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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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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.

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Body Awareness Intervention Improves Behavior

Many adolescents and young adults with behavioral disorders (e.g., Autism Spectrum, Post Traumatic Stress, Oppositional Defiant Disorder, Anorexia Nervosa) have body image challenges that negatively impact their behavior and social relationships. This is especially true for individuals who have developmental, mental health, and/or sensory processing challenges. Adolescents and young adults with body awareness challenges can be helped to improve their social skills with body awareness interventions.

Developmentally appropriate body awareness intervention involving massage, touch, movement, relaxation and mindfulness activities can take place within their work, school, home and community recreation activities. Body awareness provides the foundation for mindfulness, meditation and other calming activities that have been shown to decrease depression, anxiety, distress, aggression and addiction. Developmentally individualized body awareness tasks promote the emerging development of self-control using individual and group trauma-informed mindfulness, yoga, relaxation, visualization, massage, sensory processing, and movement activities.

Regardless of their chronological body awareness activities must match the adolescent or adult’s developmental level to be effective. The most developmentally basic and clinically effective experiences of embodiment, based on brain gym activities for special needs www.movementbasedlearning.com www.braingym.org , provide sensory awareness of the front, back, top and bottom of the body. Two activities for providing this experience is the X Marks the Spot movement game

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A second basic body orientation activity is the Roll therapyball on client core progression Strategy, in which a therapist specifically rolls a therapyball sequentially over the center, front, back, top and bottom of the body  https://www.youtube.com/watch?v=LCD9JeFviKY  

Sensory body awareness experiences help develop adolescent and young adults awareness of their body and understanding of body based triggers for early identification of the need for coping strategies.

References

Frank, J. L., Bose, B., & Schrobenhauser-Clonan, A. (2014). Effectiveness of a school-based yoga program on adolescent mental health, stress coping strategies, and attitudes toward violence: Fingdings from a high-risk sample. Journal of Applied School Psychology, 30, 29-49.

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

Silva, L. M., Schalock, M., & Gabrielsen, K. R. (2015). About face: Evaluating and managing tactile impairment at the time of Autism diagnosis. Autism research and treatment, 2015.

Taylor, S. E., & Stanton, A. L. (2007). Coping resources, coping processes, and mental health. Ann. Rev. Clin. Psychol., 3, 377-401.

 

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Using Sensory Strategies to Improve Behavior

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

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

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

References

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

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

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

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

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

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

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Environmental Adaptations for Improved Behavior

Environmental adaptations are an important yet underutilized way of helping individuals with behavioral, developmental, and sensory modulation challenges. While environmental adaptations are often included in positive behavioral support and relaxation programs, they are not given sufficient attention. A third of children with significant sensory modulation differences were found to have major psychiatric diagnoses http://www.fyiliving.com/wp-content/uploads/2010/09/re-examiningsensoryregulation.pdf Individualizing and teaching clients to use sensory environmental adaptations can significantly improve their behavior and decrease stress at school, work and home.

Environmental adaptations can provide structure and offer coping strategies that significantly reduce anxiety and improve behavior. Environmental adaptations include both the generalized and specific use of adaptive equipment and techniques. Generalized adaptive equipment and techniques such as assigned seats, reduced noise levels, posted rules and coping strategy bulletin boards provide structure for improved behavior.

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An important guideline is to increase environmental structure before increasing behavioral demands, such as beginning more academically challenging learning activities. Likewise, reducing behavioral demands can be helpful in less structured environments. When clients first begin showing anxiety or behavioral difficulties, assess if the environmental supports match the demands being made and adjust environmental adaptations accordingly.

Some clients with significant behavioral, developmental, and sensory processing challenges benefit from individualized adaptive equipment and techniques such as study carols, noise canceling head phones, and being directed to do one activity for a minimum of five minutes before cleaning up and selecting another task. Research shows that adaptive equipment helps all children feel more comfortable in stressful environments, but the effects were significantly greater for children with developmental disabilities http://www.aamse.us/sites/default/files/Influence_Adapted.pdf

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Specific environmental adaptations are most effective when they are individualized to meet the client’s behavioral goals and sensory needs. It is helpful to introduce environmental adaptations one at a time for a two-week period after practicing their use for goal achievement.

A Sensory Functional Behavioral Analysis, FAB Trigger & Coping forms, Sensory Profile, and goal-related base line data can be useful for finding the most effective environmental adaptations and tracking their effectiveness.

FABTriggerCopingFormsMasterpgno3FABTriggerCopingFormsMasterPg4FABTriggerCopingFormsMasterpgno5         It is important to clearly explain the rules for continued access to environmental adaptations before introducing them (e.g., gum chewing will be allowed only if students consistently throw their gum in the garbage when they are finished with it). Specifically considering and teaching clients to use environmental adaptations significantly improves their effectiveness for individuals with behavioral, sensory processing and developmental challenges.

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My Perspective on Sensory Integration

I frequently use Sensory Integration/Sensory Processing Intervention in my work as an occupational therapist with clients who have severe behavioral, sensory processing and developmental challenges. I get criticism both by professionals who question the validity of sensory processing intervention and those who dislike my integrating it with other treatment approaches. It is time to transcend the polarizing debate about the sensory processing model and put it in perspective.

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Like most occupational therapists my treatment grew from my clinical practice and the influence of many gifted teachers. I was introduced to sensory integration intervention in my entry-level occupational therapy training and studied it extensively at the post-graduate level. I spent thousands of dollars on my sensory processing training and although I’m frugal (my son says “a cheap skate”) it was worth every penny.

