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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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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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Neurological Foundations of Sensory Integration

Current neurological research guides therapist’s clinical reasoning for using sensory integration intervention. Recent research proposes that sensory-motor activities help typical youngsters develop internal models of their body and voluntary movements. For example through repeated touch and movement of their thumb as well as learning to ride a bicycle, children develop internal models. With repeated practice these internal models become integrated neurological representations allowing automatic feed-forward control for functional activities. We become able to automatically locate and use our thumb without looking and can ride a bike on a flat road without concentrating on the integrated arm, leg, and balance reactions involved.

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Sensory integration challenges appear related to dysfunctional interactions between the neocortex, basal ganglia and cerebellum. These dysfunctional neurological connections cause many children with sensory integration or developmental challenges to experience sensory over-sensitivity, under-sensitivity, body image, and movement planning challenges. For example, individuals with Autism Spectrum disorders and other developmental challenges appear to show significant differences from typical children in representations by the somatosensory cortex of their thumb that may reflect disrupted internal models (Coskun et al. 2009).

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Sensory integration intervention appears to promote development of internal models of body image and movement through active exploration that provides naturalistic pressure, touch, movement, visual, and auditory sensory input at an optimal level of challenge.  Sensory integration intervention involves clinical reasoning based on experience and neurological research in gradually guiding active movements involving pressure, touch, movement, visual and auditory sensory input to improve functional skills.  An understanding of this current neurological research regarding development of internal models can be useful to therapists for clinical reasoning during sensory integration intervention.

References:

Koziol, L. F., Budding, D. E., & Chidekel, D. (2011). Sensory integration, sensory processing, and sensory modulation disorders: Putative functional neuroanatomic underpinnings. Cerebellum, 10, 770-792.

http://reseauconceptuel.umontreal.ca/rid=1MWJVHX5D-CRTPQ-1GC/SPD_SI_SP_SMD%20-%20Putative%20Functional%20Neuroanatomic%20Underpinnings.pdf 

Marco, E. J., Hinkley, L. B., Hill, S. S. & Nagarajan, S. S. (2011). Sensory processing in Autism: A review of neurophysiologic findings. Pediatric Research, 69, 48R-54R.

http://www.nature.com/pr/journal/v69/n5-2/full/pr9201193a.html

 

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My Perspective on Sensory Integration

I frequently use Sensory Integration/Sensory Processing Intervention in my work as an occupational therapist with clients who have severe behavioral, sensory processing and developmental challenges. I get criticism both by professionals who question the validity of sensory processing intervention and those who dislike my integrating it with other treatment approaches. It is time to transcend the polarizing debate about the sensory processing model and put it in perspective.

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Like most occupational therapists my treatment grew from my clinical practice and the influence of many gifted teachers. I was introduced to sensory integration intervention in my entry-level occupational therapy training and studied it extensively at the post-graduate level. I spent thousands of dollars on my sensory processing training and although I’m frugal (my son says “a cheap skate”) it was worth every penny.

My sensory processing teachers have had so many students that they wouldn’t even know my name, but they transformed my professional and personal life through their mentoring. Among my most effective sensory processing teachers were the late Ginny Scardinia, Mildred Ross, Winnie Dunn, and Lucy Jane Miller. Each holds a distinct view of sensory processing intervention, is an occupational therapist, master teacher, and base their practice on the teaching of A. Jean Ayres the founder of Sensory Integration.

I first met Mildred Ross as a guest lecturer in my undergraduate occupational therapy class. Using sensory (e.g., touch, movement, smells) strategies she developed individual and group interventions that improve the functioning of individuals with severe psychiatric and developmental challenges. Disagreeing with the “experts” who viewed these clients as “hopelessly regressed psychiatric patients”, Mildred motivated her clients by respecting them as people, caring about them, and beginning at their current developmental level then gradually improving their functional skills. Mildred used a similar approach with occupational therapists, teaching us what an honor it was to help others and motivating us to improve our skills. I remember that the professors and conference leaders who invited Mildred to speak often set an egg timer for one hour before she began, and kept it ringing until she stopped speaking. Although they told me the timer was essential and I usually hate listening to people talk, I always hoped the timer would break so I could listen to her all day.https://www.youtube.com/watch?v=vHuhYaYRIb8

After five years as a school occupational therapist a unique experience introduced me to my next mentor Ginny Scardinia. I was watching my OT student treat a 6-year old girl who had developmental, behavioral, and PTSD challenges using a net swing when the girl suddenly spoke for the first time. I’d been treating that girl for half a year and gotten little response, but after that single half-hour session from my OT student the child was able to consistently speak in school. My OT intern told me that she’d learned sensory integration treatment during her previous affiliation with Ginny Scardinia at the Ayres Clinic. I soon located Ginny, took classes with her, and bugged her to teach me whenever she could from that day on.

