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Coping with Mental Health Challenges

Daily coping strategies for prevention along with coping interventions when symptoms are first noticed are extremely useful for managing mental health and behavioral challenges.  Many individuals confront mental health and behavioral challenges at some times in their life. Particularly those experiencing difficulties with substance abuse, extreme stress, developmental disorders or subtle sensory motor disorders (e.g., hyper-responsiveness, hypo-responsiveness, involuntary movements) benefit from regularly using coping strategies to manage their mental health and behavioral challenges. Mental health and behavioral challenges are eventually diagnosed as a depression, anxiety, Autism Spectrum, Post-Traumatic Stress, Borderline Personality, Psychotic or some other disorder that carries a stigma not seen in other illnesses.  While help is available it is up to each person to manage their mental health and behavioral strategies by actively using coping strategies.

The most inexpensive evidence-based coping strategy to reduce distress from mental health and behavioral challenges is doing aerobic exercise 30 minutes daily. The best exercises are the ones that individuals enjoy doing regularly. Any combination of walking, yard work, biking, running, swimming, fitness classes, karate, dance and sports are effective. In addition to lowering distress, aerobic exercise contributes to weight management and physical well-being.

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The second coping strategy that is important for people who experience mental health and behavioral challenges to do daily is a relaxation activity. Relaxation activities include progressive relaxation, visualization, yoga, mindfulness, breathing, meditation, Tai chi, Chi Gong and prayer. Like exercise the best forms are any an individual is motivated to do daily for thirty minutes. Relaxation activities can be reinforced through participating in a weekly group class that can be found for little or no cost.

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Despite the proven benefit of regular exercise and relaxation to reduce mental health and behavioral challenges many people experience problematic mental health and behavioral symptoms anyway, and will need to immediately be assessed for their need of counseling and/or medication as appropriate coping strategies. These coping strategies need to be assessed by a licensed mental health counselor, child/adolescent psychiatrist or adult psychiatrist. It is crucial to quickly find a mental health counselor and psychiatrist you trust. In addition,  some individuals also find it helpful to receive services from a licensed massage therapist for stress reduction or occupational therapist to modify their daily routines and life activities. Many individuals experience mental health and behavioral challenges and benefit from regular use of coping strategies to manage them successfully.

References

Brown, R. P. & Gerbarg, P. L. (2012). The healing power of breath. Boston, MA: Shambhala.

Cramer, S. C., Sur, M., Dobkin, B. H., O’Brien, C., Sanger, T. D., Trojanowski, J. Q. . . . & Vinogradov, S. (2011). Harnessing neuroplasticity for clinical applications. Brain, 134(6), 1591-1609.

Levit-Binnun, N., Davidovitch, M., & Golland, Y. (2013). Sensory and motor secondary symptoms as indicators of brain vulnerability. Journal of Neurodevelopmental Disorders, 5, 26. www.jneurodevdisorders.com/content/5/1/26

Perry, B. D. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma, 14(4), 240-255.

Talwar, U. K., Sharma, V., & Singh, R. (2010). Role of Yogic Exercises in Bipolar Affective Disorder and Schizophrenia. Delhi Psychiatry Journal, 13(1), 117-22.

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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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Using Sensory Strategies to Improve Behavior

Sensory strategies have a significant impact on the behavior of children and adolescents with developmental, mental health, Post Traumatic Stress Disorder and sensory processing challenges. Deep pressure touch provided by pediatric occupational therapists through massage, brushing, weighted blankets, mat sandwiches and other sensory strategies are described as extremely positive experiences for children and adolescents with developmental, mental health, Post Traumatic Stress Disorder and sensory processing challenges. Finding preferred activities is helpful because motivation can be a significant problem when treating these youngsters.

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A significant relationship was found between sensory and behavioral problems in children with developmental disorders. Research indicated that deep pressure sensory input functioned as positive reinforcement while matched sensory activities reduced repetitive non-purposeful behaviors in children with Autism Spectrum Disorder. Offering opportunities to use sensory strategies for self-regulation significantly reduced behavioral problems as well as the need for restraint and seclusion in adolescent and adult residential treatment centers for psychiatric and trauma challenges.

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The usefulness of offering clients deep pressure sensory strategies as an alternative to aggression and restraint makes sense, as it can replace the use of restraint as reinforcement for aggression with sensory activities to reinforce avoiding physical aggression. School occupational and physical therapists have begun using sensory activities as reinforcement for avoiding aggression to reduce student restraint and seclusion. SchoolOTRedAgg  The functioning of sensory strategies as positive reinforcement makes it important for therapists to avoid using sensory strategies immediately following aggressive or inappropriate behavior. Despite bitter conflicts between behaviorists, pediatricians and therapists clients would greatly benefit from their collaboration.

References

Canfield, J. M. (2008). Sensory dysfunction and problem behavior in children with autism spectrum and  other developmental disorders.