My sensory processing teachers have had so many students that they wouldn’t even know my name, but they transformed my professional and personal life through their mentoring. Among my most effective sensory processing teachers were the late Ginny Scardinia, Mildred Ross, Winnie Dunn, and Lucy Jane Miller. Each holds a distinct view of sensory processing intervention, is an occupational therapist, master teacher, and base their practice on the teaching of A. Jean Ayres the founder of Sensory Integration.

I first met Mildred Ross as a guest lecturer in my undergraduate occupational therapy class. Using sensory (e.g., touch, movement, smells) strategies she developed individual and group interventions that improve the functioning of individuals with severe psychiatric and developmental challenges. Disagreeing with the “experts” who viewed these clients as “hopelessly regressed psychiatric patients”, Mildred motivated her clients by respecting them as people, caring about them, and beginning at their current developmental level then gradually improving their functional skills. Mildred used a similar approach with occupational therapists, teaching us what an honor it was to help others and motivating us to improve our skills. I remember that the professors and conference leaders who invited Mildred to speak often set an egg timer for one hour before she began, and kept it ringing until she stopped speaking. Although they told me the timer was essential and I usually hate listening to people talk, I always hoped the timer would break so I could listen to her all day.https://www.youtube.com/watch?v=vHuhYaYRIb8

After five years as a school occupational therapist a unique experience introduced me to my next mentor Ginny Scardinia. I was watching my OT student treat a 6-year old girl who had developmental, behavioral, and PTSD challenges using a net swing when the girl suddenly spoke for the first time. I’d been treating that girl for half a year and gotten little response, but after that single half-hour session from my OT student the child was able to consistently speak in school. My OT intern told me that she’d learned sensory integration treatment during her previous affiliation with Ginny Scardinia at the Ayres Clinic. I soon located Ginny, took classes with her, and bugged her to teach me whenever she could from that day on.

Ginny Scardinia was unique in her ability to motivate me to do whatever it took to learn to help children like she could.  I recently learned that Ginny inspired many occupational therapists, and a research study was conducted summarizing her skills as a master mentor  http://www.ncbi.nlm.nih.gov/pubmed/23927618 Over 25 years have past but I still remember that after she first saw me treat she said, “You’re off to a good start, but you need to learn a lot more about neurology and sensory integration and honey, I can teach you”.   I knew that she was right and although I never reached her level as a clinician I am still trying.

Ginny inspired me to take all the sensory integration courses I could and to take motor learning classes at Columbia University T C. The motor learning research taught me that clients have the ability to recover from neurologically based challenges through engaging in developmentally appropriate sensory experiences in their natural environments. My experiences with Ginny and Mildred Ross inspired me to lead a group for children with Autism Spectrum Disorders with the help of occupational therapy students and the children’s parents.

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I met Winnie Dunn and Lucy Jane Miller at an AOTA symposium where they were mentoring new researchers by letting us help with their projects. I remember asking them both why they were developing assessments when new treatments were needed, and they told me that until we learned to measure sensory integration interventions we couldn’t improve and validate our treatments. Winnie Dunn developed the Sensory Profile, a reliable and valid measure of sensory processing abilities www.sensoryprofile.com Dr. Dunn also went on to develop an intervention model that used the sensory profile to coach clients on adapting their sensory modulation styles so they could function more effectively. http://events.jeena.org/media/blog_media/2011/05/13/Sensory_Integration.pdf  While I still do direct and group interventions I always include consultation to the client, family, and teachers regarding how their sensory styles impact their interactions and functioning.

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By taking the Sensory Profile I found I had significant Low Registration and Sensory Sensitivity, at a level where only 2 out of 100 adults my age score. Being low registration influences me to often miss sensory input that others notice. Because I am also sensory sensitive I also frequently get overwhelmed by sensory input I do notice and take a long time to accommodate to touch (e.g., I’m bothered by neck ties, rings and watches).

I’ve learned to stomp my feet and look people in the eye when they are telling me something important, and to take an hour walk when I’m feeling overwhelmed so I don’t yell at anyone. I still can’t wear a tie when I speak but can tolerate wearing shoes rather than sneakers. Knowing my sensory profile helps me accommodate my behavior to the needs of my clients. I tend to talk loudly and quickly, but consciously speak softer and slower when working with clients who have sensory sensitivity and attention deficit hyperactive disorder.

As a new researcher who was a member of Lucy Jane Miller’s team I learned to be a better observer. Although she is arguably one of the most influential leaders in sensory processing intervention (helping to create the term) what inspired me most about her was her honesty. I was putting off getting my Ph.D. because I felt I wasn’t smart enough, but was inspired when Dr. Miller asked me for help changing her flat tire. I figured if someone that smart couldn’t change a tire I could try to get my Ph.D. even though I didn’t feel smart enough.

Dr. Miller has evolved from developing assessment tools to supporting sensory processing intervention research through the Sensory Processing Disorder Network www.spdnetwork.org Her organization presents workshops on sensory processing basic and clinical research. I refer parents and clinicians to her organization because it is both factual and parent friendly.

My clinical experiences have shown me that sensory processing intervention helps clients with severe sensory processing, behavioral and developmental challenges to improve their functional skills. I have discovered the value of sensory processing intervention through individual, group, client/family education, and environmental consultation treatment. My perspective on sensory processing and professional vision wouldn’t have been possible with out my teachers and mentors. To paraphrase Isaac Newton, “If my professional vision has expanded it is because I stand tall on the shoulders of giants”.