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3 Popular Neurologically Based Treatments

Occupational, Physical and Speech/Language therapists often include popular neurologically based approaches in their interventions for students with behavioral and developmental challenges. Brain Gym, Bal-A-Vis-X and Sensory Integration Intervention are three popular neurologically based approaches to promote neurological development for improved functional skills. While many clinicians, parents and families report that these interventions are clinically useful in achieving functional goals, they are criticized for lacking adequate research support.

Given the current emphasis on using evidence-based strategies it is important that therapists using these approaches apply current research to justify their use of these popular neurologically based approaches. A good way to show the efficacy of using these approaches is through goal attainment scaling, which can validate the effectiveness of strategies in achieving the student’s education related goals SIforASDGoal It is also important to consider research related to the components of these methods.

In addition to gathering baseline data and assessing treatment effectiveness through goal attainment scaling, it is important to understand the evidence-based components of these popular neurologically based approaches that can contribute to their effectiveness. First is their emphasis on child motivation through allowing students to choose the treatment activities. Second is their use of cardiovascular and strengthening exercises, and third their implementation of pressure touch strategies.

First, these popular neurologically based approaches facilitate student motivation by involving students in selecting fun and engaging activities. While sometimes criticized for being popular “only because students enjoy them”, the importance of activities that motivate children cannot be over-emphasized.   PRT (Pivotal Response Treatment) is a behavioral intervention that emphasizes the importance of student motivation. PRT was found to be highly effective in improving communication and behavior skills in children with Autism Spectrum Disorder.   The emphasis of PRT on facilitating motivation is a major reason for this success. Client motivation is facilitated in PRT by emphasizing child choice in activity selection and reinforcing attempts. In addition to its developmental efficacy in improving communication and behavior, recent research suggests PRT promotes more normalized neurological functioning.

The second component of these popular neurologically based approaches is their use of aerobic and strengthening exercises. Participation in aerobic exercise has been repeatedly associated in research with improved attention, learning and neurological development. Regular moderate exercise for 30 minutes daily appears to promote neurological development of the hippocampus for learning in both typical students (Cramer et al., 2011) and students with neurological challenges (Ploughman, 2008).

The third evidence based component of these popular neurologically based approaches is their use of pressure touch through massage and brushing. Massage has consistently been found through repeated research to decrease pediatric stress, which can help reduce behavior and learning challenges. More specifically, Asian massage strategies were found to improve behavior and communication skills in preschoolers with Autism Spectrum Disorders (Piravij et al., 2009; Silva & Schalock, 2013) www.qsti.org

While caution should be used in applying these popular neurologically based approaches to school therapy interventions, these techniques can be useful for attaining school goals. It is important to gather baseline data and use progress toward school related goals in judging the effectiveness of these strategies. It is also important to consider research supporting the specific strategies used, as well their research supported components of student motivation, aerobic exercise, strengthening exercise, and touch pressure   Reduce Problematic Reflexes:Hab

References:

Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65(1), 76-85.

Piravej, K., Tangtrongchitr, P., Parichawan, C., Paothong, L., Sukprasong, S. (2009). Effects of Thai traditional massage on Autistic children’s behavior. Journal of Alternative and Complementary Medicine, 15(12), 1355-1361.

Ploughman, M. (2008). Exercise is brain food: the effects of physical activity on cognitive function. Developmental Neurorehabilitation, 11 (3), 236-240.

Silva, L., & Schalock, M. (2013). Treatment of Tactile Impairment in Young Children with Autism: Results with Qigong Massage. International Journal of Therapeutic Massage & Bodywork, 6(4), 12-20.

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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.

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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

 

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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,

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a sensory coping room

 

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adaptive equipment

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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

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Self-Injury is a Bad Habit

A lot of occupational therapy referrals at my psychiatric hospital are for adolescents and young adults with mental health, trauma history, developmental, and/or sensory processing challenges who repeatedly injure themselves. Individuals with trauma history and developmental challenges have greater incidences of neurological, sensory processing, and self-injury challenges. Clients with these complex difficulties benefit from integrated intervention addressing their specific triggers, coping strategies, mindfulness activities, and sensory input needs to reduce self-injurious behavior.

Long-standing self-injurious behavior has often become a bad habit. Reducing this “bad habit” can be helped by first recognizing the triggers. Research shows that the brain (Striatum at the center of the subcortical basal ganglia) forms habits by chunking behavior into a single automatic memory package. However, through planning and mindfulness the brain (Neocortex) can interrupt or stop the habit. The habitual aspects of self-injurious behavior can be address by recognizing the triggers, then replacing the bad habit of self-injury with the good habit of coping strategies that include mindfulness and sensory activities.

