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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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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.

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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.

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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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FAB Coping Card Strategy

The FAB Coping card gives clients, teachers and therapists a visual support strategy for achieving their goals. Based on Power Cards, coping cards use the child’s preferred interest to guide goal-directed behavior. Clients use an index card to depict their preferred interest, behavioral goal, coping strategies, and reinforcement schedule. Constructing and displaying the coping card focuses the client and staff on their individual goal, coping strategies, and reinforcement schedule while using their preferred interest to help achieve the goal.

For example, a student who frequently bit his hand constructed a coping card by depicting his goal (e.g., keep safe hands by not biting myself when I get upset), preferred interest (e.g., Sponge Bob), coping strategies (e.g., chewy, weighted blanket, and basket ball) and reinforcement schedule (e.g., 10 minutes of safe hands=1 sticker). The goal is written and/or drawn, stickers or drawings depict the preferred interest, and coping strategies are visually represented (colored, cut out, and pasted on an index card using the FAB Trigger & Coping forms).

FAB Coping CardFABTriggerCopingFormsMasterpgno5

 

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On the reverse side of the coping card the reinforcement schedule is written: “Safe hands for 10 consecutive minutes earns one sticker, while five stickers=1 toy car)”.  The index card is laminated and fastened to the desktop or worn as a necklace. Through their process of constructing the coping card clients and staff develop an effective functional goal, preferred interest, coping strategies, and reinforcement schedule.

Making a coping card helps teach clients how to use adaptive equipment to achieve their goal. The process of constructing the coping card focuses the client and staff on the goal and plan for achieving it.  The coping card helps to quickly remind clients and staff of the individualized program for achieving their goal.  Coping cards quickly guide busy teachers and therapists in addressing functional goals of students with significant behavioral challenges. Coping cards also encourage professional collaboration in goal development and implementation.

Reference:

Spencer, V., Simpson, C., Day, M., Buster, E. (2008).  Using the power card strategy to teach social skills to a child with Autism.  Teaching Exceptional Children Plus, 5(1), 1-10.

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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

MindfulClk3MindfulClk4

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.

MindfulClk1MindfulClk2

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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Movement Enhances Emotional Expression

Strategies combining movement with expressing feelings motivates students to improve their self-regulation skills. Movement activities that involve emotion expression are especially helpful for motivating students who have behavioral, developmental, trauma history and/or sensory processing challenges. Movement activities are fun and can easily be integrated into strategies to encourage the expression and understanding of feelings.

A strategy for young students that integrates movement with expressing feelings is Feelings Goose. This is a modification of duck-duck-goose in which the student who is “it” touches each peer on the head with alternating hands, while naming a feeling (e.g., sad). When the student touches a child on the head while expressing the opposite feeling (e.g. glad) he is chased as he attempts to run to the other student’s spot.

FeelingGoose

A strategy that has several variations for progressively older students is switch hands toss. The switch hands toss “favorites” strategy involves students passing a beanbag while expressing their favorite: sport, color, ice cream, team, vacation place, coping strategy, quality in picking a friend, what makes them a good friend, and other favorite categories. Students can pick a favorite category to lead if they are willing to go first in expressing their favorite. The “I feel” strategy involves expressing how they currently feel. In “Guess the feeling” a student acts out a feeling using their face and body and the student they throw the beanbag to guesses what they are feeling.

The most challenging switch hands toss strategy is the “I message”. An I message is a DBT statement in which a student describes an action that others do, how they feel in response, and what the behavior they want others to do. The student says “When people ______, I feel _________, so please. A positive example is “When people say hi to me, I feel happy, so please say hi when you see me”. An example of a complaint would be “When people call me Shortie, I feel angry, so please call me John”. Combining movement with expressing their feelings motivates students to actively express feelings and improves self-control.

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Behavioral & Occupational Therapists Working Together

Combining sensory processing and behavioral strategies is useful for students with complex behavior, developmental and sensory processing challenges.  Integrating sensory processing and behavioral strategies is underutilized because of the theoretical rigidity of many behavioral and occupational therapists.  However, I was lucky enough to work with a behavioral therapist who respected occupational therapists, and by working together we helped improve student behavior more easily than either of us could have working alone.   

An effective strategy for helping students who engage in repetitive behavior that interferes with their functioning or is self-injurious is the FAB Sensory Match Strategy.  The FAB Sensory Match Strategy combines offering specific sensory input and reinforcement for decreasing the repetitive behavior. The specific sensory input is developed by first considering the sensory function provided by the repetitive behavior.  If a child repeatedly bangs his hand on a desk, I go where no one will see me and do the behavior myself, considering the sensory input it provides.  Sensory processing knowledge helps in finding activities that will meet the child’s sensory needs so they don’t have to continue engaging in repetitive self-injurious behavior.

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Considering the child’s class setting, favorite activities, developmental level, and Sensory Profile I find several activities the student enjoys that provide the sensory input he’s seeking in a more appropriate way (e.g., hand drumming, pounding playdoh). Finally, the behavioral therapist helps me determine how often the child bangs his hand on the desk and the most effective reinforcement strategies.

The child is then offered the sensory activities to do whenever he chooses and is reinforced for going progressively longer periods with out banging his hand on the desk.  Behavioral therapists are trained in gathering and analyzing data to find the best reinforcement and the schedule for using it.  Occupational therapists are taught to use the Sensory Profile and a task analysis to find appropriate activities that provide the sensory input the child is getting from the repetitive behavior.  The behavioral therapist and I would assess the data on the child’s progress to determine if the reinforcement, schedule for providing it, or sensory activities needed to be adjusted.  By combining their forces behavioral and occupational therapists can integrate behavioral and sensory processing strategies to improve student’s 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.

  Mays, N.M., Beal-Alvarez, J., Jolivette, K. (2011).  Using movement-based sensory interventions to address self-stimulatory behaviors in students with Autism.  Teaching Exceptional Children, 43(6), 46-52.

  Rapp, T.R. (2006).  Toward an empirical method for identifying matched stimulation for automatically reinforced behavior: A preliminary investigation.  Journal of Applied Behavioral Analysis, 39, 137-140.