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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.

MatSandwichPropLayondog

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.

KONICA MINOLTA DIGITAL CAMERA

KONICA MINOLTA DIGITAL CAMERA

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.

Trager and me Original

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

XMarkstheSpot

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

HoldingHeadTx

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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Role of school OT’s, PT’s, SLP’s in Behavior Intervention

School Occupational, Physical and Speech Therapists play a significant role in improving student behavior. While traditionally viewed exclusively as the role of school social workers, psychologists, and behaviorists the complex problems of students with interrelated behavioral and developmental challenges can be helped by the contribution of school therapists.  The relationship between behavioral problems, the occupation of students, communication/language abilities, and gross motor skills supports the role of school occupational, speech/language and physical therapists as members of school teams helping students with behavioral and developmental challenges.

By teaming with occupational, speech/language and physical therapists, teachers and school mental health specialists can enhance their school positive behavioral support programs with expanded use of visual supports, mindfulness, music, exercise, and sensory-motor activities (Patten et al., 2013; Schaaf et al., 2014).  There is emerging evidence that cardiovascular and resistance exercise enhances body awareness, attention, as well as functional strength and endurance for improved participation in school learning tasks http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208137/pdf/nihms297861.pdf

School therapists can utilize evidence based mindfulness strategies as movement breaks that improve attention, and integrate behavioral strategies into their school therapy to enhance student’s school behavior.  Behavior for Therapists Slides The picture below describes the FAB Strategies adaptation of the PATHS PBS Turtle Technique to help students with special needs learn to calm down and avoid aggression.

FABModifiedTurtleTech

The AOTA supports the role of school occupational therapy in helping to improve student’s behavior (Cahill & Pagano, 2015).  The following Occupational Therapy article describes clinical school occupational therapy strategies that can be used to reduce student aggression  (Click on highlighted, then double click on lower heading) SchoolOTRedAgg

References

Cahill, S. M. & Pagano, J. L. (2015). Reducing restraint and seclusion: The benefit and role of occupational therapy. AOTA School Mental Health Toolkit. http://www.aota.org/-/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Reducing-Restraint-and-Seclusion.pdf

Flook, L., Smalley, S., Kitil, M., Galla, B., Kaiser-Greenland, S., Locke, J., Ishijima, E., Kasari, C. (2010). Effects of mindful awareness practices on executive functions in elementary school children. Journal of Applied School Psychology, 26(1), 70-95. http://skolenforoverskud.dk/Artikler%20-%20mindfulness/Flook-Effects-of-Mindful-Awareness-Practices-on-Executive-Function-1.pdf

Kazdin, A. E. (2008). The Kazdin Method for parenting the Defiant Child. NY, NY: Mariner Books.

Laugeson, E. A. (2014). The PEERS curriculum for school-based professionals: Social skills training for adolescents with autism spectrum disorder. Routledge.

Mahammadzaheri, F., Koegel, L. K., Rezaee, M., Rafiee, S. M. (2014). A randomized clinical trial comparison between pivotal response treatment (PRT) and structured applied behavioral analysis (ABA) intervention for children with autism. Journal of autism and developmental disorders, 44(11), 2769-2777.

Schaaf, R. C., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., van Hooydonk, E., … & Sendecki, J. (2014). An intervention for sensory difficulties in children with Autism: A randomized trial. Journal of autism and developmental disorders, 44(7), 1493-1506.

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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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.

PlayTx

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.

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Occupational Therapy in Adolescent Mental Health

I was recently honored to present Grand Rounds at Solnit Children’s Center, the adolescent psychiatric hospital where I work. GrandRoundsOT Outline Our dynamic transdisciplinary team over the past 5 years was able to significantly reduce the use of restraint and seclusion.OT role in Restraint Reduction Solnit which was celebrated by making a bench for the hospital grounds from restraint beds (which are no longer used).

