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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.

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FAB Strategies Mindfulness Movement Activities

I wanted to share this video of my FAB Strategies Mindfulness Movement activities to improve student’s behavior  https://www.facebook.com/educationresourcesinc/videos/943257499082558/ It was recorded by ERI at their Therapy in the Schools Conference.  Mindfulness movement activities are simple to do and can improve attention as well as enhance behavior by reducing student’s anxiety and giving them a break from seated work.

Mindfulness movement activities help all students yet are especially helpful for students with developmental disabilities, anxiety, sensory processing challenges, Post Traumatic Stress Disorder, ADHD, and/or other behavioral challenges.  Brief five minute mindfulness movement activities can help students attend better and promote the processing of academic learning when done between academic subjects (e.g., after math before proceeding to language arts).  Mindfulness movement activities can also be done in conjunction with teaching Positive Behavioral Support Interventions and used as a pre-correction before challenging school activities (e.g., lunch, playground, assemblies, and transitions).

In this video I demonstrate Touching the head-shoulders-stomach for sensory body awareness, Belly breathing, Hand opening and stretching to prevent hand cramping from writing (while breathing in) followed by thumb fisting as a mudra for relaxation (while breathing out)

MindfulClk1MindfulClk2

Bird breathing, and Mindful Clock Sitting (righting reactions moving forward-back and laterally).

Mindful clock standing activities can also be used, particularly to help students with sensory irritability gain basic body awareness of the anterior-posterior portions of their body through forward-back balancing movements  

MindfulClk3MindfulClk4

as well as sensory awareness and stability of the bottom (feet) and top (head) of their body through squatting then moving on their toes.

SquatToes

I hope more early childhood and special education teachers as well as occupational, physical, speech/language and mental health therapists will begin using basic sensory mindfulness movement activities with their students.  Mindfulness movement activities offer a great opportunity for teachers and therapists to integrate and co-teach the academic and developmental curriculum areas.  As we continue to integrate the regular and special education curriculums, mindfulness movement activities can benefit students while promoting transdisciplinary interactions between teachers and therapists.

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The Importance of Parents

As an occupational therapist working with children and adolescents who have special needs, I am repeatedly impressed by the amazing love and perseverance of their parents.  Supporting and encouraging parents is the most important job of doctors and therapists who are trying to help children and adolescents.  I repeatedly recall my doctoral dissertation on parental perceptions of feeding their young children who had special challenges.

ParChildIntFeeding Pagano Dissertation2000

My study found that half of the parents who had young children with developmental and feeding problems had problematic levels of parental stress.  I further discovered that feeding satisfaction was inversely related to parental stress, with parents who were most satisfied with their feeding experience reporting the least parental stress.  When rating the influence of occupational and speech therapy intervention on their feeding experience 42% reported a positive effect, 23% both a positive and negative effect, and 11% a negative or no effect.

In my current work with adolescents who have psychiatric illness I continue to see the great healing effects of supportive parents.  It is extremely important for therapists and physicians to support these parents through their trials, and help them understand the importance of taking care of themselves.  Parents reported that the most effective component of therapy in reducing parental stress was the experience that the therapist cared about them and their child.  If I do nothing else as a therapist, I hope to always convey to youngsters and their parents how truly valuable and important they are.

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Sensory Integration Needs to Evolve

Following its initial development by A. J. Ayres, Sensory Integration Intervention has been slowly evolving.   As a result of this slow evolution, two major problems threaten the sensory integration frame of reference. First is the problematic discrediting of sensory integration research by some behaviorists and pediatricians who favor interventions that are too rigid or medication based to optimally help children.  Second is intervention borrowing sensory integration terminology with out adequate expertise in carrying out the strategies.  Increasing use of “brushing, sensory diets, sensory equipment, and comfort rooms” developed and used by teachers and mental health therapists with out adequate guidance from therapists trained in sensory integration significantly dilute the effectiveness of sensory integration intervention.

Luckily, many well trained therapists continue the evolution of sensory integration intervention.  While these excellent contributions are too vast to cover fully, I want to review three major areas of evolution in sensory integration intervention that serve as a foundation for further expansion.  Related to each evolution I will mention and provide links to clinicians who have built on sensory integration in a way that has been most helpful to me in my intervention as an occupational therapist working with children and adolescents who have behavioral, psychiatric, early trauma, Autism Spectrum Disorders, and other developmental challenges.

The first evolution contributes sound research, theory, and standardized sensory integration terminology to clinical sensory integration intervention.  This evolution is led by Lucy Jane Miller and her colleagues at the Sensory Processing Disorder SPD Network www.spdnetwork.org  While the therapists significantly contributing to the SPD Network are too numerous to mention fully, I want to describe two that greatly contribute to my practice in child and adolescent psychiatry.  Diana Henry www.ateachabout.com offers many helpful clinical intervention strategies.  The late Jane Koomar, Teresa May-Benson and her associates at OTA Watertown www.otawatertown.com and the Spiral Foundation conduct research and teach clinical sensory integration strategies that enhance attachment and the development of children with early trauma challenges.

