EFFECTIVELY TREAT BEHAVIOR IN CHILDREN P. 2 · 2018-06-14 · Integrating Behavioral With Sensory...

EFFECTIVELY TREAT BEHAVIOR IN CHILDREN P. 2

© copyright 2018 by John Pagano, Ph.D., OTR/L New additions or changes

John Pagano, Ph.D., OTR www.fabstrategies.org

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Best Clinical Resources P. 6 FabERI Supp fabstrategies.org

•  Autism Visuals visuals.autism.net •  Behavioral Strategies (feeling wheel, Tucker Turtle) <www.challengingbehavior.org> •  Brown, R. P. & Gerbarg, P. L. (2012). The healing power of breath. Boston, MA: Shambhala. www.breath-body-mind.com

•  Committee for Children. (2009). <www.cfchildren.org> Second Step PBS

•  DECA Assessment & PBS <www.devereuxearlychildhood.org>

•  Doidge, N. (2016). The brain’s way of healing: Remarkable discoveries and recoveries from the frontiers of neuroplasticity. New York: Penguin Books.

•  Dunn, W. Sensory Profile <www.sensoryprofile.com>

•  Field, T. Touch Research Institute <www6.miami.edu/touch-research> •  Greenland, S.K. (2010). The Mindful Child. New York, NY: Free Press.<http://susankaisergreenland.com>.

•  Kazdin, A.E. (2008). The Kazdin Method for parenting the defiant child. NY, NY: Mariner Books.

•  Koester, C. (2012) Movement Based Learning. Braingym for special education. <www.movementbasedlearning.com> •  Laugeson, E. A. (2014). The PEERS curriculum. www.semel.ucla.edu/peers •  PATHS PBS Curriculum. www.pathseducation.com •  Positive Behavioral Support Help <www.pbisworld.com> •  Silva et al. (2009). QST program Sensory Massage.<www.qsti.org> •  Schaaf, R. C. & Mailloux, Z. (2015). Clinician's guide for implementing Ayres Sensory

Integration: promoting participation for children with autism. Bethesda, MD: AOTA Press. •  Stahmer & Suhrheinrich, 2011. Classroom Pivotal Response Teaching. NY, NY: Guilford Press. •  Watling, R., Davies, P. L., Koenig, K. P., & Schaaf, R. C. (2011). Occupational therapy practice

guidelines for children and adolescents with challenges in sensory processing and sensory integration. American Occupational Therapy Association.

Behavioral Assessment © Copyright 2017 by John Pagano, Ph.D., OTR/L P. 12

•  Include standardized, norm-referenced, strength-based assessment of Protective Factors: Initiative, Attachment, & Self-Control

•  Screen or assess both internalizing and externalizing behavioral concerns

•  Takes parents and teachers/therapists 5-10 minutes to fill out, rating the same form

•  Infant/Toddler b-3; DECA for 3-5 years; Devereux Behavior Rating Scale School Form (ages 5-12 & 13-17 years)

•  Alternative: Ages & Stages Questionnaires: Social-Emotional (ASQ-SE) 6 mo.-5 years

Revised 4-19-01

Student’s Name____________________________ Date: __________________________________

Behavior: _________________________________ Respondent: ____________________________

QUESTIONS ABOUT BEHAVIORAL FUNCTION (QABF)Rate how often the student demonstrates the behaviors in situations where they might occur. Be sure to rate how ofteneach behavior occurs, not what you think a good answer would be.

