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Combined Behavior & Sensory Evaluation

Adding a brief behavioral function assessment enables pediatric occupational therapists to apply sensory strategies that better help youth with complex behavioral challenges. Integrating the QABF and Sensory Profile 2 (Dunn, 2014) assessment can improve pediatric occupational therapy behavioral outcomes (McCall et al., 2016; Lydon et al., 2017). Sensory Integration Intervention is helpful for children and adolescents with complex behavioral challenges because it is one of very few things that they are motivated to do. Understanding the client’s sensory profile and the function or purpose of their most problematic behavior helps guide occupational therapy treatment.

A case study illustrates how combining the Short Sensory Profile and QABF guides integrated sensory and behavioral intervention. The client is a fifteen year old with a diagnosis of Autism Spectrum Disorder and Intellectual Disability who bit and punched his parents and psychiatric hospital staff. Given the severity of his behavioral challenges my occupational therapy assessment included the  “QABF” Questions About Behavior Function and Short Sensory Profile 2 assessments.

The “QABF” Questions About Behavior Function assessment is a quick and reliable parent/staff report rating scale that quickly identifies the reason that the client engages in problematic behavior. The OT identifies the client’s most problematic behavior and describes it objectively. The QABF then asks parents/staff to rate how frequently the client engages in the target behavior (see QABF sample below, included with the permission of Johnny Matson, Ph.D.).

QABF15yroldCogDis

I determined that this client’s most problematic target behavior was biting & punching. The client’s residential unit staff rated the frequency of the client’s use of biting & punching to achieve 25 possible reinforcers. By adding the total scores for each major function of behavior in the bottom row, the client’s highest scores show that the primary reasons for his biting and punching were Escape and Attention, respectively.

Because Escape and Attention were the primary functions of the client’s inappropriate behavior intervention involved consultation between his occupational, speech/language and mental health therapist to develop a communication and reinforcement system for appropriately requesting attention and to escape tasks. Based on the student’s individual abilities, the team decided that if the student said “no thank you” he would immediately get out of all demands. To avoid over use of the “no thank you” statement to avoid tasks, the amount of work required for receiving rewards was initially reduced by a third. It was also decided that if he approached staff and looked towards them he would immediately receive attention.

The Short Sensory Profile 2 was rated for the client by his residential unit staff. His scores indicated much more than others for sensory sensitivity and sensory seeking. These scores and his clinical observations showed a tendency to become hyper-reactive and not habituate or “get use to” sensory input, as well as sensory seeking of deep pressure touch input. His parents and hospital staff also reported a tendency to bite or hit so he could be restrained, an important contribution of sensory assessments sometimes missed by the QABF assessment.

Research supports that adolescents with a diagnosis of Autism Spectrum and Anxiety Disorder as well as significant sensory sensitivity, tend to be overwhelmed by sound and touch input related to a neurological tendency to not habituate to this stimuli (Green et al., 2016).  It is also often clinically reported that some adolescents with Autism Spectrum and Anxiety Disorder act physically aggressive to obtain the deep pressure input of being physically restrained. The client’s Sensory Profile 2 results and clinical observations were integrated with the QABF results into his treatment by his occupational, speech/language and mental health therapist .

Whenever the client calmly approached the occupational therapist and said “hug” deep pressure was offered. Deep pressure was never given following hitting or punching, because this would have reinforced these inappropriate behaviors. Integrating the QABF and Sensory Profile 2 assessment enabled the team to implement sensory strategies that reinforced appropriate behavior  (McCall et al., 2016; Lydon et al., 2017). 

References

Dunn W. (2014). Sensory profile 2: User’s manual. Psych Corporation. www.sensoryprofile.com

Green, S. A., Hernandez, L., Bookheimer, S. Y., & Dapretto, M. (2016). Salience network connectivity in autism is related to brain and behavioral markers of sensory overresponsivity. Journal of the American Academy of Child & Adolescent Psychiatry, 55(7), 618-626.

Lydon, Helena, Olive Healy, and Ian Grey. “Comparison of behavioral intervention and sensory integration therapy on challenging behavior of children with autism.” Behavioral Interventions 32, no. 4 (2017): 297-310.

McCall, J., Derby, M. K., & McLaughlin, T. F. (2016). The effects of matching sensory profile results to functional analysis and preference assessment for the in home treatment of aberrant behaviors in two children with Autism Spectrum Disorders. International Journal of English and Education, 5(1), 368-390.