Recognizing the environmental triggers (e.g., “being told no”) and body triggers (e.g., “crying”) that precede self-injurious behavior empowers clients.  Research shows many adolescents and adults report their motivational triggers for injuring themselves are to: “distract myself from negative thoughts and feelings, feel something when I feel numb, get social attention, and/or get out of unwanted social situations”. An understanding of their early motivational, environmental, and body triggers empowers people who self-injure to discover and use effective coping strategies.

A useful self-assessment I developed for clients with self-injurious behavior is the PaganoFABTriggerCopingForms copyClients choose the three environmental and body triggers that most often precede their self-injurious behavior. Their triggers can serve as early warning signs that they need to use coping strategies. On each of the coping strategies pages the client selects their 3 most effective coping strategies. Their selections remind clients of their most common triggers and effective coping strategies related to self-injury. When introducing the coping forms the therapist demonstrates any unfamiliar mindfulness and sensory coping strategies. behindthelabel.co.uk

It is helpful to review the trigger and coping strategies the client determines are most relevant to their self-injurious behaviors, building on their most effective coping strategies. The most helpful new coping strategies to try are usually physical activities, rather than strategies such as talking to a friend. Commonly effective new physical coping strategies for reducing self-injury include hobbies (e.g., art), mindfulness movement (e.g., opening their hand while breathing in, then closing their hands by breathing out), and sensory strategies (e.g., focusing on the bottom of their feet or palms of their hands).

FAB Basic Mindfulness Movement

For clients who appear to have sensory processing challenges, it is helpful to have them self-assess using the Sensory Profile http://www.sensoryprofile.com  For example, if a client has significantly different tactile sensitivity and self-cuts, using a vibrating bath brush may be useful as a sensory replacement for habitual self-cutting. It is important to be sure that brushing does not cause skin irritation and that clients never brush over open wounds. To interrupt the self-cutting habit the brush can be located where they most frequently engage in self-injury (such as their bedroom) to facilitate the use of self-brushing as replacing the habit of cutting with a less dysfunctional habit (brushing).

Finally, because self-injury may already be established as a habit, reinforcement is helpful (e.g., being given praise and a vibrating bath brush following two weeks of safe behavior). A helpful tool for clients with sensory modulation difficulties is rating their energy level and planning activities to keep a medium energy level and prevent self-harm using the Energy Modulation Wheel.

FABEnergModWheelTemplateFABEnergyModulationWheel

 

A helpful tool for individuals with sensory and developmental challenges is using a laminated index card that reminds clients of their goal, hero, and coping strategies for preventing self-injurious behavior using a COPING CARD

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Reference: Gaybiel, A. M. & Smith, K. S. (2014). Good habits, bad habits. Scientific American, 310(6), 38-43. Nock, M. K., Prinstein, M. J., Sterba, S. K. (2009). Revealing the form and function of self-injurious thoughts and behaviors: A real-time ecological assessment study among adolescents and young adults. Journal of Abnormal Psychology, 118(4), 816-827. http://dash.harvard.edu/bitstream/handle/1/4134406/Nock_FormFunction.pdf

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Facilitating Adaptive Behavioral Responses

Occupational therapy uses specific child-directed sensory activities to achieve adaptive behavioral responses. To achieve adaptive responses specific support is provided to assure that the behavioral demands are challenging but not too difficult to achieve. Sensory coping strategies and sensory coping areas can be used to obtain the right combination of challenges and supports for adaptive behavioral responses.

 

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While occupational therapy sensory activities are often criticized as being “fun but too frivolous for school”, students must be willing to actively participate in activities in order to learn from them. Discovering students’ interests is crucial for developing activities they will actively engage in to improve their adaptive behavioral responses. Once students are willingly engaging in activities the tasks can be gradually modified to promote their goal-directed adaptive behavioral responses (e.g., frustration tolerance, attention, seated attention, direction following, keeping safe hands).   An individualized program of sensory copying strategies that promote self-control can be developed using the FAB STRATEGIES Form COLOR

 

 

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Once therapists and teachers find engaging activities it is important to continuously modify the tasks so they are at a level that is not too hard or easy for the student. Students with behavioral, developmental, trauma history, and/or sensory processing challenges frequently show poor motivation and school behavioral problems because their developmental level and interests do not match the classroom curriculum. A preschooler at a six month developmental level obviously needs modifications in the typical preschool curriculum developed for four to five year olds. A more complicated challenge is the student with behavioral, developmental, trauma history, and/or sensory processing challenges who functions at significantly different levels in various developmental areas, requiring diverse challenges in different developmental areas (e.g., two year old social and six year old reading skills).

Because of delayed behavioral skills many children benefit from a sensory coping area they can use when they begin reacting negatively to environmental triggers (e.g., “being told what to do, being told no”) or showing body triggers (e.g., “acting hyper, hand fisting”).   Sensory coping areas can vary from a special desk in the back of the class where the student can take a break to a designated room where the child can go with a teacher to do their self-calming activities.  It is helpful to record the activities used and affects of the sensory coping room using the FAB Sensory Coping Area Log Occupational therapy directed sensory coping strategies and sensory coping areas are helpful ways of promoting child-directed sensory activities that promote students’ adaptive behavioral responses.