X = Doesn’t apply 0 = Never 1 = Rarely 2 – Some 3 = Often

Score Number Behavior

1. Engages in the behavior to get attention.

2. Engages in the behavior to escape work or learning situations.

3. Engages in the behavior as a form of “self-stimulation”.

4. Engages in the behavior because he/she is in pain.

5. Engages in the behavior to get access to items such as preferred toys, food, or beverages.

6. Engages in the behavior because he/she likes to be reprimanded.

7. Engages in the behavior when asked to do something (get dressed, brush teeth, work, etc.

8. Engages in the behavior even if he/she thinks no one is in the room.

9. Engages in the behavior more frequently when he/she is ill.

10. Engages in the behavior when you take something away from him/her.

11. Engages in the behavior to draw attention to himself/herself.

12. Engages in the behavior when he/she does not want to do something.

13. Engages in the behavior because there is nothing else to do.

14. Engages in the behavior when there is something bothering him/her physically.

15. Engages in the behavior when you have something that he/she wants.

16. Engages in the behavior to try to get a reaction from you.

17. Engages in the behavior to try to get people to leave him/her alone.

18. Engages in the behavior in a highly repetitive manner, ignoring his/her surroundings.

19. Engages in the behavior because he/she is physically uncomfortable.

20. Engages in the behavior when a peer has something that he/she wants.

21. Does he/she seem to be saying, “come see me” or “look at me” when engaging in the behavior?

22. Does he/she seem to be saying, “leave me alone” or “stop asking me to do this” when engagingin the behavior?

23. Does he/she seem to enjoy the behavior, even if no one is around?

24. Does the behavior seem to indicate to you that he/she is not feeling well?

25. Does he/she seem to be saying, “give me that (toy, food, item)” when engaging in the behavior?

Attention Escape Non-social Physical Tangible

1. Attention 2. Escape 3. Self-stim 4. In pain 5. Access to items

6. Reprimand 7. Do something 8. Thinks alone 9. When ill 10. Takes away

11. Draws 12. Not do 13. Nothing to do 14. Physical problem

15. You have

16. Reaction 17. Alone 18. Repetitive 19. Uncomfortable 20. Peer has

21. “Come see” 22. “Leave alone” 23. Enjoy by self 24. Not feeling well 25. “Give me that”

Total Total Total Total Total

SENSORY DISCRIMINATION DISORDERS P. 16

© Copyright 2016 by John Pagano, Ph.D., OTR/L

1. Sensory Discrimination Disorders-difficulty distinguishing, interpreting, and organizing sensory information for functional use, contributing to disorganization and school difficulties. Sensory Discrimination Disorders can be for tactile, proprioceptive, vestibular and interoception sensory input e.g., hunger (Miller & Collins, 2012; Miller et al., 2007; Watling et al., 2011)

Tx-Light touch, deep pressure touch, Awareness of front-back, top-bottom of body through movement, obstacle courses, touch. Core input.

SENSORY DISCRIMINATION DISORDERS P. 16

© Copyright 2016 by John Pagano, Ph.D., OTR/L

1. Sensory Discrimination Disorders-difficulty distinguishing, interpreting, and organizing sensory information for functional use, contributing to disorganization and school difficulties. Sensory Discrimination Disorders can be for tactile, proprioceptive, vestibular and interoception sensory input e.g., hunger (Miller & Collins, 2012; Miller et al., 2007; Watling et al., 2011)

Tx-Light touch, deep pressure touch, Awareness of front-back, top-bottom of body through movement, obstacle courses, touch. Core input.

BODY SCHEME-Sensory Discrimination Disorder

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3.  Sensory Modulation Disorders-Difficulty regulating sensory registration to respond to take in functionally important environmental information and screen out functionally irrelevant input. 2-5 year olds with PDD had significantly greater hyper-reactivity, hypo-reactivity, and self-regulation difficulties (Ben-Sasson et al., 2007; Silva & Schalock, 2011). Assessed by Sensory Processing Measure: Preschool (2-5 yrs.), Home or Classroom (5-12 years) or Sensory Profile.

a. Sensory Overresponsivity- Sensory Sensitive/Hyper-reactivity) react more to sensory. More than half of youth with Autism Spectrum Disorders showed auditory and tactile overresponsivity related to decreased amygdala & sensory cortex habituation(Green et al., 2015)b. Sensory Underresponsivity- (Low Registration/Hypo-reactivity) do not notice sensory input, habituate quicklyc. Sensory Seeking- actively seek out sensory inputd. Sensory Avoiding- actively avoid sensory input(Watling et al., 2011; Schaaf & Mailloux, 2015)

