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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.

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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”.

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Movement for Mindfulness

Mindfulness is the process of paying attention to what you are currently doing and feeling. Attention is a vital skill that is too often underemphasized, particularly when teaching young and developmentally challenged individuals. Movement strategies are useful for teaching mindfulness, self-control, and attention. Several useful movement strategies are listed below that can help young and developmentally challenged people to be mindful and pay attention better.

Standing Mindful Clock: A movement activity to promote mindfulness and body awareness, especially with people who lack the coordination to use deep breathing for relaxation. It involves verbalizing specific words (designated in bold print) while moving in a specific sequence (described in italics) to promote basic awareness of the front, back, top and bottom of the body. The entire sequence is done 3 times.

Tic squat Tock stand on toes Like a squat Clock stand on toes
‘Till we squat Find our stand on toes Center assume a centered standing position
Tic lean forward Tock lean back Like a lean forward Clock lean back
‘Till we lean forward Find our lean back Center assume a centered standing position

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Tense & relax muscles: A brief progressive relaxation strategy involving the muscles people often tense up when their anxious. Participants tense their muscles for 3 seconds then relax 5-10 seconds, doing each numbered section 3 times.

1) Tense; then relax all the muscles of your face and jaw.
2) Elevate both shoulders towards your ears; then drop and relax both shoulders.
3) Fist hands tightly; then completely relax both wrists, hands & fingers.

Bird: A strategy that uses simple movement to teach deep breathing for relaxation. Gradually lift both arms (from the sides like a jumping jack or straight up vertically) while breathing in and expanding your belly. Then at a slower rate lower both arms while breathing out.

Nose Breathe: A strategy that combines hand stretching with deep breathing for relaxation. The nose breathe strategy is especially helpful for students whose hands feel tense or spasm from handwriting or who have difficulty using breathing for relaxation. The fingers are extended and separated for relaxation, then the thumb is fisted in a mudra hand posture that promotes relaxation. It is done three to six times after the hand motions are learned.
1) Breathe in through your nose (making your belly go out) while opening your hands wide, extending and separating your fingers.
2) At a slower rate breathe out while bringing your thumb inside your hands making fists.

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Focus on Feet: Eyes closed feel one big toe, the smaller toe next to it, center toe, second smallest toe, and little toe. Feel your toes, bend them, notice if you have socks on and whether there are holes in your socks. Move back to feel the ball of your foot, back further and feel the arch of your foot and notice if it hits the ground. Move back again to feel your heel. Finally, feel or press down on the entire bottom of your foot.

Focus on Palms: Put your open hands in Dali Lama prayer position and push them together as hard as possible for 10 seconds doing an isometric contraction. Then position your hands palms up and close your eyes. Feel your thumb, pointer, middle, ring, and little finger. Then feel the palms of your hands for 5-10 seconds.

References:
Brain Gym International http://www.braingym.org
Greenland, S. K. The Mindful Child. http://www.susankaisergreenland.com/
Koester, Ceci http://www.movementbasedlearning.com

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Behavioral & Sensory Strategies for Young Students

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Integrated sensory processing and behavioral strategies improve the behavior of pre-school and kindergarten students. Combining Positive Behavioral Support and sensory processing adaptive equipment and techniques can help regular and special education students behave better, pay attention, and learn. A helpful initial resource for pre-school and kindergarten teachers is www.pbisworld.com which suggests behavioral strategies and classroom adaptations.

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The PBIS World website helps pre-school and kindergarten teachers identify the most problematic student behaviors. PBIS World then provides a menu of appropriate Tier 1 regular classroom, Tier 2 small group, and Tier 3 individual interventions to choose from for improving behavior. Free data tracking forms are also provided for monitoring the effectiveness of the selected behavioral interventions.

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Special education teachers as well as occupational, speech-language, or mental health therapists can assist teachers in identifying the best Tier 1 interventions for a specific student, and can assist the teacher by providing Tier 2 or Tier 3 interventions within and outside the classroom. It is important for team members to provide consistency between Tier 1, 2, and 3 interventions so students are not confused by varied rules and procedures.  Tier 1 Preschool and Kindergarten classroom interventions combining sensory processing and positive behavioral support are suggested using the FAB Strategies Form.