BenchDCdRestraint

Occupational Therapy is a vital intervention for adolescents with mental health, PTSD and developmental challenges.  Occupational therapists address adolescent mental health in schools, outpatient mental health clinics, youth psychiatric hospitals, and juvenile detention facilities. Occupational Therapy (O. T.) focuses on promoting adolescent’s occupations, the things they want or need to do. Adolescent’s occupations typically include school,

KarateHorseGroom

activities of daily living (e.g., grooming, keeping their room clean), prevocational activities, sports, exercise, and social activities. For example, intervention on developing occupations is needed by some adolescents recovering from drug addiction, where their primary activities of taking drugs and doing illegal activities (to earn money for drugs) must be replaced by a new lifestyle with more functional occupations.  I am repeatedly impressed by my client’s and their families’ ability to confront the challenges of mental illness, and their unique gifts as individuals http://www.behindthelabel.co.uk

Occupational therapy offers unique contributions to adolescent mental health intervention due to its foundations in neurology, physiology, psychology, development, human occupations, and sensory processing. At Solnit Children’s Center the primary frames of reference used include: mindfulness, sensory processing, sensory massage, trauma informed care, Pivotal Response Training (a research proven form of Applied Behavioral Analysis), exercise, and developmental intervention. Occupational therapy is a vital component of transdisciplinary team intervention for adolescents with mental health challenges.

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FAB Strategies® to Improve Self-Control

FAB Strategies® are Functionally Alert Body Strategies that can be used by parents, teachers, as well as Occupational, Speech, Physical, and Mental Health therapists to improve youngster’s functional behavior.  FAB Strategies® were developed to guide transdisciplinary intervention for individuals with developmental, mental health, post traumatic stress disorder, and sensory processing challenges. FAB Strategies® combines developmental, sensory processing, behavioral, touch pressure, mindfulness, movement and neuropsychology interventions to help individuals with complex behavioral challenges.

The four sections of FAB Strategies® are environmental adaptation, sensory modulation, positive behavioral support, and physical self-regulation strategies. While reducing aggression in special needs students FAB Strategies® simultaneously facilitates attention, learning, and parental involvement in typical students. FAB Strategies® can be used for regular class teaching as well as small group and individual intervention sessions. Many typical students lack adequate seated attention, self-control, and sensory-motor skills to master their academic learning requirements. FAB Strategies® are fun active learning tasks that engage students’ musical, visual-spatial, auditory, interpersonal, and bodily-kinesthetic intelligence to improve learning.

FAB Strategies® are guided by the FAB Strategies® to Improve Self-Control form FAB STRATEGIES FORM and FAB Strategies® for Pre-K and Kindergarten form FAB StrategiesPre&KForm. The FAB Strategies® forms list strategies organized into four sections addressing: environmental adaptation, sensory modulation, positive behavioral support, and physical self-regulation strategies. The teachers and therapists develop a functional goal and choose at least one strategy from each section for goal attainment. Strategies chosen are checked and underlined for use across disciplines.

The FAB Strategies® forms can be used as a checklist of helpful activities to consider when developing transdisciplinary interventions for students with behavioral challenges. The FAB Strategies® forms were also designed as an efficient way to develop home programs and provide a list of effective strategies when students transfer to other teachers and therapists. The FAB Strategies form enables teachers and therapists to individualize interventions that improve behavior in response to each student’s developmental level and individual needs.

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School Occupational Therapy for Developmental Trauma

School occupational therapists emphasis on therapeutic relationships, mental health, sensory processing, attachment, development, purposeful activity and self-regulation offer a unique contribution for improving the behavior of students with developmental trauma disorder. School behavioral problems related to developmental trauma are seen in students who have experienced early chronic abuse. Many students with developmental trauma difficulties have significant sensory modulation, emotion regulation, attachment, self-regulation, sensorimotor, somatic, and developmental challenges.  Working in conjunction with school psychologists, social workers, and guidance counselors, occupational therapists can help improve the mental health and behavior of students who have developmental trauma challenges http://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/Fact-Sheets/OT%20%20School%20Mental%20Health%20Fact%20Sheet%20for%20web%20posting%20102109.pdf http://www.aota.org/-/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Reducing-Restraint-and-Seclusion.pdf

Occupational therapy for improving the behavior of students with developmental trauma can include energy level modulate, sensory processing, deep pressure touch, and mindfulness strategies. The energy level modulate strategy involves increasing students’ awareness of their arousal level and teaching them to modulate dysfunctional high or low energy levels to better participate in school learning tasks. It can be introduced by explaining that “some students who have had difficult experiences early in their life can get into trouble by overreacting when they have really big feelings”. The energy level modulate strategy teaches students to identify whether their current energy level feels “High” (hyper, off the wall, with stiff muscles like raw spaghetti), “Medium” (just right and ready to learn) or “Low” (tired, numb, with loose muscles like over cooked spaghetti).