Ginny Scardinia was unique in her ability to motivate me to do whatever it took to learn to help children like she could.  I recently learned that Ginny inspired many occupational therapists, and a research study was conducted summarizing her skills as a master mentor  http://www.ncbi.nlm.nih.gov/pubmed/23927618 Over 25 years have past but I still remember that after she first saw me treat she said, “You’re off to a good start, but you need to learn a lot more about neurology and sensory integration and honey, I can teach you”.   I knew that she was right and although I never reached her level as a clinician I am still trying.

Ginny inspired me to take all the sensory integration courses I could and to take motor learning classes at Columbia University T C. The motor learning research taught me that clients have the ability to recover from neurologically based challenges through engaging in developmentally appropriate sensory experiences in their natural environments. My experiences with Ginny and Mildred Ross inspired me to lead a group for children with Autism Spectrum Disorders with the help of occupational therapy students and the children’s parents.

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I met Winnie Dunn and Lucy Jane Miller at an AOTA symposium where they were mentoring new researchers by letting us help with their projects. I remember asking them both why they were developing assessments when new treatments were needed, and they told me that until we learned to measure sensory integration interventions we couldn’t improve and validate our treatments. Winnie Dunn developed the Sensory Profile, a reliable and valid measure of sensory processing abilities www.sensoryprofile.com Dr. Dunn also went on to develop an intervention model that used the sensory profile to coach clients on adapting their sensory modulation styles so they could function more effectively. http://events.jeena.org/media/blog_media/2011/05/13/Sensory_Integration.pdf  While I still do direct and group interventions I always include consultation to the client, family, and teachers regarding how their sensory styles impact their interactions and functioning.

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By taking the Sensory Profile I found I had significant Low Registration and Sensory Sensitivity, at a level where only 2 out of 100 adults my age score. Being low registration influences me to often miss sensory input that others notice. Because I am also sensory sensitive I also frequently get overwhelmed by sensory input I do notice and take a long time to accommodate to touch (e.g., I’m bothered by neck ties, rings and watches).

I’ve learned to stomp my feet and look people in the eye when they are telling me something important, and to take an hour walk when I’m feeling overwhelmed so I don’t yell at anyone. I still can’t wear a tie when I speak but can tolerate wearing shoes rather than sneakers. Knowing my sensory profile helps me accommodate my behavior to the needs of my clients. I tend to talk loudly and quickly, but consciously speak softer and slower when working with clients who have sensory sensitivity and attention deficit hyperactive disorder.

As a new researcher who was a member of Lucy Jane Miller’s team I learned to be a better observer. Although she is arguably one of the most influential leaders in sensory processing intervention (helping to create the term) what inspired me most about her was her honesty. I was putting off getting my Ph.D. because I felt I wasn’t smart enough, but was inspired when Dr. Miller asked me for help changing her flat tire. I figured if someone that smart couldn’t change a tire I could try to get my Ph.D. even though I didn’t feel smart enough.

Dr. Miller has evolved from developing assessment tools to supporting sensory processing intervention research through the Sensory Processing Disorder Network www.spdnetwork.org Her organization presents workshops on sensory processing basic and clinical research. I refer parents and clinicians to her organization because it is both factual and parent friendly.

My clinical experiences have shown me that sensory processing intervention helps clients with severe sensory processing, behavioral and developmental challenges to improve their functional skills. I have discovered the value of sensory processing intervention through individual, group, client/family education, and environmental consultation treatment. My perspective on sensory processing and professional vision wouldn’t have been possible with out my teachers and mentors. To paraphrase Isaac Newton, “If my professional vision has expanded it is because I stand tall on the shoulders of giants”.