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Therapist & Teacher Joint Roles in Behavior Goals P. 24 © copyright 2017 by John Pagano, Ph.D., OTR/L

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OT, PT, SLP, SW, SC are SISP Specialized Instructional Support Personnel, under the new ESSA (Every Student Succeeds Act) (2015). SISP expanded role in addressing the needs of at risk students, which may include school-based mental health, specialized instructional support, parent engagement, and school climate programs IEP GOALS: Increase attention average attention span for classroom learning tasks to five consecutive minutes. Average seated attention to classroom learning tasks of fifteen minutes. Increase use of safe hands by demonstrating less than 2 incidences of hitting others daily.•  Increase frustration tolerance by waiting for four minutes

for individual teacher attention without yelling. www.nasisp.org/ESEA.html www.DrKathySeifert.com

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Individual Therapy in school setting

Targeted Small Group Tx

School/Class

WHERE should school therapists TREAT?

Consistent Interventions to Improve Learning Behavior

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Color pdf on My Blog Post Rainbow Goal

FAB TURTLE TECHNIQUE Copyright © 2017 by John Pagano, Ph.D., OTR/L

1.  NOTICE Environmental & Body Triggers

STOP!!!! 2. GO TO THE SENSORY CALMING AREA 3. DO YOUR INDIVIDUAL COPING STRATEGY 4. WHEN NOT AGGRESSIVE, LEAVE THE SENSORY CALMING AREA 5.  LATER, PROBLEM SOLVE WITH HELP

(Domitrovich et al., 2013)

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FAB Pressure Touch Research P. 35 © Copyright 2016 by John Pagano, Ph.D., OTR/L

•  Pressure touch and weight bearing increase vagal activity and calming through stimulating pressure receptors (Field, 2010), while resistance exercises enhanced proprioception and motor planning skills (Kaufman & Schilling, 2007)

•  Preschoolers with ASD (Autism Spectrum Disorder) given sensory massage showed improved behavior and language regardless if initially hyper-responsive, hypo-responsive, or both sensory modulation challenges (Silva et al., 2011; Silva et al., 2012)

•  Parent massage improved parent-child relationship and child body awarenesss, social and communication skills in kids with severe developmental disabilities (Henoch et al., 2010).

•  Preschoolers with Mild ASD symptoms showed significantly greater improvement with parent’s giving them sensory massage, while those with severe ASD symptoms showed significant improvement given therapist and parent massage (Silva, Schlock & Gabrielsson, 2011)

•  Children with PDD given massage in addition to sensory processing intervention showed significantly greater behavioral improvement in addition to the benefits from Sensory Processing Intervention (Piravej et al., 2009)

Environmental Adaptations P. 37B

© Copyright 2017 by John Pagano, Ph.D., OTR/L

• SBIs are individualized environmental & sensory strategies to improve behavior by addressing sensory modulation and sensory discrimination challenges (Watling et al., 2011)

• SBIs are a component of evidence-based PBIS, Floortime for ASD (Hess, 2013), Collaborative Problem Solving for ODD (Pollastri et al., 2013), & SMART approach for PTSD (Warner et al., 2014)

• Learning and behavior are improved in ASD & Sensory Sensitivity who have decreased habituation by reducing visual, auditory, tactile & combined distractions through sit separate-desks further distance apart (Green et al., 2015); noise canceling headphones, thicker walls, quieter class; study carol reducing visual distractions, & slowing teacher pace as needed (Ashburner et al., 2008; Kinnealey et al., 2012)

• Attention and learning can be further improved by an individualized increase of the sensory modalities and salience of teaching cues through simultaneously hearing and hearing instructions, adding highlighting color to key information, AV microphone, fidgets, adding movement to learning activities (Zentall et al., 2013; Murray et al., 2009)

SBI (Sensory-Based Interventions) P. 37C© Copyright 2018 by John Pagano, Ph.D., OTR/L

• OT directed sensory-motor activities done by parents 30 min. daily sensory significantly improved cognition in preschoolers (Woo et al., 2015) and 1-18 yr. olds with ASD & DD (Arnoff et al., 2016)

• Using Trigger & Coping Forms to direct coping strategies significantl reduced restraint & seclusion in adult psychiatric patients (Lee et al., 2010)

• Energy level modulation teaching resulted in significantly improved self-control and neurological changes (Soh et al., 2015)

SENSORY CORTEX high road

AMYGDALA SENSORY THALAMUS

EMOTIONAL STIMULUS

EMOTIONAL RESPONSE

(LeDoux, 2014)

low road rage

© copyright 2009 by John Pagano, OTR/L, Ph.D.