Reference:

Stackhouse, T. M. (2014). The adaptive response to the just-right challenge: Essential components of sensory integration intervention. Sensory Integration Special Interest Section Quarterly, 37(2).  

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Improving Sensory Integration, Emotion Regulation, & Learning

Occupational, Speech/Language, and mental health therapists can work in conjunction with teachers to integrate sensory integration and mindfulness activities with positive behavioral support preventive interventions. Sensory Integration can help enhance emotion regulation and behavior. Synthesizing sensory integration with positive behavioral support strategies comprehensively addresses the development of sensory seeking, novelty seeking, and impulsive behaviors associated with conduct disorder behaviors. The synthesis of sensory integration and behavioral strategies has been extremely affective for my students with behavioral, psychiatric, sensory processing, and learning challenges.

Occupational therapists using sensory integration benefit from synthesizing the Sensory Integration and Positive Behavioral Support frames of reference to improve student’s occupational performance at home and school. It is important to work with teachers, families, as well as Speech/language and mental health therapists in schools to comprehensively address the learning needs of children with behavioral, sensory processing, and learning challenges. While schools tend to delegate the students needs (e.g., cognitive, psychological, physical, social) to diverse professionals they come to school as whole unique individuals.

The DECA and PATHS positive behavioral support programs work well in conjunction with occupational, speech/language, and mental health therapy intervention. The DECA assessment address the resiliency skills of attachment, initiative, and self-control while also screening for internalizing and externalizing behavior concerns. If a child has difficulties in self-control (e.g., never listen to or respect others) this goal area can be comprehensively addressed to improve learning. Examples of sensory integration classroom modifications that help address this goal are a sensory quiet area for use when becoming upset, a study carol to limit distractions, and a wall pushup bulletin board.

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Infusing mindfulness movement activities into the PATHS positive behavioral support program can help hyper-reactive students pay attention.

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MindfulClk3MindfulClk4

The PATHS program includes lessons regarding understanding feelings, respecting others, and providing reinforcement for respecting others. Too often school staff members are so busy dealing with problem behaviors that we forget to reinforce the behaviors we want.  Collaboration between teachers and occupational, speech/language and mental health therapists in the schools can enhance positive behavioral support programs and student behavior.

References:

Fishbein, D. & Tarter, R. (2009). Infusing neuroscience into the study and prevention of drug misuse and co-occurring aggressive behavior. Substance Use & Misuse, 44,1204-1235.

Greenberg, M.T. (2006). Promoting resilience in children and youth: Preventive interventions and their interface with neuroscience. Ann. N.Y. Acad. Sci., 1094; 139-150.

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Classroom Sensory Integration Equipment

This post describes the FAB Procedure for using sensory integration informed adaptive equipment and techniques in the classroom to improve behavior and learning.  Strategies are individualized for regular and special education students with behavioral, developmental, and sensory processing challenges.  The procedure is described sequentially, followed by an example provided in italics.

  1. Choose one goal involving adaptive equipment or techniques to improve the student’s behavior, learning and future.  Collect base line data regarding the frequency of this behavior. 

Sam is an intelligent kindergartener who can not stay seated more than five minutes in December.  He needs to stay seated for fifteen minutes next year to succeed in first grade.  His goal is: Sam will maintain seated attention for fifteen consecutive minutes. 

2. Consider the student’s need for sensory input using the Sensory Profile, an activity analysis, and the FAB Trigger & Coping Forms.

Sam’s scores on the Short Sensory Profile showed definite difference in Underresponsive/Seeks Sensation and Tactile Sensitivity.  Sam’s most effective coping strategies on the FAB Trigger & Coping Forms included theraband exercises.  His activity analysis found Sam kicked his legs and wrapped his feet around the desk while seated.   

  1. Select adaptive equipment or techniques to help achieve the student’s goal.

ChairlegsTherabandTheraband chairarm rotation

Sam was found to enjoy and sit longer given theraband (an exercise band) tied around the legs of his chair.  This allowed Sam to move and provide himself with deep pressure input through his legs while seated.

     4. After getting parent permission, introduce adaptive equipment as well as the rules and expectations for continued use.

Parental permission was obtained and the adaptation was introduced. Sam was told he could use the theraband on his chair if it helped him pay attention while seated as long as he did not untie it or disturb others.  

     5. Reward and monitor progress toward the student’s goal, and modify the plan as needed.

Sam was rewarded with a sticker he could cash in for a prize whenever he sat and paid attention for over fifteen minutes.  Progress was recorded showing increased seated attention, so use of  the adaptation was continued.

