0

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.

MatSandwichPropLayondog

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.

PatNatGuardRifleTripLeanPropTactParachute

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.

0

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.

HoldingHeadTx

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.

0

School Occupational Therapy for Developmental Trauma

School occupational therapists emphasis on therapeutic relationships, mental health, sensory processing, attachment, development, purposeful activity and self-regulation offer a unique contribution for improving the behavior of students with developmental trauma disorder. School behavioral problems related to developmental trauma are seen in students who have experienced early chronic abuse. Many students with developmental trauma difficulties have significant sensory modulation, emotion regulation, attachment, self-regulation, sensorimotor, somatic, and developmental challenges.  Working in conjunction with school psychologists, social workers, and guidance counselors, occupational therapists can help improve the mental health and behavior of students who have developmental trauma challenges http://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/Fact-Sheets/OT%20%20School%20Mental%20Health%20Fact%20Sheet%20for%20web%20posting%20102109.pdf http://www.aota.org/-/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Reducing-Restraint-and-Seclusion.pdf

Occupational therapy for improving the behavior of students with developmental trauma can include energy level modulate, sensory processing, deep pressure touch, and mindfulness strategies. The energy level modulate strategy involves increasing students’ awareness of their arousal level and teaching them to modulate dysfunctional high or low energy levels to better participate in school learning tasks. It can be introduced by explaining that “some students who have had difficult experiences early in their life can get into trouble by overreacting when they have really big feelings”. The energy level modulate strategy teaches students to identify whether their current energy level feels “High” (hyper, off the wall, with stiff muscles like raw spaghetti), “Medium” (just right and ready to learn) or “Low” (tired, numb, with loose muscles like over cooked spaghetti).

Visual chart for rating arousal level and if it feels comfortable

Visual chart for rating arousal level and if it feels comfortable

The energy level modulate strategy is extremely useful in school settings for students with sensory modulation difficulties who become aggressive following activities that raise their energy levels extremely high. While many students can use the energy level modulate strategy with teacher encouragement, some students with sensory modulation difficulties and developmental trauma need assistance. For example, a student receiving occupational therapy attended a wild physical education class where the students ran, screamed and threw balls at each other. His classmates behaved appropriately upon returning to class. However, this student who had significant sensory sensitivity and developmental trauma challenges was unable to sit down upon returning to class and threw a chair.

Following this experience the occupational therapist taught the school physical education teachers and mental health therapists the energy level modulate strategy so students could rate their energy levels before returning to class. The teacher or therapist would bring students who rated their energy level as uncomfortably high to a designated staff member (e.g., occupational therapist, speech therapist, principle, resource room teacher) who would help the student do pushups or other individualized sensory coping strategies to lower their energy level before returning to class.

The most effective strategies for normalizing energy levels involve deep pressure through the joints with slow linear movements. Activities such as regular or wall pushups, moving furniture, moving mats, delivering messages or boxes of books throughout the school, or wheelbarrow walking on your hands over a therapy ball can help achieve this.

Wallpushups

Special consideration can be given in the energy level modulate strategy for students with both sensory modulation and developmental trauma challenges who have become use to maintaining a high energy level that interferes with appropriate attention and behavior for school functioning. This difficulty can be indicated by students who describe their energy level as “Hyper and comfortable” and students who actively resist efforts by their teachers and therapists to calm down to a functional energy level where they can pay attention to classroom activities. For students who resist regulating their energy to a functional level it is helpful for the therapist to begin by matching the student’s initial energy level, then support the student during individual sessions to gradually modulate their energy level.  http://www.traumacenter.org/products/pdf_files/Body_Change_Score_W0001.pdf 

Individual OT sessions using sensory processing, deep pressure touch, and sensory mindfulness strategies help students with self-regulation and developmental trauma challenges improve their attention, seated attention, and behavior for participation in school learning tasks.

ComicCopingMindfulClock1ChairlegsTheraband

These interventions emphasize child-focused activities that optimally challenge students to discover activities that will enable them to modulate dysfunctional arousal levels for improved school functioning. Sensory processing interventions promote attachment relationships combining child-directed activities at their optimal level of challenge with an attitude of PACE (playfulness, acceptance, curiosity and empathy). Offered respectfully with choices to decline, firm pressure touch strategies can enhance attachment, relationships, and self-control in students with behavioral and developmental trauma challenges. Attached is a link showing integrated use of behavioral, sensory processing, PACE, and FAB Pressure Touch strategies. While this treatment was done with a preschooler who had Asperger’s syndrome, a similar approach is often also helpful for students with behavioral and developmental trauma challenges https://www.youtube.com/watch?v=W8fMdJ6l0AM

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.

Engel-Yeger, B., Palgy-Levin, D., & Lev-Wiesel, R. (2013). The Sensory Profile of People With Post-Traumatic Stress Symptoms. Occupational Therapy in Mental Health, 29(3), 266-278.

