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FAB Trigger & Coping Forms

The FAB Trigger & Coping Forms are an assessment that can be included in occupational, physical, and speech/language therapy assessments to help students identify their most problematic triggers and most affective coping strategies. The FAB Trigger & Coping Forms are helpful in developing student’s awareness of their triggers for misbehavior, and used in developing affective coping strategies. Students are asked to identify three pictures from each page depicting their biggest environmental triggers, body triggers, and coping strategies for preventing misbehavior.

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The FAB Trigger & Coping Forms are particularly useful for motivating students with complex behavioral problems by building on their existing understanding of the triggers and coping strategies related to their problematic behavior. I have been using them as a component of my occupational therapy evaluation for the past fifteen years and found this assessment motivates students and improves their self-control. Students with complex behavioral challenges can be uncooperative during therapy assessments because they are skeptical that anything can help them. The FAB Trigger & Coping Forms enable therapists to introduce students to new, fun coping strategies at the beginning of the assessment, motivating them to participate in the assessment and therapy. It is made clear that everyone is an individual, and it is up to the student to choose the coping strategies they enjoy and find most useful.

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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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Assessing Sensory & Behavior Challenges

Many clients have interrelated sensory processing and behavior challenges that interfere with their functioning. Sensory processing disorders are distinct from behavior disorders (e.g., Oppositional Defiant, Post Traumatic Stress, Autism Spectrum, and Bipolar Disorder) but clients who have these mental health diagnoses are significantly more likely to have sensory processing challenges as well.

It is important that clients who have both sensory processing and behavior challenges affecting their functioning receive an evaluation that addresses both difficulties. Regardless if the evaluation is done by an occupational and/or mental health therapist (psychologist, social worker, licensed professional counselor, behaviorist) it is important to assess both sensory processing and behavioral functioning. Coordinated assessment by both an occupational and mental health therapist can be extremely helpful.

It is helpful if the sensory processing and behavior assessment include observations and a norm-referenced, reliable and valid measurement tool. The sensory processing clinical observations can describe whether the client becomes overly excited during movement activities, is able to pay attention in loud environments, touches people and objects more frequently than others his age, is easily distracted, and the length of attention span for both preferred and adult directed activities. Standardized assessments include the Short Sensory Profile sensoryprofile.com and Sensory Processing Measure http://www.wpspublish.com/store/p/2991/sensory-processing-measure-spm

Behavior observations can include the frequency of inappropriate behaviors (e.g., yelling, screaming, swearing, hitting, biting, spitting) as well as the most common setting events, antecedents, and consequences related to them. Standardized behavior assessments include the Devereux Behavior Rating Scale-School Form and the Ages and Stages Questionnaire: Social Emotional.

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Whenever clients present with interrelated sensory processing and behavioral concerns related to their functioning both issues need to be comprehensively addressed. The assessment needs to include functional base lines data, prioritize functional goals, and recommend needed intervention. Comprehensively assessing the client’s interrelated sensory processing and behavior concerns guides affective intervention for both problems.

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School Sensory Modulation Strategies

Sensory modulation strategies, a component of sensory integration intervention, help improve behavior and reduce the need for harsh discipline in schools. Sensory modulation strategies teach students to be aware of and regulate their arousal levels for appropriate behavior and learning.  Sensory modulation strategies are particularly useful for students with behavioral, mental health, trauma history, developmental, and/or sensory processing challenges.

Sensory modulation strategies help students adjust their arousal level for improved self-control. They learn to notice whether their arousal level is low (they feel numb), medium (just right for learning) or high (too hyper to pay attention) and use coping strategies to adjust their energy level.

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Most students learn best when they’re in a quiet alert state rather than overly relaxed or excited.