The FAB procedure guides the use of sensory processing adaptive equipment and techniques in school, assuring that any adaptations used assist with goal achievement.

References:

Dunn, W. (2007).  Supporting children to participate successfully in everyday life by using sensory processing knowledge.  Infants & Young Children, 20(2), 84-101.  www.sensoryprofile.com

Stahmer, A., Suhrheinrich, J., Reed, S., Schreibman, L., Bolduc, C. (2011).  Classroom Pivotal Response Teaching for children with Autism.  New York, NY: Guilford Press.

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Sensory Strategies Improve Learning

Classroom environmental adaptations can enhance behavior and learning.  However, effectively using adaptive equipment and techniques involves more than handing out adaptive equipment.  To improve learning and avoid causing additional classroom management problems it is important to specifically consider how sensory strategies can improve an individual student’s behavior for enhanced learning.SensoryRoom

Sensory Integration and Positive Behavioral Support strategies can be combined to develop effective coping strategies.  The first step is to choose one specific goal involving adaptive equipment and techniques that improves the student’s behavior, learning and future.  Select a goal that is most important for improving behavior and is attainable within six months.  The goal is worded positively and is incompatible with the inappropriate behavior that interferes with learning.

For students who have multiple needs research suggests prioritizing goals that can reduce future school aggression such as: safe hands (no hitting), polite voice (no yelling), as well as increased attention and seated attention.  After the goal is chosen collect base line data on how often the desired behavior occurs.  Use the base line data to refine the goal before choosing adaptive equipment.

Next consideration is given to the student’s specific need for sensory input.  The Sensory Profile and an activity analysis are useful tools for finding effective adaptive equipment and techniques.  The Sensory Profile is a reliable, valid assessment that identifies significantly different sensory behaviors.  If a student’s scores show a definite difference in Sensory Seeking/Low Registration (e.g. a significant difference found in only 2 out of 100 students their age) this provides clues about the sensory input needed.  Sensory processing disorders are complicated, and each student’s individual sensory needs must be addressed.

Next an activity analysis is done to explore the sensory input the student may be getting through the inappropriate behavior, sensory strategies that have helped him in the past, and his favorite activities.  Begin the activity analysis by considering the sensory input the student receives from the problematic behavior (e.g. wiggling his fingers in front of his eyes so frequently that it interferes with learning).  Determine if he is doing this for attention, sensory input, or both.  If he is doing the behavior for sensory input, go where no one will see you and imitate the student’s behavior to determine the sensory input it provides (e.g., finger movement, visual stimulation, or both).

Further assessment for developing coping strategies can be gathered using the FABTriggerCopingForms filled out by the student or parent, who choose on each page the three most frequent situations and body reactions that precede the inappropriate behavior and the most helpful coping strategies for avoiding inappropriate behavior.  This provides greater information regarding the role served by the behavior and possible alternative activities that provide the needed input. INSERT  Choose the adaptive equipment or techniques that will help achieve the student’s goal using information from the SensoryProfile, activity analysis, and FAB Trigger & Coping forms.

 

StudyCarol

Once adaptive equipment or techniques are chosen introduce them in a way that maximizes success.  Given current school inclusion practices many classrooms include students with diverse developmental levels.  It is helpful for teachers and therapists to initially explain to the class that they have different needs and abilities, and will be treated fairly but not equally.  Students will be given different rules, equipment and expectations based on their individual needs.  Adaptive equipment is then tried with individual students “for the day as an experiment that will be continued only if used appropriately to help reach their goal”

ClassRules

Specifying rules for continued use of adaptive equipment or techniques before introducing them avoids potential problems.  Many teachers forbid adaptive strategies because they interfere with classroom management (e.g., forbid gum chewing because gum is stuck on seats; don’t allow fidget toys because students throw or make loud noises with them).  Setting clear limits that adaptive equipment will no longer be used if students break the rules or don’t progress toward their goal make teachers and parents more willing to try them.

It is also important and challenging to be sure parents/guardians approve of adaptive equipment before it is used.  The best way to do this is by discussing it at a parent conference.  When this is not possible write a note describing the goal and reason for the adaptations.  Then ask the parent to sign permission for the goal and specific adaptive equipment to be tried on the bottom of the form.

FAB STRATEGIES FORM

Finally, additional reinforcement with a sticker chart or other reward is given to the student for making progress towards their goal.  By keeping track of goal progress from the base line, it is easy to show that the plan is working or modify it if it is ineffective.  While this process of combining sensory and behavioral strategies is criticized because it does not show whether the plan worked for sensory or behavioral reasons, it affectively improves student 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.  www.sensoryprofile.com

Seifert, K. (2011).  CARE-2 Assessment: Chronic Violent Behavior and Treatment Needs.  Boston, MA: Acanthus Publishing.  www.drkathyseifert.com