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Sensory Modulation in Pre-K & Kindergarten

Many children with behavioral, developmental and sensory challenges have difficulty maintaining a quiet alert state for learning.  These children tend to be low registration (miss important sensory input) and/or sensory sensitive (overly responsive to functionally irrelevant sensory input) the majority of the time.  The Sensory Profile is a reliable, valid assessment that can be used to determine if children have significantly different sensory modulation.  It is important to help children with significantly different sensory modulation to learn to monitor and regulate their arousal levels and maintain a quiet alert state for learning.  Colors can help children understand their sensory modulation level by using Blue to designate hypo-responsive, green an optimal quiet alert state for learning, yellow a hyper-responsive, and red an extreme hyper-responsive state.connotapres2017handout

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A visual support integrating colors, energy levels, and sensory modulation can help children learn to identify and modulate their arousal levels.  Children are encouraged to work with the teacher or therapist to identify their common feelings and actions when experiencing various energy levels.

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A simpler alternative is to make a High, Low and Medium Energy visual, and have children identify their arousal level and whether their current energy level feels O.K. or not O.K and why.  Some children learn better using the visual supports shown above, while others do better without it through only adult modeling. without it can be used to teach children to modulate their arousal levels. For example, the therapist might model by saying, I am high energy and feel not OK, because I’m too hyper to be a good teacher.  My heart is beating really fast, I’m breathing fast, my hands are shaking, my arms feel tight like raw spaghetti, and I’m talking fast and loud.  I’m going to do 10 pushups to lower my energy level”.

For some children high energy is their only problem, while others experience low energy as well.  For low energy children I model “I’m low energy and feel not OK  because I don’t have enough energy to be an exciting teacher.  My heart rate and breathing feel slow, my arms are soft like over-cooked spaghetti, and I’m talking slowly and soft.  I feel sad and dead inside.  I’m going to do do 10 fast jumping jacks to increase my energy level”.

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As children develop, yellow can be added to designate a slightly hyper-alert state that precedes the red hyper-arousal state in which they misbehave.  This is helpful because early recognition of high energy is easier to control.  They can also be encouraged to use colors to relate their most frequent arousal level accompanying their feelings. The student who constructed the feeling wheel shown below depicted sad and lonely as low energy; embarrassed as high energy; and frustrated & mad as very high energy.  In addition, happy & nervous were depicted as related to both average energy and high energy states.

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A general FAB Strategy for helping all students modulate their energy levels is to first decrease, then if needed gradually increase sensory input.  This is depicted below using a visual support that shows a student who frequently fluctuates between a low energy and high energy state, with only a small window of quiet alert functioning.  In a classroom the teachers response would involve first lowering the noise level and visual distractions for a dysfunctional high energy or low energy student.  This alone will often enable students to achieve a quiet alert state.  If they are still not in a quiet alert state, give graded input from the lowered sensory level in a predictable, socially acceptable way until a quiet alert state is reached.

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Once the therapist is able to vary environmental input to enable a student to reliably achieve a quiet alert state, they can help the teachers, parents and student to do this independently.

Therapists and teachers can expand their understanding of arousal levels by synthesizing theories of the Autonomic Nervous System, sensory modulation, influences of early childhood PTSD, and Bipolar Disorder to expand their understanding of arousal level challenges.  The focus is on helping children notice when they first enter the blue or yellow zones, so they can find ways to increase or decrease their arousal levels as needed.

fab-energy-level-theoryStudents can use colors through visual supports, modeling, and/or using the smells of the scented color markers to learn if they are in the blue, green, yellow or red arousal zone.  This understanding provides a foundation for developing individualized coping strategies to manage their arousal levels.

 

 

 

 

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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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Applying FAB Strategies

I developed FAB Strategies (Functionally Alert Behavior Strategies) to help children, adolescents and young adults who have complex behavioral challenges.  The FAB Strategies Form guides the use of environmental adaptation, sensory modulation, positive behavioral support, and physical self-regulation strategies.  The FAB Strategies forms enable teachers, families as well as occupational, physical, speech/language and mental health therapists to work towards the same functional behavioral goals using consistent strategies.  The copyrighted FAB strategies forms are offered free of charge to therapists for use in developing home programs that improve functional behavior.

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FAB Strategies combines positive behavioral support and sensory processing strategies to improve behavior.   School occupational therapists can effectively team with parents and school staff to reduce school aggression, restraint and seclusion.

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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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Behavioral, Sensory & Mindfulness Strategies

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

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

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

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

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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.