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.

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.

0

Transdisciplinary School Strategies Enhance Inclusion

It is common for early education classes to include undiagnosed special needs students.  While the students often eventually qualify for special education services their teachers need strategies to meet the immediate needs of these students within the regular classroom.  This is important for both the special needs students and the ability of all the other students to learn.  Fortunately, transdisciplinary use of positive behavioral support strategies improve behavior and learning in regular and special education students in a variety of settings.

Teachers are becoming overwhelmed with the demands of increasing academic standards and students with developmental, behavioral, and mental health challenges.  Meanwhile, related services personnel are recognizing the importance of working in conjunction with classroom teachers to best serve students.  There has been much hostile criticism of related services staff by some early childhood faculty and organizations.  Despite this teachers, parents, and students have increasingly recognized the contribution of related services staff including occupational, speech/language, physical, and mental health therapists (social workers, school psychologists, guidance counselors). Teachers and related services staff have particularly found value in teaming together in implementing evidence-based positive behavioral support interventions.

ElemSchWalPush Wallpushups

Teachers and related services staff learn from working together to more effectively educate students using positive behavioral support interventions.  In my over thirty years working as a school occupational therapist with regular and special education students I have learned from teachers and other special services school staff many strategies to improve student learning and behavior.  Particularly using positive behavioral support strategies we have effectively integrated special and regular education students in activities to improve their behavior and learning.  My attached list of Evidence-BasedClassBehaviorStrategies has resulted from this collaboration.

References:

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.

Simonsen, B., Fairbanks, S., Briesch, A., Myers, D., & Sugai, G. (2008).  Evidence-based practices in classroom management: Considerations for research to practice.  Education and Treatment of Children, 31(3), 351-380.

Simonsen, B., Britton, L. & Young, D. (2010).  School-wide positive behavior support in an alternative school setting.  Journal of Positive Behavioral Intervention, 12(3), 180-191.