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Maintaining appropriate arousal levels also involves social skills, as different levels of arousal are expected during class and at recess.  Occupational and mental health therapists can team with teachers to use sensory modulation strategies with students who have self-control challenges. Clinical research shows that sensory modulation strategies can improve behavior and reduce the need for restraints and other harsh discipline methods.

http://www.traumacenter.org/products/pdf_files/Can%20the%20Body%20Change%20the%20Score_Sensory%20Modulation_SMART_Adolescent%20Residential%20Trauma%20Treatment_Warner.pdf

Sensory modulation strategies are especially affective for students with severe behavioral, mental health, trauma history, developmental, and/or sensory processing challenges.  Students are taught to identify when they begin experiencing environmental and body triggers to use their most affective sensory coping strategies http://www.sensoryconnectionprogram.com/what_helps_poster_activity.pdf

 

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If sensory modulation or behavioral interventions alone are not working, combining both strategies using picture reminders can be helpful.

Busy teachers may sometimes attend to disruptive and ignore appropriate behavior, and reversing this can make a huge difference. For some students, individual sessions with an occupational and/or mental health therapist are used to teach sensory modulation, while others learn sensory modulation strategies by therapists working with the teacher or leading groups. Sensory modulation strategies can include teaching students to do pushups for self calming when they’re hyper or going to a quiet area for a few minutes to calm down so they won’t misbehave and are able to learn. Therapists need to try various strategies with students to find what works best.  Sensory modulation strategies in schools may involve the use of a quiet area in the class room,

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a sensory coping room

 

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adaptive equipment

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or bulletin boards reminding students of class rules  and sensory coping strategies.  Working together therapists and teachers can use sensory modulation strategies to improve their students’ behavior and learning.

Reference:

Chalmers, A., Harrison, S., Mollison, K., Molloy, N., & Gray, K. (2012). Establishing sensory-based approaches in mental health inpatient care: a multidisciplinary approach. Australasian Psychiatry, 20(1), 35-39. www.rompa.com/media/free-resources/establishing_sensory-based_approaches_in_mental_health.pdf

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Coping With Hearing Voices

Hearing voices that others don’t perceive is a challenging difficulty for a small but significant number of children, adolescents, and adults. While some people who hear voices do not experience functional problems, many do.  Medications help some but not all people who have functional difficulties involving hearing voices, but do not always eliminate the problem. In addition unlike cardiac disease, people who hear voices also have to deal with being discriminated against and uncomfortable discussing their experiences, something medication does not address.

My experience of working with children, adolescents, and adults with functional problems related to hearing voices got me to research non-medication interventions that could help. While little non-medication research is done in the United States, support groups and coping strategies are used extensively in England to help people with functional problems related to hearing voices. Recently, the Connecticut Department of Mental Health offered a workshop by Rachel Waddingham http://www.behindthelabel.co.uk a United Kingdom interventionist whose work I’d read about. Ms. Waddingham described how support groups, mindfulness activities, and the use of coping strategies can help children and adults who hear voices as a component of their intervention.

As an occupational therapist working in psychiatry I use purposeful activities and coping strategies extensively with some children, adolescents, and young adults who have functional problems related to hearing voices. I sometimes use propelling scooter boards, exercise, taking clients to therapeutic horse back riding, mindfulness activities, and other coping strategies as part of a comprehensive treatment program to help individuals who hear voices.

Engaging in meaningful activities helps assess and promote functional skills. To help youth and adults with functional difficulties related to hearing voices find meaningful coping strategies, I ask them to select 3 from each page of the PaganoFABTriggerCopingForms copy It is helpful to build on the coping strategies the individual is already using affectively to help them better manage their biggest environmental and body triggers.

As a school occupational therapist in a psychiatric hospital school I use partial sentences to simultaneously address writing and provide opportunities to express feelings. In the following example using partial sentences a student expressed her fear of hearing voices and loneliness of not seeing her mom.

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Coping cards are index cards that are constructed to address the student’s functional goal.  Using an index card a student uses pictures or words to describe their functional goal, preferred interest, reinforcement schedule, and most affective coping strategies.  This reminds students and staff of their individual goal and coping strategies for achieving the goal.

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Public school occupational therapy bulletin boards are another way of teaching about coping strategies while showing that occupational therapy can be useful for all students. It helps address the bias some students have that occupational therapy is “only for mentally retarded and crazy kids”, and teachers are always willing to let me have one of their bulletin boards.

