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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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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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Using Sensory Strategies to Improve Behavior

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

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

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

References

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

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

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

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

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

Warner, E., Spinazzola, J., Westcott, A., Gunn, C. & Hodon, H. (2014). The body can change the score. Journal of Child & Adolescent Trauma, 7(4), 237-246.

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Light touch and Holding Interventions

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

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

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

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

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

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

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

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

References:

Beider, S., Mahrer, N. E., Gold, J. I. (2007). Pediatric massage therapy: An overview for clinicians. Pediatric Clinics of North America, 54(6), 1025-1041.

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

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

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

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

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PRT Treatment in SLP, OT, & PT

PRT (Pivotal Response Treatment) is an important frame of reference for Speech/Language Pathologists, Occupational Therapists and Physical Therapists. PRT uses applied behavioral analysis principles as well as child choice, reinforcing attempts, varying activities, alternating familiar with challenging activities, and direct natural reinforcers. PRT’s transdisciplinary family-centered approach makes it particularly appropriate for allied health therapists.

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PRT shows significantly greater effectiveness for treating Autism Spectrum Disorder than traditional ABA  https://www.autismspeaks.org/sites/default/files/docs/koegel_prt_rancomized_controlled_trial_of_prt.pdf and facilitates neuroplasticity in young children with Autism Spectrum Disorders PRT NeurogenisisArt.  In addition to its usefulness for addressing language and behavioral challenges related to Autism Spectrum Disorders, PRT is a clinically relevant intervention for addressing other developmental and psychiatric challenges (e..g., fragile x syndrome, cognitive deficits, developmental trauma disorder, oppositional defiant disorder, depression, anxiety). Treatment is done with the family across disciplines in the child’s natural environment, so gains in language and motor skills are generalized to improve functioning.

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PRT strategies can be integrated with language, sensory and movement strategies as a component of occupational, speech and physical therapy interventions SensoryBehavior  I have found PRT is a particularly valuable treatment frame of reference for Speech/Language, Occupational and Physical Therapists.

References

Amaral, D. G., Schumann, C. M., & Nordahl, C. W. (2008). Neuroanatomy of Autism. Trends in Neuroscience, 31(3), 137-145.

Voos, A. C., Pelphrey, K. A., Tirrell, J., Bolling, D. Z., Wyk, B. V., Kaiser, M. D., McPartland, J. C., Volkmar, F. R. (2012). Neural mechanisms of improvements in social motivation after pivotal response treatement: Two case studies. Journal of Autism Dev Disord, 43(1), 1683-1689.