The second evolution is the brief valid assessment of sensory modulation problems and their treatment through adaptive equipment and techniques.  Winnie Dunn has led this evolution through her research and development of the Sensory Profile and sensory integration based consultation strategies.  Others that have greatly helped my practice through environmental adaptations include Tina Champagne www.ot-innovations.com whose work with sensory coping rooms and adaptive equipment has helped psychiatric hospitals significantly reduce the use of restraint, replacing it with sensory coping rooms and equipment that empowers clients to learn effective coping strategies.  The adaptive sensory strategies developed through the Alert Program by Sherry Shellenberger and Mary Sue Williams www.alertprogram.com have also helped empower children with behavioral challenges to actively learn coping strategies.  Mention also needs to be made of Patricia & Julia Wilbarger’s  development of the sensory diet www.avanti-ed.com  Problems with misuse of the sensory diet by untrained individuals while significant are contrary to how the Wilbarger’s instructed it be used.

The third evolution is the development of touch pressure strategies as an individualized component of Ayres’ Sensory Integration that was initially expanded on by Knickerbocker.  The Wilbarger Protocol (brushing) is brilliant despite problems resulting from its misuse that are contrary with how it was taught by the Wilbargers.  Two other helpful contributions to this evolution are research efficacy of touch pressure through massage from Tiffany Field http://www6.miami.edu/touch-research and Qigong Sensory Treatment (QST) touch pressure based on Tui Na massage.  QST is developed and research validated by Dr. Silva www.qsti.org

QST was found through repeated research to significantly improve behavior and sensory processing in preschoolers with Pervasive Developmental Disorders.  QST research and my clinical experiences suggest the use of QST touch pressure offers great promise as a touch pressure strategy done as a component of Sensory Integration Intervention, particularly for youngsters with Autism Spectrum Disorders and/or an early trauma history.  Research suggests that young children with Autism Spectrum Disorders who are hyper-responsive to touch benefit from sensory processing intervention, while both hyper and hypo-responsive preschoolers with Autism Spectrum Disorders show significantly improved behavior and sensory processing skills following firm pressure touch.  I adapted the work of Knickerbocker, Tiffany Field, and QST to develop FAB Pressure Touch Strategies.   A major difference of FAB Pressure Touch Strategies is that therapists individualize it to reach the child’s functional goals as one component of comprehensive intervention.

The three evolutions of clinical, environmental adaptation, and pressure touch strategies in sensory integration provide a solid foundation for the development of Sensory Integration Intervention, and it is important to stay updated on this clinical and research work. Although proponents of the three evolutions conflict at times, these disagreements are insignificant given the contribution that all these intervention methods offer in conjunction with one another.  Sensory integration is now ready to further evolve into a solid research based frame of reference that is a specialized component of occupational, physical, and speech therapy practice.  Critics of sensory integration have used their objections to this frame of reference to advocate against children receiving occupational therapy services.  Sensory integration intervention is not all of occupational therapy, but is an important frame of reference for the profession.

My development of FAB Strategies offers an example of ways therapists can knowledgeably include sensory integration intervention as one goal directed component of a comprehensive intervention strategy for children and adolescents with behavioral, developmental, and sensory processing challengesFAB Functionally Alert Behavior STRATEGIES While a written format of strategies is described, interventions including the use of touch pressure strategies are individualized by trained therapists to attain their client’s goals.  In FAB Strategies the goal is used to guide development of intervention composed of environmental adaptations, sensory modulation, positive behavioral support, and physical self-regulation strategies.  I urge other occupational therapists to continue the evolution led by Ayres and her initial followers to further help and guide their clients.

References:

Ayres, A. J. (2005). Sensory integration and the child: 25th Anniversary Edition.  Los  Angeles, CA: Western Psychological Services.

Higbee, T.S., Chang, S., Endicott, K. (2005).  Noncontingent access to preferred sensory stimuli as a treatment for automatically reinforced stereotypy.  Behavioral Interventions, 20, 177-184.

Kimball, J. G., Lynch, K. M., Stewart, K. C., Williams, N. E., Thomas, M. A. & Atwood, K. D. (2007).  Using salivary cortisol to measure the effects of a Wilbarger protocol-based procedure on sympathetic arousal: A pilot study.  American Journal of Occupational Therapy, 61(4), 406-413.

McClafferty, H., Sahler, O. J., Wiley, S. E. (2012).  Sensory Integration therapies for children with developmental and behavioral disorders.  Pediatrics, 129(6), 1186-1189.

Schaaf, R.C., & Miller, L.J. (2005).  Occupational therapy using a sensory integrative approach for children with developmental disabilities.  Mental Retardation and Developmental Disabilities Research Reviews, 11, 143-148.