McGinnis, A. A., Blakely, E. Q., Harvey, A. C., & Rickards, J. B. (2013). The behavioral effects of a procedure used by pediatric occupational therapists. Behavioral Interventions, 28(1), 48-57.

O’Hagen, M., Divis, M., & Long, J. (2008). Best practice in the reduction and and elimination of seclusion and restraint; Seclusion: time for change. Aukland: Te Pou Te Whakaaro Nui: The National Center of Mental Health Research, Information and Workforce Development.

Rapp, J. T. (2006). Toward an empirical method for identifying matched stimulation for automatically reinforced behavior: A preliminary investigation. Journal of Applied Behavioral Analysis, 39(1), 137-140.

Sutton, D., Wilson, M., Van Kessel, K., & Vanderpyl, J. (2013). Optimizing arousal to manage aggression: A pilot study of sensory modulation. International Journal of Mental Health Nursing, 22, 500-511.

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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Light touch and Holding Interventions

Light touch and holding strategies promote body awareness and social-emotional skills in children and adolescents with behavioral challenges. Deep pressure touch is a more common therapeutic intervention. However, light touch and holding are valuable therapeutic options for promoting attention, body awareness and social-emotional skills.

KONICA MINOLTA DIGITAL CAMERA

KONICA MINOLTA DIGITAL CAMERA

Body awareness, stress and somatic pain challenges negatively impact behavior in many children and adolescents with developmental, sensory processing, Post-Traumatic Stress Disorder, internalizing behavioral concerns and other psychiatric disorders.  Attention, body awareness, stress and somatic pain problems can be addressed through the use of light touch and holding strategies.  Light touch and holding strategies are particularly useful for improving and directing functional attention, and provide a valuable option for reducing stress, somatic pain, and social-emotional problems when deep pressure massage is contraindicated.  Particularly for young people experiencing acute pain, edema, taking analgesic medications (e.g., which can decrease pain perception) or taking antidepressant medications (e.g., which can cause light headedness and dizziness) light touch and holding are preferred.

Recent research indicates that positively perceived slow, light touch specifically activates CT afferent fibers connecting to the Insular Cortex that convey social-emotional interactions and our internal sense of self.  FAB Strategies utilizing light touch and holding include: Vibration to the Back, Arms, & Body as well as the Rolling the arm, Back X, Spine crawl, Head crown, and Foot input.  These light touch and holding techniques which are components of FAB Strategies will be described below.

It can be clinically useful to provide extremely irritable children and adolescents who have significant body awareness challenges repeated sensory experiences of the front, back, top and bottom of their bodies. FAB Strategies light touch and holding techniques were developed to provide sensory experiences of the front, back, top and bottom of the body as a foundation for improved body awareness and social-emotional skills.  In addition to the light touch and holding strategies the awareness of the front, back, top and bottom of the body is practiced through several FAB Strategies deep pressure touch and mindful movement activities.

Vibration to the Back, Arms, & Body provide light touch input.  Vibration can also be applied to various body parts with eyes open and closed, to increase body awareness by having clients identify each body part as it is touched (e.g., arm, left ankle).  Light touch can also be provided through the Rolling the arm strategy.  The therapist rolls the arm in a palm open, thumb lateral direction providing relaxation.

Trager and me Original

The Back X involves drawing an X across the back with your fist, while the Spine crawl involves moving up the spine to give awareness of the back. The Back X and Spine Crawl can be done as part of the X Marks the spot light touch game

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The Head Crown involves 10 second holding on the head, first on both sides then on the front and back of the head.

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Foot input involves massage and holding of the feet to provide improved sensory awareness of the feet as the foundation and bottom of the body.  Foot input can be followed by stretching exercises to help decrease the likelihood of habitual toe walking.  Light touch and holding strategies are a valuable intervention to improve attention, body orientation and social-emotional skills through interpersonal touch.  Light touch and holding can also decrease stress, pain, and provide comfort when more intense massage is contraindicated.

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.

Bjornsdotter, M., Loken, L., Olausson, H.., Valbo, A., & Wessberg, J. (2009). Somatotopic organization of gentle touch processing in the posterior insular cortex. The Journal of Neuroscience, 29(29) 9314-9320.

Koester, C. (2012). Movement based learning for children of all abilities. Reno, NV: Movement Based Learning Inc.

McGlone, F., Wessberg, J., & Olausson, H. (2014). Discriminative and affective touch: Sensing and feeling. Neuron, 82(4), 737-755.

Perini, I., & Olausson, H. (2015). Seeking pleasant touch: Neural correlates of behavioral preferences for skin stroking. Frontiers in Behavioral Neuroscience, 9.

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3 Popular Neurologically Based Treatments

Occupational, Physical and Speech/Language therapists often include popular neurologically based approaches in their interventions for students with behavioral and developmental challenges. Brain Gym, Bal-A-Vis-X and Sensory Integration Intervention are three popular neurologically based approaches to promote neurological development for improved functional skills. While many clinicians, parents and families report that these interventions are clinically useful in achieving functional goals, they are criticized for lacking adequate research support.

