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Sensory-Based Interventions in School Occupational Therapy

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

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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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.

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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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Sensory-Based Interventions (SBIs) Improve Behavior

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

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

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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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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.