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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).

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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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Guest Blog on Child Trauma & Addiction

Note from John Pagano FAB Strategies: I received this guest blog story from Constance Ray. She tells Shawn’s story of how he is courageously living each day to overcome childhood trauma and addiction, and prevent it’s legacy in his own family. May of the teens I work with show the same courage in facing family trauma and addiction. You can e-mail Constance and find out more about her work at information@recoverywell.org     Photo By: Pixabay

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Shawn’s Journey to the Top: How He Overcame an Abusive Childhood and Addiction

When we picture addiction, the image that often comes to mind is that of an adult. However, what many people don’t realize is that childhood experiences often set the stage for potential addictive behaviors later on in life. Once it has its iron hold, it can seem impossible to get out. We talked with one addiction survivor about how he not only broke free from his dark past, but found it in his heart to forgive.

Shawn’s Story

Shawn’s story begins when he was just a young teenager. While other boys his age were learning life skills from their fathers, Shawn did his best to avoid his father and the accompanying pain.

“I grew up in an extremely abusive household. I was abused mentally, physically, and emotionally by my dad. I started using cocaine to numb the pain. I didn’t use it everyday, but I used it often and I used it on and off for about 20 years,” Shawn said.

Fast-forward several years later, and Shawn found himself moving to Rhode Island after a failed marriage, leaving behind a son. He remarried, but the drug use followed, sending him spiraling into depression.

“One day, my wife had enough of what I was doing and tossed me out on the street. My so-called ‘friends’ at the time all backed out and were nowhere to be found,” Shawn said. “I had nowhere to go and nowhere to stay, and so I was homeless.”

Shawn was left with nothing but a motorcycle to his name, but even that failed him.

“I’ve been riding a motorcycle for nearly 40 years and never had a wreck, but one day I left the kickstand out and wrecked my bike, breaking four ribs in the process,” Shawn explained. “I was without a job, without a home, without my wife, and I was in a lot of pain. And that’s when I felt like God said to me that it was time to get my life together.”

Looking up addiction rehabs on his phone, it just so happened that the first one he came across was the Treehouse in Texas. Not able to afford the trip, Shawn’s family chipped in, much to his disbelief.

“Most surprisingly, my son helped to pay for my plane ticket, which made me feel both good and bad about where my addiction had taken me,” Shawn said.

Shawn credits the kind and caring staff for helping him put an end to his drug use and move forward from his painful childhood.

“I learned to forgive; I forgave my dad and let go of that anger and pain. I forgave myself for all of the hurting that I caused myself and my family. I really had a spiritual awakening at the Treehouse. When I surrendered to God, I felt like I was 1,000 pounds lighter, because He took all of that from me,” Shawn said.

As for his family, Shawn said they are continuing to heal each and every day, crediting his wife for saving him from a life of drug abuse and sadness.

“I’m still working to try to patch things up with my wife. I know that the day she put me out of the house is what saved my life … I know everything happened this way for a reason, and I am going to do everything I can to make it work with us. I’m also working towards reconnecting with my son,” Shawn said.

Addiction was Shawn’s way of coping with the pain his father caused him, but he realizes now that ultimately, everything he did was self-inflicted as a way to dull the pain.

“I was so used to being put down and was never good enough for my father, but now I truly know that I have a purpose in life: to help others and to enjoy life as it comes — through good and bad,” Shawn said.

No matter how difficult your past has been, drugs are never the answer. Facing it is scary, but you aren’t in this alone. Like Shawn, you can break free from whatever has caused you such immense pain, beat your addiction, and find your life’s purpose.

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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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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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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.