Visual chart for rating arousal level and if it feels comfortable

Visual chart for rating arousal level and if it feels comfortable

The energy level modulate strategy is extremely useful in school settings for students with sensory modulation difficulties who become aggressive following activities that raise their energy levels extremely high. While many students can use the energy level modulate strategy with teacher encouragement, some students with sensory modulation difficulties and developmental trauma need assistance. For example, a student receiving occupational therapy attended a wild physical education class where the students ran, screamed and threw balls at each other. His classmates behaved appropriately upon returning to class. However, this student who had significant sensory sensitivity and developmental trauma challenges was unable to sit down upon returning to class and threw a chair.

Following this experience the occupational therapist taught the school physical education teachers and mental health therapists the energy level modulate strategy so students could rate their energy levels before returning to class. The teacher or therapist would bring students who rated their energy level as uncomfortably high to a designated staff member (e.g., occupational therapist, speech therapist, principle, resource room teacher) who would help the student do pushups or other individualized sensory coping strategies to lower their energy level before returning to class.

The most effective strategies for normalizing energy levels involve deep pressure through the joints with slow linear movements. Activities such as regular or wall pushups, moving furniture, moving mats, delivering messages or boxes of books throughout the school, or wheelbarrow walking on your hands over a therapy ball can help achieve this.

Wallpushups

Special consideration can be given in the energy level modulate strategy for students with both sensory modulation and developmental trauma challenges who have become use to maintaining a high energy level that interferes with appropriate attention and behavior for school functioning. This difficulty can be indicated by students who describe their energy level as “Hyper and comfortable” and students who actively resist efforts by their teachers and therapists to calm down to a functional energy level where they can pay attention to classroom activities. For students who resist regulating their energy to a functional level it is helpful for the therapist to begin by matching the student’s initial energy level, then support the student during individual sessions to gradually modulate their energy level.  http://www.traumacenter.org/products/pdf_files/Body_Change_Score_W0001.pdf 

Individual OT sessions using sensory processing, deep pressure touch, and sensory mindfulness strategies help students with self-regulation and developmental trauma challenges improve their attention, seated attention, and behavior for participation in school learning tasks.

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These interventions emphasize child-focused activities that optimally challenge students to discover activities that will enable them to modulate dysfunctional arousal levels for improved school functioning. Sensory processing interventions promote attachment relationships combining child-directed activities at their optimal level of challenge with an attitude of PACE (playfulness, acceptance, curiosity and empathy). Offered respectfully with choices to decline, firm pressure touch strategies can enhance attachment, relationships, and self-control in students with behavioral and developmental trauma challenges. Attached is a link showing integrated use of behavioral, sensory processing, PACE, and FAB Pressure Touch strategies. While this treatment was done with a preschooler who had Asperger’s syndrome, a similar approach is often also helpful for students with behavioral and developmental trauma challenges https://www.youtube.com/watch?v=W8fMdJ6l0AM

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.

Engel-Yeger, B., Palgy-Levin, D., & Lev-Wiesel, R. (2013). The Sensory Profile of People With Post-Traumatic Stress Symptoms. Occupational Therapy in Mental Health, 29(3), 266-278.

Hanson, J. L., Chung, M. K., Avants, B. B., Shirtcliff, E. A., Gee, J. C., Davidson, R. J., & Pollak, S. D. (2010). Early stress is associated with alterations in the orbitofrontal cortex: a tensor-based morphometry investigation of brain structure and behavioral risk. The Journal of neuroscience30(22), 7466-7472.

http://www.jneurosci.org/content/30/22/7466.long

Hughes, D. A. (2011). Attachment-focused family therapy workbook. New York, NY: W. W. Norton & Co.

Warner, E., Koomar, J., Lary, B., & Cook, A. (2013). Can the body change the score? Application of sensory modulation principles in the treatment of traumatized adolescents in residential settings. Journal of Family Violence, 28(7), 729-738.