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While some special education faculty, behaviorists, pediatricians, and occupational therapists object to combining behavioral and sensory strategies it makes sense to combine these clinically proven interventions before using medications.

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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

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Sensory Integration Needs to Evolve

Following its initial development by A. J. Ayres, Sensory Integration Intervention has been slowly evolving.   As a result of this slow evolution, two major problems threaten the sensory integration frame of reference. First is the problematic discrediting of sensory integration research by some behaviorists and pediatricians who favor interventions that are too rigid or medication based to optimally help children.  Second is intervention borrowing sensory integration terminology with out adequate expertise in carrying out the strategies.  Increasing use of “brushing, sensory diets, sensory equipment, and comfort rooms” developed and used by teachers and mental health therapists with out adequate guidance from therapists trained in sensory integration significantly dilute the effectiveness of sensory integration intervention.

Luckily, many well trained therapists continue the evolution of sensory integration intervention.  While these excellent contributions are too vast to cover fully, I want to review three major areas of evolution in sensory integration intervention that serve as a foundation for further expansion.  Related to each evolution I will mention and provide links to clinicians who have built on sensory integration in a way that has been most helpful to me in my intervention as an occupational therapist working with children and adolescents who have behavioral, psychiatric, early trauma, Autism Spectrum Disorders, and other developmental challenges.

The first evolution contributes sound research, theory, and standardized sensory integration terminology to clinical sensory integration intervention.  This evolution is led by Lucy Jane Miller and her colleagues at the Sensory Processing Disorder SPD Network www.spdnetwork.org  While the therapists significantly contributing to the SPD Network are too numerous to mention fully, I want to describe two that greatly contribute to my practice in child and adolescent psychiatry.  Diana Henry www.ateachabout.com offers many helpful clinical intervention strategies.  The late Jane Koomar, Teresa May-Benson and her associates at OTA Watertown www.otawatertown.com and the Spiral Foundation conduct research and teach clinical sensory integration strategies that enhance attachment and the development of children with early trauma challenges.

The second evolution is the brief valid assessment of sensory modulation problems and their treatment through adaptive equipment and techniques.  Winnie Dunn has led this evolution through her research and development of the Sensory Profile and sensory integration based consultation strategies.  Others that have greatly helped my practice through environmental adaptations include Tina Champagne www.ot-innovations.com whose work with sensory coping rooms and adaptive equipment has helped psychiatric hospitals significantly reduce the use of restraint, replacing it with sensory coping rooms and equipment that empowers clients to learn effective coping strategies.  The adaptive sensory strategies developed through the Alert Program by Sherry Shellenberger and Mary Sue Williams www.alertprogram.com have also helped empower children with behavioral challenges to actively learn coping strategies.  Mention also needs to be made of Patricia & Julia Wilbarger’s  development of the sensory diet www.avanti-ed.com  Problems with misuse of the sensory diet by untrained individuals while significant are contrary to how the Wilbarger’s instructed it be used.

The third evolution is the development of touch pressure strategies as an individualized component of Ayres’ Sensory Integration that was initially expanded on by Knickerbocker.  The Wilbarger Protocol (brushing) is brilliant despite problems resulting from its misuse that are contrary with how it was taught by the Wilbargers.  Two other helpful contributions to this evolution are research efficacy of touch pressure through massage from Tiffany Field http://www6.miami.edu/touch-research and Qigong Sensory Treatment (QST) touch pressure based on Tui Na massage.  QST is developed and research validated by Dr. Silva www.qsti.org

QST was found through repeated research to significantly improve behavior and sensory processing in preschoolers with Pervasive Developmental Disorders.  QST research and my clinical experiences suggest the use of QST touch pressure offers great promise as a touch pressure strategy done as a component of Sensory Integration Intervention, particularly for youngsters with Autism Spectrum Disorders and/or an early trauma history.  Research suggests that young children with Autism Spectrum Disorders who are hyper-responsive to touch benefit from sensory processing intervention, while both hyper and hypo-responsive preschoolers with Autism Spectrum Disorders show significantly improved behavior and sensory processing skills following firm pressure touch.  I adapted the work of Knickerbocker, Tiffany Field, and QST to develop FAB Pressure Touch Strategies.   A major difference of FAB Pressure Touch Strategies is that therapists individualize it to reach the child’s functional goals as one component of comprehensive intervention.

