New research supports the efficacy of combining mindful breathing, body awareness, and a calm alert state as components of intervention to help youth with complex behavioral challenges. Teachers as well as Occupational, Speech/language, Physical and mental health therapists can benefit from transdisciplinary strategies integrating mindful breathing, interoceptive awareness, and sensory modulation interventions to help youth with complex behavioral challenges (Pagano, 2019).
A useful evidence-based intervention to include for teaching mindful breathing is the Breath-Body-Mind approach. Breath-Body-Mind combines graded movement and Qi-Gong breathing activities to help individuals with PTSD, mental health, and developmental challenges self-regulate and expand their interoceptive awareness. I became a teacher of Breath-Body-Mind and combine it with other mindfulness strategies to help adolescents with behavioral challenges.
Preschool children randomly assigned to a mindfulness and social skills curriculum showed greater improvement in social skills and learning. It was noted that the impact of the contemplative practice sessions lasted only one day and needed to be done regularly, with young children attending best to mindfulness practices that involve movement and props (Poehlmann-Tynanet al., 2016; Flook et al., 2015). Contemplative practice of 30-45 minutes is found to significantly reduce the need for physical interventions to control aggression in adolescent psychiatric institutions (Felver et al., 2016). Caregivers, children, and adults with Autism Spectrum Disorders (ASD) who received mindfulness practice all reported significant gains in well-being immediately and 3-months after intervention. Reduction in child aggressive and self-injurious behaviors were found in children with ASD whose parents practiced mindfulness (Hartley et al., 2019).
Interoceptive Awareness (IA) is the ability to notice, monitor, give meaning to and regulate the internal conditions of the body (Craig, 2015). IA ability effects the occupational performance of emotional regulation (e.g., noticing that fisted hands mean I’m getting angry and should take a walk for self-regulation) and the use of sensory coping strategies. Both sensory modulation and IA are atypical in adolescents with ASD (DuBois et al., 2016), PTSD and mental health challenges (Khalsa et al., 2018). Recent interoceptive research suggests the need for new multi-disciplinary interventions and a revision of sensory integration theory for adolescents with Autism Spectrum Disorder, PTSD, and mental health challenges (DuBois et al., 2017; Khalsa et al., 2018).
IA is integrated in the insula with exteroceptive sensory input from active movements, proprioception and vestibular input (Craig, 2015). It is important to integrate new neural network models and and an understanding of Autonomic Nervous System reactions to stress into sensory modulation intervention and integrate it with other approaches (Christensen et al., 2020).
Dysfunctional stress responses are expressed along a typical continuum of differences but are significantly more likely in youth with mental health and developmental disorders. Both a lack of interoceptive awareness and sensory modulation disorders relate to a continuum of CNS differences in stress response.
Children and adolescents with ASD, particularly those with sensory sensitivity, have heightened heart rate acceleration. This increased heart rate was associated with significantly greater activation in the amygdala and frontal brain regions associated with habituation. This pattern has also been observed in individuals who have trauma histories in response to stimuli that evoke their trauma experiences. These youth have significantly decreased ability to habituate to irrelevant sensory stimuli due to functioning in the amygdala and sensory cortices (DuBois et al., 2016; Green et al., 2015).
Sensory Modulation is the ability to regulate and organize sensations in a graded adaptive manner. Sensory modulation Disorder (SMD) reflects disruption of habituation and sensitization within the CNS, behaviorally categorized as hyper/over-responsive and/or hypo/under-responsive. SMD is an integral aspect of stress response physiology. Sensorimotor-focused treatment strategies can benefit from being integrated with socio-emotional and play-based approaches (Christensen et al., 2020).
The mindful breathing and body awareness interventions work well when combined with sensory modulation interventions. While approximately 5% of typical youth have a sensory processing problem, the rate is approximately 33% for youth with behavioral, mental health and developmental challenges. Approximately 50-90% of youth with ASD also have a sensory processing problem. Given the high percentage of youth who have both sensory and behavioral challenges interdisciplinary efforts to address both challenges appear indicated.
The relationship between interoceptive awareness and sensory modulation disorders is supported by a recent study showing that youth with ASD and significant Sensory Sensitivity (a sensory modulation disorder) had significantly increased heart rate and slower habituation. These differences were significantly related to greater activation in the amygdala (limbic regions) and frontal (sensory) brain regions to mildly aversive stimuli and decreased habituation in these regions as well as behavioral manifestations of sensory over-responsivity (Jung et al., 2021). It appears most helpful to use compensatory sensory strategies and environmental adaptations with this group (Green et al., 2019).
Finally, use of massage and back vibration strategies that teach body awareness appears helpful for youth with PTSD, substance abuse, and sensory modulation difficulties.
Both sensory-based and interoceptive awareness interventions appear to help with self-regulation. The Interoceptive Curriculum was taught to children with Autism and appeared to increase their interoceptive awareness (Hample et al., 2020). Sensory processing and interoception are atypical in adolescents with ASD (DuBois et al., 2016). In children and adolescents with ASD tactile under-responsivity correlated strongly with increased social and communication impairment, while tactile sensory seeking was strongly associated with repetitive behavior, social, and non-verbal communication impairment.
MABT (Mindful Awareness in Body-Oriented Therapy) is an evidence-based approach combining massage, self-touch, and psycho-education to improve interoceptive awareness. MABT significantly improves substance abuse recovery, PTSD symptoms, interoceptive awareness, and physiological measures of emotion regulation in comparison to health education treatment both immediately and six months after MABT intervention. Participants in MABT are given home assignments to increase their body awareness that they report increase their mindfulness even after the treatment is over (Price et al., 2019; Price & Herting, 2013; Price & Mehling, 2016).
Clinical experience suggests the integration of mindful breathing, body awareness, and a calm alert state can help youth with complex behavioral challenges. A developmental approach involving prompts and active movement best enables youth to benefit from these activities. Recent research and clinical experiences suggest the need to for interdisciplinary efforts to modify mindfulness, mindful breathing, self-touch, and massage practices to help youth with mental health and developmental delays to improve their self-regulation and behavioral skills.
References
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Price CJ, Thompson EA, Crowell S, Pike K. Longitudinal effects of interoceptive awareness training through mindful awareness in body-oriented therapy (MABT) as an adjunct to women’s substance use disorder treatment: A randomized controlled trial. Drug and alcohol dependence. 2019 May 1;198:140-