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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.).

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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 

 

1

Individualizing Coping Strategies to Improve Behavior

The use of coping strategies is an evidence-based intervention that improves behavior.  It is commonly used in school positive behavioral support programs and mental health interventions to improve functional skills.  Coping strategies enable individuals to manage their strong feelings of sadness, anger, or anxiety with out violence or other functional difficulties.  Coping strategies are a proven component of school Positive Behavioral Support programs (Second Step, PATHS, DECA), Dialectic Behavior Therapy (DBT) and CBT (Cognitive Behavior Therapy).

Learning to use coping strategies to manage depression, anxiety, and aggression can be particularly challenging for individuals with behavioral, mental health, developmental, trauma history, and/or sensory processing challenges.   Learning to consistently implement coping strategies is a long process that can be facilitated by teachers, family members, as well as occupational, speech/language, physical, and mental health therapists.  It is important when evaluating coping strategies with clients to assess their efficacy in facilitating short-term and long-term frustration tolerance and functioning.  For example, some client attempts to cope with strong feelings provide short-term relief (e.g., self-injurious behaviors, risky sex, drug and alcohol abuse) but worsen long-term coping and functioning.  It is often necessary to exert considerable effort to help clients find the best fit of coping strategies to improve their functioning across settings.

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Careful consideration of client’s interests, developmental level, sensory processing, as well as success and challenges in implementing coping strategies is a good place to start.  Coping strategies involving physical movement are usually most successful when teaching new coping strategies to clients.  Inclusion of physical exercise, music, sensory equipment and adaptive techniques, mindfulness strategies, yoga, and touch strategies can be particularly helpful for individuals with special needs.

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A helpful tool is having clients select 3 items from each page of triggers and coping strategies on the FABTriggerCopingForms

An understanding of the client’s unique environmental triggers (situations such as “being told no”) and body triggers (e.g., “breathing fast; crying”) that precede disabling anxiety or aggression are helpful in teaching coping strategies.  When evaluating the effectiveness of coping strategies those that show the greatest effectiveness with slight environmental and body triggers can be expanded on.  Repeatedly practice and reinforce clients for successfully using coping strategies in controlled settings, while gradually increasing their stress levels.  Once strong feelings can be consistently managed with coping strategies in controlled settings, begin practicing and reinforcing them in supported naturalistic settings.  While coping strategies are difficult to learn they are worth the effort, as they are extremely helpful in increasing client’s functioning.

References:

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

Kovacs, M. & Lopez-Duran, N. (2012).  Contextual emotion regulation therapy: A developmentally-based intervention for pediatric depression.  Child and adolescent psychiatric clinics of North America, 21(2), 327.