Silva, L. M., Schalock, M. (2013).Prevalence and significance of abnormal tactile responses in young children with Autism.  North American Journal of Medicine and Science, 6(3), 121-127.

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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.

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Pediatricians on Sensory Integration for Developmental and Behavioral Disorders

As a pediatric occupational therapist for 30 years, reading the American Academy of Pediatrics policy statement on sensory integration therapies for children with developmental and behavioral disorders (American Academy of Pediatrics, 2012) impacted me deeply.  My reaction is bests summarized by the movie title The Good, the Bad, and the Ugly. 

The Good is the best practice directive for implementing sensory integration interventions strategies (also called sensory processing, sensory-motor, and sensory strategies) for developmental and behavioral disorders.  I agree with the policy that best practice is the use of sensory integration intervention to achieve sensory related functional goals as one component of a comprehensive treatment strategy. I also agree with the pediatrician statement that in certain specific situations behavioral strategies can be more affective than sensory integration for children with severe Autism who do not respond to people.  It is helpful to be reminded of these best practice guidelines.

The Bad of the pediatrician’s policy are several deceptive omissions that may harm children and confuse parents.  First, while the policy mentions that sensory integration is used by occupational therapists, they do not mention that it is one of several approaches that occupational therapists comprehensively use with children who have developmental and behavioral challenges.  My occupational therapy interventions for children with developmental and behavioral challenges often includes sensory integration in purposeful play activities but equally utilizes the behavioral, cognitive behavioral, mindfulness, massage, and developmental frames of reference. Second, the policy statement omits that OT uses sensory integration interventions because there is evidence they provide effective activities (Smith et al., 2005) and environmental modifications (Dunn et al., 2012).  Sensory activities can frequently initially be the only intrinsically motivating interactions with children who have developmental and behavioral challenges (Parham et al., 2011; Pfeiffer et al., 2011), and can be clinically effective in reducing the need for or amounts of medications with potential side effects prescribed to manage behaviors.  

 Given the recent seated academic emphasis beginning in pre-school, sensory strategies provide a needed active multiple intelligence approach to learning that involves bodily-kinesthetic and visual-spatial experiences enabling learning in students with developmental and behavioral challenges (Brand, 2006).  In my work over the past 30 years treating children with severe developmental and behavioral challenges I’ve found sensory strategies are an important frame of reference that integrates extremely well with the behavioral (Pivotal Response Training) and developmental models.  I  obtained a Master’s Degree in Special Education and a Ph.D. in Marriage & Family Studies but chose not to pursue certification as a special education teacher or Marriage & Family Therapist.  While I team extensively with and greatly respect Special Education teachers and Marriage & Family Therapists, I stayed only an OT because I‘ve found great value in occupational therapy including use of a sensory integration intervention model.

The ugly is the confusion the omissions mentioned above in the American Academy of Pediatrics policy statement on sensory integration therapies for children with developmental and behavioral disorders bring to parents and medical doctors and the lack of respect they convey to the occupational therapy profession.  Which leads me to the reason that while I hate conflict with doctors, I wrote this response to the American Academy of Pediatrics policy statement on sensory integration therapies for children with developmental and behavioral disorders

Many years ago I worked with a child who had severe developmental and behavioral problems and was being expelled from preschool. His mother had me work with the preschool using a combined sensory integration and behavioral frame of reference.  The teachers implemented my consultation suggestions and were pleased with his behavioral improvement, when suddenly the mother stopped the OT at the urging of her pediatrician who said “I hate the OT sensory stuff”.   The child’s behavior deteriorated and he was eventually heavily medicated for his behavior so he would not be expelled.

I work extensively with pediatricians (mostly developmental pediatricians) and continue to respect pediatricians. While I appreciate their best practice reminders I worry that the American Academy of Pediatrics policy statement on sensory integration therapies for children with developmental and behavioral disorders will prejudice pediatricians against occupational therapists, and hurt pediatrician’s relationships with parents who appreciate what we do to help their children.

References:

American Academy of Pediatrics. (2012).  Policy Statement:  Sensory Integration therapies for children with developmental and behavioral disorders.  Pediatrics, 129; 1186-1189.   

Brand, S.T. (2006).  Facilitating emergent literacy skills: A literature-based, multiple intelligence approach.  Journal of Research in Childhood Education, 21(2), 133-148. 

Dunn, W., Cox, J., Foster, L., Mische-Lawson, L. & Tanquary, J. (2012).  Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: A pretest-posttest repeated-measure design.  American Journal of Occupational Therapy, 66, 520-528. 

Smith, S.A., Press, B., Koenig, K.P., Kinnealey, M. (2005).  Effects of sensory integration intervention on self-stimulating and self-injurious behaviours.  American Journal of Occupational Therapy, 59, 418-425.