FAST

SLOW REVIEW

Hear Screaming

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•  Sensory input is reinforcement-Kids with ASD put round puzzles in significantly more often when this behavior was followed by a preferred deep pressure mat sandwich (McGinnis et al., 2013)

•  Sensory input improves behavior when given to more appropriately replace non-social, (automatic, sensory) reinforcement (Murray et al., 2009)

•  Sensory integration worsens behavior if it reinforces inappropriate or escape behavior, by doing QABF (Lydon et al., 2017), Sensory Profile and a preference assessment SI improves behavior (McCall et al., 2016)

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Evidence-Based Class Behavior Strategies Integrating Special Needs Adaptations

© Copyright 2015 by John Pagano, Ph.D., OTR/L

♣ A structured classroom environment with maximal open space, dividers, and minimal distractions. Cut out foot prints, stop signs, and masking tape can help students remember physical boundaries. Study carols and optimally stable sitting (symmetrical,

neutral pelvis against seat back, ninety degree angle of thighs, calves, and supported feet) can promote attention.Children with good balance but difficulty remaining seated can benefit from Theraband tied on the legs or arms of their chair, disk-o-sit cushions therapyball seats, or standing.

♣ Maximizing students opportunities to respond in class with small erasable boards they hold up to answer questions, computer assignments, and peer tutoring. ♣ Teach, review, and post a few major classroom procedures and expectations. Strategically place visual schedules, social stories, choices, self-control reminders; prepare before transitions; directions to choose 1 activity for a set period before cleaning up and choosing another task; and a designated sensory quiet area in the class room can promote direction following. ♣ Teach feelings and social skills using positive behavioral support strategies. Basic positive behavioral support strategies (Turtle technique, Character comics; Play plan and review; Stretching exercises, Favorites toss, Focus on feet, Tense & relax muscles; Freeze dance) can be co- led with school related services mental health, occupational, speech-language and physical therapists. For challenging groups it is especially helpful to use co-leaders, one leads the group while the other supports students with direction

following. ♣ Sticker chart system rewarding specific desired behavior. Differential reinforcement can reward students for avoiding inappropriate, self-injurious, or aggressive behavior. Children who work with multiple staff can construct and use a Coping card- a

laminated index card listing their behavior goal, reinforcement plan, and pictures of their preferred character and coping strategies. ♣ Group reinforcement opportunities for the class to earn special privileges through appropriate behavior. Additional positive behavioral support activities, mindfulness games, exercise, movement, and music breaks (e.g., Giant steps, Simon says, Mindful clock, Lean on me song & dance, Hot cross buns activity, Pushups) can be earned by the class for safe behaviors during break activities and returning to class work immediately after breaks.

Reference: 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), 351-3.

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References

© Copyright 2017 by John Pagano, Ph.D., OTR/L • Henoch, I., Bjorkdahl, A., Darfeldt, K., Berglind, N., Uvnas, K. &

Moller, A. (2010). Soft skin massage for children with severe developmental disabilities: Caregivers' experiences. Scandanavian Journal of Disability Research, 12(4), 221-232.

• Hess, R. S., Pearrow, M., Hazel, C.E., Sander, J. B., & Wille, A. M. (2017). Enhancing the behavioral and mental health services within school-based contexts. Journal of Applied School Psychology, 33(3), 214-232.

• Lee S, Cox A, Whitecross F, et al. Sensory assessment and therapy to help reduce seclusion use with service users needing psychiatric intensive care. Journal of Psychiatric Intensive Care, 6, 1–8.