Given the current emphasis on using evidence-based strategies it is important that therapists using these approaches apply current research to justify their use of these popular neurologically based approaches. A good way to show the efficacy of using these approaches is through goal attainment scaling, which can validate the effectiveness of strategies in achieving the student’s education related goals SIforASDGoal It is also important to consider research related to the components of these methods.

In addition to gathering baseline data and assessing treatment effectiveness through goal attainment scaling, it is important to understand the evidence-based components of these popular neurologically based approaches that can contribute to their effectiveness. First is their emphasis on child motivation through allowing students to choose the treatment activities. Second is their use of cardiovascular and strengthening exercises, and third their implementation of pressure touch strategies.

First, these popular neurologically based approaches facilitate student motivation by involving students in selecting fun and engaging activities. While sometimes criticized for being popular “only because students enjoy them”, the importance of activities that motivate children cannot be over-emphasized.   PRT (Pivotal Response Treatment) is a behavioral intervention that emphasizes the importance of student motivation. PRT was found to be highly effective in improving communication and behavior skills in children with Autism Spectrum Disorder.   The emphasis of PRT on facilitating motivation is a major reason for this success. Client motivation is facilitated in PRT by emphasizing child choice in activity selection and reinforcing attempts. In addition to its developmental efficacy in improving communication and behavior, recent research suggests PRT promotes more normalized neurological functioning.

The second component of these popular neurologically based approaches is their use of aerobic and strengthening exercises. Participation in aerobic exercise has been repeatedly associated in research with improved attention, learning and neurological development. Regular moderate exercise for 30 minutes daily appears to promote neurological development of the hippocampus for learning in both typical students (Cramer et al., 2011) and students with neurological challenges (Ploughman, 2008).

The third evidence based component of these popular neurologically based approaches is their use of pressure touch through massage and brushing. Massage has consistently been found through repeated research to decrease pediatric stress, which can help reduce behavior and learning challenges. More specifically, Asian massage strategies were found to improve behavior and communication skills in preschoolers with Autism Spectrum Disorders (Piravij et al., 2009; Silva & Schalock, 2013) www.qsti.org

While caution should be used in applying these popular neurologically based approaches to school therapy interventions, these techniques can be useful for attaining school goals. It is important to gather baseline data and use progress toward school related goals in judging the effectiveness of these strategies. It is also important to consider research supporting the specific strategies used, as well their research supported components of student motivation, aerobic exercise, strengthening exercise, and touch pressure   Reduce Problematic Reflexes:Hab

References:

Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65(1), 76-85.

Piravej, K., Tangtrongchitr, P., Parichawan, C., Paothong, L., Sukprasong, S. (2009). Effects of Thai traditional massage on Autistic children’s behavior. Journal of Alternative and Complementary Medicine, 15(12), 1355-1361.

Ploughman, M. (2008). Exercise is brain food: the effects of physical activity on cognitive function. Developmental Neurorehabilitation, 11 (3), 236-240.

Silva, L., & Schalock, M. (2013). Treatment of Tactile Impairment in Young Children with Autism: Results with Qigong Massage. International Journal of Therapeutic Massage & Bodywork, 6(4), 12-20.

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Occupational Therapy in Adolescent Mental Health

I was recently honored to present Grand Rounds at Solnit Children’s Center, the adolescent psychiatric hospital where I work. GrandRoundsOT Outline Our dynamic transdisciplinary team over the past 5 years was able to significantly reduce the use of restraint and seclusion.OT role in Restraint Reduction Solnit which was celebrated by making a bench for the hospital grounds from restraint beds (which are no longer used).

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Occupational Therapy is a vital intervention for adolescents with mental health, PTSD and developmental challenges.  Occupational therapists address adolescent mental health in schools, outpatient mental health clinics, youth psychiatric hospitals, and juvenile detention facilities. Occupational Therapy (O. T.) focuses on promoting adolescent’s occupations, the things they want or need to do. Adolescent’s occupations typically include school,

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activities of daily living (e.g., grooming, keeping their room clean), prevocational activities, sports, exercise, and social activities. For example, intervention on developing occupations is needed by some adolescents recovering from drug addiction, where their primary activities of taking drugs and doing illegal activities (to earn money for drugs) must be replaced by a new lifestyle with more functional occupations.  I am repeatedly impressed by my client’s and their families’ ability to confront the challenges of mental illness, and their unique gifts as individuals http://www.behindthelabel.co.uk

Occupational therapy offers unique contributions to adolescent mental health intervention due to its foundations in neurology, physiology, psychology, development, human occupations, and sensory processing. At Solnit Children’s Center the primary frames of reference used include: mindfulness, sensory processing, sensory massage, trauma informed care, Pivotal Response Training (a research proven form of Applied Behavioral Analysis), exercise, and developmental intervention. Occupational therapy is a vital component of transdisciplinary team intervention for adolescents with mental health challenges.

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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.

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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.