Vollmer, T. R., & Matson, J. L. (1995). User’s guide: Questions about behavioral function (QABF). Baton Rouge, LA: http://www.disabilityconsultants.org 

 

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Brain Based Emotion Regulation Strategies

Brain based therapy applies current neuropsychology to developing emotion regulation strategies. Emotion regulation involves learning to non-aggressively express strong feelings. People initially process anger and other negative emotions unconsciously in the right cerebral hemisphere, but require cross-hemispheric communication involving the left cerebral hemisphere for conscious awareness, verbal expression and emotion regulation (Riggs et al., 2006; Shobe, 2014). The Switch hands toss, ball bouncing, and drumming strategies were developed to help link movement activities with the verbal expression of feelings.

Research suggests that communicating negative feelings between the brain hemispheres for emotion regulation can be particularly difficult for students with complex behavioral disorders, including diagnoses of Autism Spectrum (Anderson et al., 2010) and/or Post Traumatic Stress Disorder (Pechtel & Pizzagalli, 2011), who have significantly reduced neurological communication between the cerebral hemispheres. Many of these students, as well as those with ADHD or neurological immaturity, also resist remaining seated and discussing their feelings and behaviors. Because expressing feelings is difficult for students with complex behavioral challenges, they tend to avoid practicing it.

The Switch hands toss, ball bouncing, and drumming strategies were developed to use movement games to promote the verbal expression of feelings in students with complex behavioral challenges. The Switch hands toss strategies combine passing a beanbag with the verbal expression of preferences, feelings, values, and choices. The ball bouncing and drumming strategy similarly combine two hand sequential activities with the verbal expression of feelings. Building on Positive Behavioral Support activities that teach emotions and express feelings, the switch hands toss, ball bouncing, and drumming strategies are fun interactive tasks that can be done individually with students and in groups. Both the movement and expression of feeling are developmentally individualized to improve emotion regulation and verbal skills.

Drumming

Current brain research suggests that most students initially process anger and other negative emotions unconsciously in the right cerebral hemisphere, but require cross-hemispheric communication involving the left cerebral hemisphere for conscious awareness, verbal expression and emotion regulation (Riggs et al., 2006; Shobe, 2014). This can be particularly challenging for students with complex behavioral challenges. Research indicates significantly greater difficulties with neurological communication between the left and right cerebral hemispheres in students with a diagnosis of Autism Spectrum and/or Post Traumatic Stress Disorder.  The picture below shows the corpus callosum (marked as number 1 in black) a major network of nerves connecting the cerebral hemispheres.

LimbicSystem

The switch hands toss, ball bouncing, and drumming strategies combine sequential two handed movement activities with the expression of feelings. These strategies combine movement with the verbal expression of feelings to promote functional communication between both cerebral hemispheres. The switch hands toss, ball bouncing, and drumming strategies are easily graded by matching the specific movement and verbal expression to the student or group’s level.

The switch hands toss, ball bouncing, and drumming strategies address the verbal expression of: favorites (e.g., color, team, quality in a friend), best coping strategy, guessing the feeling or degree of feeling expressed by the therapist or peers, right now I feel _____, and I messages (e.g., when you yell at me, I feel sad, so please speak to me politely). These strategies enable students to express their feelings with out needing to be seated or the center of attention. The switch hands toss, ball bouncing, and drumming strategies offer fun Positive Behavioral Support activities to improve emotional awareness and the verbal expression of feelings.

References:

Anderson, J. S., Druzgal, T. J., Froehlich, A., DuBray, M. B., Lange, N., Alexander, A. L., & Lainhart, J. E. (2010). Decreased interhemispheric functional connectivity in autism. Cerebral cortex, 190.

Bengtsson, S.L., Nagy, Z., Skare, S., Forsman, L., Forssberg, H., Ullen, F. (2005). Extensive piano practicing has regionally specific effects on white matter development. Nature Neuroscience, 8, 1148-1150.

Miller, A. L., Rathus, J. H. & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. NY, NY: The Guilford Press.

Pechtel, P., & Pizzagalli, D. A. (2011). Effects of early life stress on cognitive and affective function: an integrated review of human literature. Psychopharmacology, 214(1), 55-70.

Riggs, N. R., Greenberg, M. T., Kusche, C. A., Pentz, M. A. (2006). The mediational role of neurocognition in the behavioral outcomes of a social-emotional prevention program in elementary school students: Effects of the PATHS curriculum.   Prevention Science, 7(1), 91-102.

Shobe, E. R. (2014). Independent and collaborative contributions of the cerebral hemispheres to emotional processing. Frontiers in human neuroscience, 8.

Sun, F. T., Miller, L. M., Rao, A. A., Esposito, M. D. (2007). Functional connectivity of cortical networks involved in bimanual motor sequence learning. Cerebral Cortex, 17(5), 1227-1234.

