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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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FAB Strategies Mindfulness Movement Activities

I wanted to share this video of my FAB Strategies Mindfulness Movement activities to improve student’s behavior  https://www.facebook.com/educationresourcesinc/videos/943257499082558/ It was recorded by ERI at their Therapy in the Schools Conference.  Mindfulness movement activities are simple to do and can improve attention as well as enhance behavior by reducing student’s anxiety and giving them a break from seated work.

Mindfulness movement activities help all students yet are especially helpful for students with developmental disabilities, anxiety, sensory processing challenges, Post Traumatic Stress Disorder, ADHD, and/or other behavioral challenges.  Brief five minute mindfulness movement activities can help students attend better and promote the processing of academic learning when done between academic subjects (e.g., after math before proceeding to language arts).  Mindfulness movement activities can also be done in conjunction with teaching Positive Behavioral Support Interventions and used as a pre-correction before challenging school activities (e.g., lunch, playground, assemblies, and transitions).

In this video I demonstrate Touching the head-shoulders-stomach for sensory body awareness, Belly breathing, Hand opening and stretching to prevent hand cramping from writing (while breathing in) followed by thumb fisting as a mudra for relaxation (while breathing out)

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Bird breathing, and Mindful Clock Sitting (righting reactions moving forward-back and laterally).

Mindful clock standing activities can also be used, particularly to help students with sensory irritability gain basic body awareness of the anterior-posterior portions of their body through forward-back balancing movements  

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as well as sensory awareness and stability of the bottom (feet) and top (head) of their body through squatting then moving on their toes.

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I hope more early childhood and special education teachers as well as occupational, physical, speech/language and mental health therapists will begin using basic sensory mindfulness movement activities with their students.  Mindfulness movement activities offer a great opportunity for teachers and therapists to integrate and co-teach the academic and developmental curriculum areas.  As we continue to integrate the regular and special education curriculums, mindfulness movement activities can benefit students while promoting transdisciplinary interactions between teachers and therapists.

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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.

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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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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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Assessing Sensory & Behavior Challenges

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

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

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

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

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

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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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Facilitating Adaptive Behavioral Responses

Occupational therapy uses specific child-directed sensory activities to achieve adaptive behavioral responses. To achieve adaptive responses specific support is provided to assure that the behavioral demands are challenging but not too difficult to achieve. Sensory coping strategies and sensory coping areas can be used to obtain the right combination of challenges and supports for adaptive behavioral responses.

 

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While occupational therapy sensory activities are often criticized as being “fun but too frivolous for school”, students must be willing to actively participate in activities in order to learn from them. Discovering students’ interests is crucial for developing activities they will actively engage in to improve their adaptive behavioral responses. Once students are willingly engaging in activities the tasks can be gradually modified to promote their goal-directed adaptive behavioral responses (e.g., frustration tolerance, attention, seated attention, direction following, keeping safe hands).   An individualized program of sensory copying strategies that promote self-control can be developed using the FAB STRATEGIES Form COLOR

 

 

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Once therapists and teachers find engaging activities it is important to continuously modify the tasks so they are at a level that is not too hard or easy for the student. Students with behavioral, developmental, trauma history, and/or sensory processing challenges frequently show poor motivation and school behavioral problems because their developmental level and interests do not match the classroom curriculum. A preschooler at a six month developmental level obviously needs modifications in the typical preschool curriculum developed for four to five year olds. A more complicated challenge is the student with behavioral, developmental, trauma history, and/or sensory processing challenges who functions at significantly different levels in various developmental areas, requiring diverse challenges in different developmental areas (e.g., two year old social and six year old reading skills).

Because of delayed behavioral skills many children benefit from a sensory coping area they can use when they begin reacting negatively to environmental triggers (e.g., “being told what to do, being told no”) or showing body triggers (e.g., “acting hyper, hand fisting”).   Sensory coping areas can vary from a special desk in the back of the class where the student can take a break to a designated room where the child can go with a teacher to do their self-calming activities.  It is helpful to record the activities used and affects of the sensory coping room using the FAB Sensory Coping Area Log Occupational therapy directed sensory coping strategies and sensory coping areas are helpful ways of promoting child-directed sensory activities that promote students’ adaptive behavioral responses.

Reference:

Stackhouse, T. M. (2014). The adaptive response to the just-right challenge: Essential components of sensory integration intervention. Sensory Integration Special Interest Section Quarterly, 37(2).