Hanson, J. L., Chung, M. K., Avants, B. B., Shirtcliff, E. A., Gee, J. C., Davidson, R. J., & Pollak, S. D. (2010). Early stress is associated with alterations in the orbitofrontal cortex: a tensor-based morphometry investigation of brain structure and behavioral risk. The Journal of neuroscience30(22), 7466-7472.

http://www.jneurosci.org/content/30/22/7466.long

Hughes, D. A. (2011). Attachment-focused family therapy workbook. New York, NY: W. W. Norton & Co.

Warner, E., Koomar, J., Lary, B., & Cook, A. (2013). Can the body change the score? Application of sensory modulation principles in the treatment of traumatized adolescents in residential settings. Journal of Family Violence, 28(7), 729-738.

0

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.

0

School Sensory Modulation Strategies

Sensory modulation strategies, a component of sensory integration intervention, help improve behavior and reduce the need for harsh discipline in schools. Sensory modulation strategies teach students to be aware of and regulate their arousal levels for appropriate behavior and learning.  Sensory modulation strategies are particularly useful for students with behavioral, mental health, trauma history, developmental, and/or sensory processing challenges.

Sensory modulation strategies help students adjust their arousal level for improved self-control. They learn to notice whether their arousal level is low (they feel numb), medium (just right for learning) or high (too hyper to pay attention) and use coping strategies to adjust their energy level.

EnergyLevBasicAngerMeter

Most students learn best when they’re in a quiet alert state rather than overly relaxed or excited.

VolumeMeter

Maintaining appropriate arousal levels also involves social skills, as different levels of arousal are expected during class and at recess.  Occupational and mental health therapists can team with teachers to use sensory modulation strategies with students who have self-control challenges. Clinical research shows that sensory modulation strategies can improve behavior and reduce the need for restraints and other harsh discipline methods.

http://www.traumacenter.org/products/pdf_files/Can%20the%20Body%20Change%20the%20Score_Sensory%20Modulation_SMART_Adolescent%20Residential%20Trauma%20Treatment_Warner.pdf

Sensory modulation strategies are especially affective for students with severe behavioral, mental health, trauma history, developmental, and/or sensory processing challenges.  Students are taught to identify when they begin experiencing environmental and body triggers to use their most affective sensory coping strategies http://www.sensoryconnectionprogram.com/what_helps_poster_activity.pdf

 

ModReinfDon'tBiteHandPowerCardVisSchedSelfCont

If sensory modulation or behavioral interventions alone are not working, combining both strategies using picture reminders can be helpful.

Busy teachers may sometimes attend to disruptive and ignore appropriate behavior, and reversing this can make a huge difference. For some students, individual sessions with an occupational and/or mental health therapist are used to teach sensory modulation, while others learn sensory modulation strategies by therapists working with the teacher or leading groups. Sensory modulation strategies can include teaching students to do pushups for self calming when they’re hyper or going to a quiet area for a few minutes to calm down so they won’t misbehave and are able to learn. Therapists need to try various strategies with students to find what works best.  Sensory modulation strategies in schools may involve the use of a quiet area in the class room,

SensoryCopingRm

a sensory coping room

 

Therabandfeet

adaptive equipment

ElemSchWalPushOTCopingBoard

or bulletin boards reminding students of class rules  and sensory coping strategies.  Working together therapists and teachers can use sensory modulation strategies to improve their students’ behavior and learning.

Reference:

Chalmers, A., Harrison, S., Mollison, K., Molloy, N., & Gray, K. (2012). Establishing sensory-based approaches in mental health inpatient care: a multidisciplinary approach. Australasian Psychiatry, 20(1), 35-39. www.rompa.com/media/free-resources/establishing_sensory-based_approaches_in_mental_health.pdf

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.

WallpushupsProneTherapyballfar

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.

CopingMindfulClock2

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.

2

Classroom Exercise Improves Transitions and Learning

As greater educational demands are made on students and teachers, often beginning in preschool or kindergarten, it is increasingly important to embed brief exercise strategies into the elementary school curriculum.  Movement activities done before transitions enable students to integrate their learning and behave more appropriately.  Increasing time spent in seated teaching and testing along with the integration of special needs students into regular classrooms makes the inclusion of movement strategies increasingly important.

Transition strategies include signals, music and exercise activities that integrate and improve learning while preparing students for new tasks.  Some children require extra time to process information, especially developmentally immature children and those with developmental challenges. While thought by some administrators to take away from learning, twenty minutes of added daily physical activities embedded into the classroom curriculum significantly improves behavior, attention, fitness as well as math and reading achievement compared to classes given equivalent time to seated learning tasks.

Several FAB Strategies can be implemented in under five minutes in regular classrooms to promote student’s behavior and learning.

ClassExercise

FAB classroom exercise strategies integrate mindfulness, stretching and movement activities Transition Strategies  Students are taught to move vigorously then transition back to academic learning.

MindfulClock2 MindfulClock1

Additional activities can be found for various grade levels at <www.pecentral.org>

References:

Donnelly, J. E. & Lambourne, K. (2011).  Classroom-based physical activity, cognition, and academic achievement.  Preventive Medicine, 52, S36-S42.

Erwin, H., Fedewa, A., & Ahn, S.(2012).  Student academic performance outcomes of a classroom physical activity intervention: A pilot study.  International Electronic Journal of Elementary Education, 4(3), 473-487.