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The needs of individuals who hear voices is inadequately addressed in the United States because of the fear and biases related to this problem and it is time we professionals address it. Coping strategies have been a useful component of my interventions for individuals with functional difficulties related to hearing voices.

 

References:

Farhall, J., Greenwood, K. M., & Jackson, H. J. (2007). Coping with hallucinated voices in schizophrenia: A review of self-initiated strategies and therapeutic interventions. Clinical Psychology Review, 27(4), 476-493.

Kovacs, M. & Lopez-Duran, N. (2012). Contextual emotion regulation therapy: A developmentally-based intervention for pediatric depression. Child and adolescent psychiatric clinics of North America, 21(2), 327.

 

 

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FAB Turtle Teaches Self-Control

The FAB Turtle Technique is a practical evidence-based method of teaching self-control to pre-school and kindergarten students. The turtle technique is a component of the PATHS positive behavioral support program using classroom routines, rewards, stories, puppets, crafts, and activities. The turtle technique is based on Tucker Turtle, who learns to control his aggression when he feels angry so he doesn’t upset his friends. Preschool and kindergarten teachers around the world use this technique to promote self-control, with free resources available at http://www.challengingbehavior.org/do/resources/teaching_tools/ttyc_toc.htm#turtle .

In addition to its usefulness with typical preschool and kindergarten students, the turtle technique can be modified to teach self-control to pre-school through fifth grade students with special needs (e.g., emotional, trauma history, developmental, and/or sensory processing challenges). Free resources for students with special needs are offered using the FAB Turtle Strategy.

FAB Turtle Technique

The FAB turtle strategy modifies the turtle technique as: 1) Stop immediately after noticing your environmental and body triggers 2) Go to the classroom sensory calming area 3) Do your individualized coping strategies in the sensory calming area 4) When you are sure you will not act aggressively return to your seat 5) Later the teacher will guide you in problem solving and reward you for doing the turtle strategy to avoid aggression.

The FAB turtle strategy modifies the turtle technique going into your shell by putting your shirt over your head when angry to going to the sensory calming area (e.g., designated area in the back of the classroom that other students can not enter). The turtle technique 3 deep breaths to calm down are substituted with the student’s individualized coping strategy (e.g., pushups, mindfulness activities). Emphasis is placed on the student not leaving the sensory calming area until they are certain they won’t act aggressively, and delaying as long as necessary before problem solving as students with special needs may need longer periods of time to calm down. While the student might need to be reminded of the initial conflict, this additional time provides the calmness needed for problem solving.

The FAB turtle strategy individualizes the turtle technique for students with special needs by building on the original turtle technique curriculum and resources.

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The FAB turtle strategy can be used to individualize the turtle technique for children with special needs in inclusive classrooms. Teachers can also begin by using the FAB turtle strategy for students with special needs, then transition them to the turtle technique and other positive behavioral support strategies.

References:
Domitrovich, C. E., Cortes, R. C., & Greenberg, M. T. (2007). Improving young children’s social and emotional competence: A randomized trial of the preschool “PATHS” curriculum. The Journal of Primary Prevention, 28(2), 67-91.
Pagano, J. L. (2005). Functionally approached body strategies for young children who have behavioral and sensory processing challenges. Available online at http://www.eric.ed.gov search by ERIC # ED490718 http://eric.ed.gov/?q=John+Pagano+2005&id=ED490718
Riggs, N.R., Greenberg, M.T., Kusche, C.A., Pentz, M.A. (2006). The mediational role of neurocognition in the behavioral outcomes of a social-emotional prevention program in elementary school students: Effects of the PATHS curriculum. Prevention Science, 7(1), 91-102.

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Sensory Strategies Improve Learning

Classroom environmental adaptations can enhance behavior and learning.  However, effectively using adaptive equipment and techniques involves more than handing out adaptive equipment.  To improve learning and avoid causing additional classroom management problems it is important to specifically consider how sensory strategies can improve an individual student’s behavior for enhanced learning.SensoryRoom

Sensory Integration and Positive Behavioral Support strategies can be combined to develop effective coping strategies.  The first step is to choose one specific goal involving adaptive equipment and techniques that improves the student’s behavior, learning and future.  Select a goal that is most important for improving behavior and is attainable within six months.  The goal is worded positively and is incompatible with the inappropriate behavior that interferes with learning.

