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Sensory-Based Interventions in School Occupational Therapy

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

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It is also important to distinguish occupational therapy using sensory-based interventions (SBIs) from Sensory Integration Therapy (SIT). SBIs and SIT are both occupational therapy interventions based on sensory integration theory, but are different interventions that have distinct research support. Sensory Integration therapy (SIT), also referred to as Ayres Sensory Integration® (ASI), is the specific use of individualized child-directed activities that adhere to designated core concepts involving the use of sensory interactions to facilitate an adaptive response (Schaaf & Mailloux, 2015).

SIT is not considered an appropriate occupational therapy model for use in many school systems. However, medical referrals for SIT can be extremely helpful for student who do well at school but demonstrate inappropriate behavior when they get home. Clinic occupational therapy involving SIT can also be helpful for reducing stress and improving behavior in some students immediately following transitions such as discharge home from a psychiatric hospital.

Sensory-based interventions (SBIs) are used by school occupational therapy practitioners to achieve objective behavioral improvement by addressing specific sensory modulation challenges. Sensory modulation is the ability to respond to functionally relevant sensory information while screening out functionally irrelevant information (Watling et al., 2011). Sensory modulation disorders are both distinct from and significantly more likely to co-occur in students with mental health, Post-Traumatic Stress, and Autism Spectrum Disorder.

SBIs can significantly improve self-regulation and reduce distress in students with complex behavioral challenges by teaching them to monitor and regulate their arousal level for improved behavior. Students who have sensory modulation disorders can be taught to notice whether their arousal level is too high (hyper and fidgety interfering with learning) or too low (sleepy and sluggish) for learning, then use coping strategies to change their arousal related behavior to a more functional level. Most students learn best in a quiet alert state rather than when they are overly excited or lethargic.

Maintaining an appropriate arousal level involves sensory, social and behavioral skills. Using sensory modulation skills for appropriate behavior requires the social skills to understand their current arousal level and the unique expectations of differing school environments (e.g., there are usually higher arousal level expectations in physical education than in reading class). Once a student identifies his current behavior of running around and shouting during reading class as a problem, he must have the sensory and behavioral skills to engage in sensory coping strategies that lower his arousal level. While therapists, teachers and parents initially help students recognize and reward them for modulating their arousal levels for improved behavior, the ultimate goal is to teach students to independently regulate their arousal levels for school learning.

It is helpful for school occupational therapy practitioners using SBIs to consult with teachers, social workers, speech/language pathologists and behaviorists when applying SBIs. Occupational therapy using SBIs can be integrated with school Positive Behavioral Support and the Pivotal Response Training behavioral frame of reference to use sensory coping strategies that are embedded in classroom routines. Pivotal Response Training offers a child-centered behavioral approach that integrates well with occupational therapy using SBIs to improve school behavior. Pivotal Response Training uses applied behavioral analysis to developmentally address motivation, interactions, and generalization of skills. Rather than say “swing” and be given food as a reinforcement, a student would say “swing” and immediately be pushed on the swing (Stahmer et al., 2010).

School occupational therapy practitioners have the unique skills to help students understand and regulate their specific sensory modulation challenges to achieve school goals of improve behavior for learning. SBIs offer occupational therapy practitioners a tool for expanding their role in schools beyond (Tier 3) individual treatment. SBIs can also be provided through (Tier 2) targeted small group and (Tier 1) school wide interventions.

An example of a Tier 1 school wide intervention is an occupational therapy bulletin board developed to introduce occupational therapy and the use of sensory-based interventions for improved self-control to the school. This therapist asked students to identify the “popular kids”, and after getting consistent responses invited these students to volunteer to contribute their hand prints and first name to the occupational therapy bulletin board. The board described wall pushups as a way of modulating high arousal levels that were negatively impacting behavior. With teacher encouragement students were invited when they passed by the occupational therapy bulletin board to do wall pushups in the hands of their favorite “popular kid”.

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Case Study of School Occupational Therapy Using SBIs

School occupational therapy practitioners can help students understand and regulate their unique sensory modulation challenges to achieve school goals of improved behavior for learning. “Robert” was a kindergarten student referred for an occupational therapy evaluation to address his inability to remain seated. His teachers reported that Robert was a motivated student with good intelligence but that his inability to remain seated for five consecutive minutes would interfere with his ability to succeed in first grade, where the teacher expected students to maintain seated attention for a minimum of two consecutive hours.

