory modulation challenges. While environmental adaptations are often included in positive behavioral support and relaxation programs, they are not given sufficient attention. A third of children with significant sensory modulation differences were found to have major psychiatric diagnoses http://www.fyiliving.com/wp-content/uploads/2010/09/re-examiningsensoryregulation.pdf Individualizing and teaching clients to use sensory environmental adaptations can significantly improve their behavior and decrease stress at school, work and home.

Environmental adaptations can provide structure and offer coping strategies that significantly reduce anxiety and improve behavior. Environmental adaptations include both the generalized and specific use of adaptive equipment and techniques. Generalized adaptive equipment and techniques such as assigned seats, reduced noise levels, posted rules and coping strategy bulletin boards provide structure for improved behavior.

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An important guideline is to increase environmental structure before increasing behavioral demands, such as beginning more academically challenging learning activities. Likewise, reducing behavioral demands can be helpful in less structured environments. When clients first begin showing anxiety or behavioral difficulties, assess if the environmental supports match the demands being made and adjust environmental adaptations accordingly.

Some clients with significant behavioral, developmental, and sensory processing challenges benefit from individualized adaptive equipment and techniques such as study carols, noise canceling head phones, and being directed to do one activity for a minimum of five minutes before cleaning up and selecting another task. Research shows that adaptive equipment helps all children feel more comfortable in stressful environments, but the effects were significantly greater for children with developmental disabilities http://www.aamse.us/sites/default/files/Influence_Adapted.pdf

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Specific environmental adaptations are most effective when they are individualized to meet the client’s behavioral goals and sensory needs. It is helpful to introduce environmental adaptations one at a time for a two-week period after practicing their use for goal achievement.

A Sensory Functional Behavioral Analysis, FAB Trigger & Coping forms, Sensory Profile, and goal-related base line data can be useful for finding the most effective environmental adaptations and tracking their effectiveness.

FABTriggerCopingFormsMasterpgno3FABTriggerCopingFormsMasterPg4FABTriggerCopingFormsMasterpgno5         It is important to clearly explain the rules for continued access to environmental adaptations before introducing them (e.g., gum chewing will be allowed only if students consistently throw their gum in the garbage when they are finished with it). Specifically considering and teaching clients to use environmental adaptations significantly improves their effectiveness for individuals with behavioral, sensory processing and developmental challenges.

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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.