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Touch Intervention to Improve Child & Adolescent Behavior

Evidence based touch strategies are an important part of my occupational therapy interventions for children and adolescents with behavioral, psychiatric, developmental, and sensory processing challenges. Although touch is a component of typical attachment and development, many excellent mental health therapists do not include touch in their interventions with children and adolescents, and warned me against using touch when I began working in pediatric psychiatry 30 years ago.   I include touch as part of my psychiatric interventions with children and adolescents based on research showing its efficacy for improving mental health and social skills in children and adolescents with Autism Spectrum Disorders, psychiatric disorders, behavioral problems, early trauma challenges, and sensory processing challenges.

Specific guidelines are needed when using touch with children and adolescents with mental health challenges, because these youngsters may have past experiences of physical abuse, sexual abuse or child neglect that make touch problematic.  I always provide touch only after getting permission from the parent and child, repeatedly urging the youngster to let me know and any time if they want me to stop immediately, and in conjunction with their mental health therapist.  Implementing touch in this manner, I have only had one incident of a child demonstrating distress as a result of being touched during my 20 years of full time practice, and have seen a dramatic reduction in physical and verbal aggression with improvements in behavior, social skills, and attention span.

My use of pressure touch in FAB “Functionally Alert Behavior” Strategies differs from traditional massage and brushing protocols.  There is evidence for massage as an intervention to improve social skills with children who have Autism Spectrum Disorders and clinical experiences of scrub brushing improving behavior in children with sensory processing challenges, but both of these methods are sensory stimulation techniques that are implemented in a prescribed manner.  In FAB Strategies pressure touch is included in the sensory modulation section as one component of an interdisciplinary program to achieve specific behavioral objectives.  The touch is individually developed and modified by the therapist to achieve the child’s goals.

Touch pressure in FAB Strategies is provided through equipment, independent exercises, brushing, massage, or joint compression strategies.  The touch pressure strategies are individualized and modified to achieve the child or adolescent’s specific behavioral goals (e.g., reduced physical aggression, reduced verbal aggression, improved communication, increased social skills).   Equipment and exercises used to provide pressure touch in FAB Strategies include: theraband exercises, wall pushups, theraplast, playdoh, hugging a stuffed animal, a weighted blanket, a pressure or weighted vest, and a body sock.  Pictures of the exercises and equipment touch strategies are identified on the FAB Coping Forms, and can be reviewed during the initial evaluation.

FABCopingForms WallpushupsProneTherapyballfar

All of these strategies provide pressure through the joints. An advantage of the exercise and equipment touch pressure strategies is that they are controlled by the child or adolescent and can be done independently as a coping strategy.  We have pressure receptors in our body (e.g., enabling us to point to our wrist with out looking) and exercises, equipment, or direct touch that activates these receptors provides youngsters with a calming sensation (e.g., like when a mother hugs her child) that can be a useful coping strategy.

Pressure touch can also be provided directly by therapists, parents, and teachers as a coping strategy using the FAB Pressure Touch Strategies.  The FAB Pressure Touch Strategies (taught in my workshops) include the: head crown, shoulders squeeze, spine roll, back protocol, back, arm, legs, feet, and face strategies. Direct touch FAB Strategies listed on the FAB Coping Forms above include get a hug and FAB Pressure Touch (a variety of massage and brushing strategies begun with touch on the back).  Direct touch may reduce physical and verbal aggression when no other strategies are affective, and can be beneficial to improve attachment and relationships.  While some of the FAB Pressure Touch Strategies are currently used by physical and occupational therapists in FAB Strategies emphasis is given to how touch “feels” in the body, affects the child or adolescent’s energy level and tension, and enables them to achieve their behavioral goals.  The link below shows the direct FAB Pressure Touch Strategies being done as a component of FAB Strategies with a preschooler who has Asperger’s Syndrome and behavior challenges http://www.youtube.com/watch?v=W8fMdJ6l0AM&feature=youtu.be

References:

Blaustein, M.E. & Kinniburgh, K.M. (2010).  Treating Traumatic Stress in Children and Adolescents.  NY, NY: The Guilford Press.

Field, T., Henandez-Reif, M., Diego, M., Schanberg, S., Kuhn, C. (2005).  Cortisol decreases and serotonin and       dopamine increase following massage therapy.  Intern. J. Neuroscience, 115, 1397-1413.

Mass. Dept. of Mental Health Safety Tool. (2006).  MacLachlan, J. & Stromberg, N. Safety Tools.

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.