The Short Sensory Profile 2 (Dunn, 2014) rated by the kindergarten teacher, was included as a component of Robert’s occupational therapy evaluation. His scores indicated much more than others Sensitivity, Registration, and Sensory as well as just like the majority of others Seeking, Avoiding, and Behavioral. Based on the Short Sensory Profile 2 as well as other evaluation findings, school occupational therapy services including SBIs was recommended to address the goal of maintaining seated attention for fifteen consecutive minutes.

Occupational therapy services included both direct intervention and consultation with the teacher and Robert to increase awareness of strategies to increase seated attention. The visual support shown below was used to guide their understanding of Robert’s sensory modulation challenges and guide strategies for using SBIs to improve seated school attention. Consultation was initially directed at identifying whether Robert’s arousal level was in the quiet alert state, too hyper or too hypo-responsive for appropriate seated attention.

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When Robert or his teacher noticed he was too hypo or hyper-responsive to stay seated they would decrease, then if needed sequentially increase sensory input until he could resume sitting. This visually supported decrease, then if needed gradually increase sensory input to maintain a quiet alert state strategy can be useful for guiding teachers and students in adjusting arousal levels for learning. During individual occupational therapy specific SBIs were tried, and those that helped Robert maintain seated attention were taught to him and his teacher.

When Robert became too hyper or hypo-responsive to remain seated the environmental stimuli was initially reduced (e.g., by lowering extraneous classroom noise levels and having Robert wear noise canceling headphones). If a quiet alert state was not adequately achieved for him to resume sitting, sensory input was incrementally increased from this lowered level until he could resume sitting (e.g.. the teacher used color lined paper for reading then placed Theraband on Robert’s chair legs so he could get deep pressure input by kicking).

Chairleg Theraband

The specific SBIs described above were tried based on clinical reasoning during individual occupational therapy sessions and found to improve seated attention. Clinical reasoning that led to lowering extraneous classroom noise levels and using noise cancelling headphone was based on research suggesting that students with sensory sensitivity were significantly more distracted by auditory input due to decreased neurological habituation (Green et al., 2015) and showed improved learning given reduced noise distractions (Kinnealey et al., 2012). The use of color lined paper was tried based on research suggesting that adding colored cues can enhance reading (Zentall et al., 2013). Finally, the SBI of tying Theraband to the legs of the chair was based on sensory integration theory suggesting that providing proprioceptive input helps organize behavior (Schaaf & Mailloux, 2015).

School occupational therapy practitioners can apply specific goal-directed SBIs to improve student behavior. SBIs can be used not only in individual occupational therapy intervention, but in small group and school wide interventions as well. It is important to give school staff an understanding of occupational therapy using SBIs to improve behavior for participation in classroom learning tasks (Watling et al., 2011).

References

Dunn, W. (2014). Sensory Profile 2. Bloomington, MN: Pearson.

Green, S. A., Hernandez, L., Bookheimer, S. Y., & Dapretto, M. (2016). Salience network connectivity in autism is related to brain and behavioral markers of sensory overresponsivity. Journal of the American Academy of Child & Adolescent Psychiatry, 55(7), 618-626.

Green, S. A., Hernandez, L., Tottenham, N., Krasileva, K., Bookheimer, S. Y., & Dapretto, M. (2015). Neurobiology of sensory overresponsivity in youth with autism spectrum disorders.

Kinnealey, M., Pfeiffer, B., Miller, J., Roan, C., Shoener, R., & Ellner, M. L. (2012). Effect of classroom modification on attention and engagement of students with autism or dyspraxia. American Journal of Occupational Therapy, 66, 511–519.

Schaaf, R. C. & Mailloux, Z. (2015). Clinician’s guide for implementing Ayres Sensory Integration: promoting participation for children with autism. Bethesda, MD: AOTA Press.

Stahmer, A. C., Suhrheinrich, J., Reed, S., Bolduc, C., & Schreibman, L. (2010). Pivotal response teaching in the classroom setting. Preventing School Failure: Alternative Education for Children and Youth, 54(4), 265-274.

Watling, R., Koenig, K., Davies, P. & Schaaf, R. (2011). Occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration. Bethesda, MD: AOTA Press.

Zentall, S. S., Tom-Wright, K., & Lee, J. (2013). Psychostimulant and sensory stimulation interventions that target the reading and math deficits of students with ADHD. Journal of attention disorders, 17(4), 308-329.

 

 

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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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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.

Adaptive Equipment

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