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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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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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Behavioral & Sensory Strategies for Young Students

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Integrated sensory processing and behavioral strategies improve the behavior of pre-school and kindergarten students. Combining Positive Behavioral Support and sensory processing adaptive equipment and techniques can help regular and special education students behave better, pay attention, and learn. A helpful initial resource for pre-school and kindergarten teachers is www.pbisworld.com which suggests behavioral strategies and classroom adaptations.

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The PBIS World website helps pre-school and kindergarten teachers identify the most problematic student behaviors. PBIS World then provides a menu of appropriate Tier 1 regular classroom, Tier 2 small group, and Tier 3 individual interventions to choose from for improving behavior. Free data tracking forms are also provided for monitoring the effectiveness of the selected behavioral interventions.

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Special education teachers as well as occupational, speech-language, or mental health therapists can assist teachers in identifying the best Tier 1 interventions for a specific student, and can assist the teacher by providing Tier 2 or Tier 3 interventions within and outside the classroom. It is important for team members to provide consistency between Tier 1, 2, and 3 interventions so students are not confused by varied rules and procedures.  Tier 1 Preschool and Kindergarten classroom interventions combining sensory processing and positive behavioral support are suggested using the FAB Strategies Form.

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While some special education faculty, behaviorists, pediatricians, and occupational therapists object to combining behavioral and sensory strategies it makes sense to combine these clinically proven interventions before using medications.

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FAB Pressure Touch Strategies

The FAB Pressure Touch Strategies help reduce anxiety, increase communication, and improve behavior with children who have self-control, developmental, and sensory processing challenges. FAB Pressure Touch was developed by adapting and synthesizing evidence-based Massage Techniques, QST, Knickerbocker Sensory Integration strategies, Trager Body Work, and NDT touch strategies to meet the needs of children with developmental, behavioral, and/or early trauma history challenges. However, distinct from the Wilbarger Protocol, massage, and prescribed body work sensory stimulation strategies FAB Pressure Touch Strategies are an individualized goal-directed approach that is a component of the total FAB Strategies program. Strategies that the therapist finds helpful should be taught to interested parents, teachers, and other team members but no minimal amount of intervention is required for results.

Individualized pressure touch and weight bearing activities can reduce anxiety and promote social development in children with Pervasive Developmental Disorder, other developmental disabilities, and behavioral problems. Because anxiety can increase children’s behavior problems, pressure touch and weight bearing are used in FAB Pressure Touch Strategies to significantly reduce anxiety in children with developmental disabilities. Behavioral improvement from pressure touch and weight bearing activities appears related to the activation of proprioceptive receptors that can be independently obtained through resistance exercises. If implementation of the FAB Pressure Touch Strategies improves behavior, children are also taught and reinforced for independently engaging in independent pressure touch and resistance exercises.

FAB Pressure Touch strategies include the: Head Crown, Shoulder squeeze, Spine roll, Back protocol tap, Back protocol press, touch on the back, as well as touch and joint compression through the arms, legs, and feet. The FAB Pressure Touch Strategies form can be attached to the FAB Strategies form to provide more detailed touch strategies. In my FAB Strategies workshops for therapists, goal-directed development and implementation of FAB Pressure Touch Strategies is learned as a component of FAB Strategies. An example of me providing intervention utilizing FAB Pressure Touch Strategies with a preschooler who has Asperger’s Syndrome and behavioral challenges is provided at http://www.youtube.com/watch?v=W8fMdJ6l0AM&feature=youtu.be

References
Beider, S., & Moyer, C. (2007). Randomized controlled trials of pediatric massage: A review. Evidence-based Complementary and Alternative Medicine, 4(1), 23-34.
Field, T., Henandez-Reif, M., Diego, M., Schanberg, S., Kuhn, C. (2005). Cortisol decreases and serotonin and dopamine increase following massage therapy. Intern. J. Neuroscience, 115, 1397-1413.
Kaufaman, L.B., & Schilling, D.L. (2007). Implementation of a strength training program for a 5-year-old child with poor body awareness and developmental coordination disorder. Physical Therapy, 87, 455-467.
Silva, L.M. Schalock, M., Gabrielsen, C. (2011). Early intervention for Autism with a parent-delivered qigong massage program: A randomized controlled trial. American Journal of Occupational Therapy, 65(5), 550-559.