The three evolutions of clinical, environmental adaptation, and pressure touch strategies in sensory integration provide a solid foundation for the development of Sensory Integration Intervention, and it is important to stay updated on this clinical and research work. Although proponents of the three evolutions conflict at times, these disagreements are insignificant given the contribution that all these intervention methods offer in conjunction with one another.  Sensory integration is now ready to further evolve into a solid research based frame of reference that is a specialized component of occupational, physical, and speech therapy practice.  Critics of sensory integration have used their objections to this frame of reference to advocate against children receiving occupational therapy services.  Sensory integration intervention is not all of occupational therapy, but is an important frame of reference for the profession.

My development of FAB Strategies offers an example of ways therapists can knowledgeably include sensory integration intervention as one goal directed component of a comprehensive intervention strategy for children and adolescents with behavioral, developmental, and sensory processing challengesFAB Functionally Alert Behavior STRATEGIES While a written format of strategies is described, interventions including the use of touch pressure strategies are individualized by trained therapists to attain their client’s goals.  In FAB Strategies the goal is used to guide development of intervention composed of environmental adaptations, sensory modulation, positive behavioral support, and physical self-regulation strategies.  I urge other occupational therapists to continue the evolution led by Ayres and her initial followers to further help and guide their clients.

References:

Ayres, A. J. (2005). Sensory integration and the child: 25th Anniversary Edition.  Los  Angeles, CA: Western Psychological Services.

Higbee, T.S., Chang, S., Endicott, K. (2005).  Noncontingent access to preferred sensory stimuli as a treatment for automatically reinforced stereotypy.  Behavioral Interventions, 20, 177-184.

Kimball, J. G., Lynch, K. M., Stewart, K. C., Williams, N. E., Thomas, M. A. & Atwood, K. D. (2007).  Using salivary cortisol to measure the effects of a Wilbarger protocol-based procedure on sympathetic arousal: A pilot study.  American Journal of Occupational Therapy, 61(4), 406-413.

McClafferty, H., Sahler, O. J., Wiley, S. E. (2012).  Sensory Integration therapies for children with developmental and behavioral disorders.  Pediatrics, 129(6), 1186-1189.

Schaaf, R.C., & Miller, L.J. (2005).  Occupational therapy using a sensory integrative approach for children with developmental disabilities.  Mental Retardation and Developmental Disabilities Research Reviews, 11, 143-148.

Silva, L. M., Schalock, M. (2013).Prevalence and significance of abnormal tactile responses in young children with Autism.  North American Journal of Medicine and Science, 6(3), 121-127.

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FAB Strategies Workshops

I’ve been getting several enquiries from therapists, parents, and teachers interested in taking my FAB (Functionally Alert Body) Strategies workshops.  FAB Strategies offer evidence based transdisciplinary mindfulness, sensory processing, handling, behavioral, art, music, and activity strategies for children with behavioral, developmental, and sensory challenges. I would enjoy discussing setting up workshops with you and can be reached at JLP96007@yahoo.com I am currently conducting efficacy research and working on a FAB Strategies Book.

Through ERI (Education Resources Inc.) I am currently offering small high quality trainings for occupational, physical, speech, and mental health therapists.  The number of participants is strictly limited so I can give individualized activity and handling instructions to each participant through laboratory sessions, where participants can learn to immediately use FAB Strategies in their clinical practice.  Professionally produced handbooks are provided for each participant with research references and unlimited ability to use my copyrighted FAB Strategies activity and handling forms.  My currently scheduled FAB Strategy Workshops are October 18 & 19, 2013 in Cedar Knoll, NJ and November 8 & 9, 2013 in Hollywood, Florida.  More information and registration informationis available at 

http://www.educationresourcesinc.com/course-details?courseid=38