For students who have multiple needs research suggests prioritizing goals that can reduce future school aggression such as: safe hands (no hitting), polite voice (no yelling), as well as increased attention and seated attention.  After the goal is chosen collect base line data on how often the desired behavior occurs.  Use the base line data to refine the goal before choosing adaptive equipment.

Next consideration is given to the student’s specific need for sensory input.  The Sensory Profile and an activity analysis are useful tools for finding effective adaptive equipment and techniques.  The Sensory Profile is a reliable, valid assessment that identifies significantly different sensory behaviors.  If a student’s scores show a definite difference in Sensory Seeking/Low Registration (e.g. a significant difference found in only 2 out of 100 students their age) this provides clues about the sensory input needed.  Sensory processing disorders are complicated, and each student’s individual sensory needs must be addressed.

Next an activity analysis is done to explore the sensory input the student may be getting through the inappropriate behavior, sensory strategies that have helped him in the past, and his favorite activities.  Begin the activity analysis by considering the sensory input the student receives from the problematic behavior (e.g. wiggling his fingers in front of his eyes so frequently that it interferes with learning).  Determine if he is doing this for attention, sensory input, or both.  If he is doing the behavior for sensory input, go where no one will see you and imitate the student’s behavior to determine the sensory input it provides (e.g., finger movement, visual stimulation, or both).

Further assessment for developing coping strategies can be gathered using the FABTriggerCopingForms filled out by the student or parent, who choose on each page the three most frequent situations and body reactions that precede the inappropriate behavior and the most helpful coping strategies for avoiding inappropriate behavior.  This provides greater information regarding the role served by the behavior and possible alternative activities that provide the needed input. INSERT  Choose the adaptive equipment or techniques that will help achieve the student’s goal using information from the SensoryProfile, activity analysis, and FAB Trigger & Coping forms.

 

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Once adaptive equipment or techniques are chosen introduce them in a way that maximizes success.  Given current school inclusion practices many classrooms include students with diverse developmental levels.  It is helpful for teachers and therapists to initially explain to the class that they have different needs and abilities, and will be treated fairly but not equally.  Students will be given different rules, equipment and expectations based on their individual needs.  Adaptive equipment is then tried with individual students “for the day as an experiment that will be continued only if used appropriately to help reach their goal”

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Specifying rules for continued use of adaptive equipment or techniques before introducing them avoids potential problems.  Many teachers forbid adaptive strategies because they interfere with classroom management (e.g., forbid gum chewing because gum is stuck on seats; don’t allow fidget toys because students throw or make loud noises with them).  Setting clear limits that adaptive equipment will no longer be used if students break the rules or don’t progress toward their goal make teachers and parents more willing to try them.

It is also important and challenging to be sure parents/guardians approve of adaptive equipment before it is used.  The best way to do this is by discussing it at a parent conference.  When this is not possible write a note describing the goal and reason for the adaptations.  Then ask the parent to sign permission for the goal and specific adaptive equipment to be tried on the bottom of the form.

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Finally, additional reinforcement with a sticker chart or other reward is given to the student for making progress towards their goal.  By keeping track of goal progress from the base line, it is easy to show that the plan is working or modify it if it is ineffective.  While this process of combining sensory and behavioral strategies is criticized because it does not show whether the plan worked for sensory or behavioral reasons, it affectively improves student behavior and learning.

References:

Dunn, W. (2007).  Supporting children to participate successfully in everyday life by using sensory processing knowledge.  Infants & Young Children, 20(2), 84-101.  www.sensoryprofile.com

Seifert, K. (2011).  CARE-2 Assessment: Chronic Violent Behavior and Treatment Needs.  Boston, MA: Acanthus Publishing.  www.drkathyseifert.com