Miriam Manela OTR/L Pediatric Occupational Therapist

transcript

M A N E L A 2 0 1 3 1

Miriam Manela OTR/LPediatric Occupational Therapist

M A N E L A 2 0 1 3

IS IT BEHAV

IORAL?

M A N E L A 2 0 1 3

UESTIO

H E BE H AV I O

R WI L

L F U L ?

L A N N I G A N & M A N E L A 2 0 1 3

Occupational Therapy in Mental Health• Participation in Meaningful Roles and Activities• Satisfaction and a Sense of purpose and Success• A way to Develop Self-Control• A Positive Self-Image• Enhance Emotional Well-Being • Promotion of Social Competence • Healthy Parent-Child & Teacher-Student RelationshipSocial Competence • Having the social, emotional, and cognitive skills to be able

to participate in all the different relationships in a person’s everyday life.

L A N N I G A N & M A N E L A 2 0 1 3

WHY ADDRESS CHILDHOOD MENTAL, EMOTIONAL AND BEHAVIORAL PROBLEMS? • Affect the way young people think, feel

and behave• Interferes with success in daily life• Stressful for the child and family• Unhappy, angry, or fearful children

struggle to meet the expectations of their roles and activities

• Diminished confidence.

L A N N I G A N & M A N E L A 2 0 1 3

WHY ADDRESS CHILDHOOD MENTAL, EMOTIONAL AND BEHAVIORAL PROBLEMS?

(CONT.)• Limited or Maladaptive Social Participation• Lack of Motivation in the Classroom and in

other Occupations• Inability to Develop a Healthy Sense of Self• Stressful Family Dynamics• Mental Health Problems (Substance Abuse and Mental Health Services Administration (SAMHSA), 2003a)

L A N N I G A N & M A N E L A 2 0 1 3

ROLE OF OT IN TREATMENT OF CHILDHOOD MENTAL HEALTH

DISORDERS• Identify factors that result in poor ability• Analyze and break down tasks • Provide the child with a sense of mastery • Enable the child to develop a healthy

identity, despite his or her emotional disorder

M A N E L A 2 0 1 3

WHEN CHILDREN MISBEHAVE, WHAT FEELINGS DOES IT CONJURE UP IN US AS THERAPISTS,

TEACHERS AND PARENTS?

M A N E L A 2 0 1 3

WHEN WE TREAT BEHAVIOR CHALLENGES WE ARE TREATING COGNITION, EMOTION AND

SENSATION.

Cognition

Sensation Emotion

M A N E L A 2 0 1 3

ATTACHMENT THEORY

M A N E L A 2 0 1 3

WHAT IS ATTACHMENT CONNECTION?

• A pattern of interaction in a specific relationship.• Develops during primary connection with caregiver-grows the brain.

M A N E L A 2 0 1 3

ATTACHMENT IS ABOUT DANGER AND SURVIVAL

• Behavioral patterns are survival strategies used by the child to get needs met

• Life and Death

• Safety

M A N E L A 2 0 1 3

GENETICS AND EXPERIENCE

Our genetic inheritance directs the overall brain organization, while experience influences how and when genes become expressed.

M A N E L A 2 0 1 3

ATTACHMENT STYLE FORMS WITHIN THE FIRST 12 MONTHS.

HOWEVER, IT CAN BE "UPDATED" WITH NEW EXPERIENCES.

M A N E L A 2 0 1 3

• The brain is dependent on experience.• Early experience shapes the architecture of

the child’s developing brain.

M A N E L A 2 0 1 3

RIGHT ORBITO-FRONTAL CORTEX

• Social intelligence, impulse control, attention and short-term memory• OFC chooses information to focus on• “Brakes of the Brain”

M A N E L A 2 0 1 3

GLEAMING AND BEAMING

M A N E L A 2 0 1 3

ATTACHMENT PATTERNS

• Type A: Avoidant of negative affect and predictable (Avoidant Attachment).

• Type B: Secure and Balanced

•Type C: Preoccupied with negative affect and unpredictable (Anxious Attachment).

M A N E L A 2 0 1 3

TYPE C (ANXIOUS) STRATEGIES

• Lack confidence in caregiver reliability• Related to anxiety and behavior disorders

M A N E L A 2 0 1 3

• Clingy, needy, insecure• Keeps caregiver engaged

M A N E L A 2 0 1 3

• Over-feelers• Anxious• Preoccupied with negative emotions• Unpredictable in their behavior

M A N E L A 2 0 1 3

EXAGGERATED NEGATIVE AFFECTPREOCCUPIED WITH NEGATIVE AFFECT

M A N E L A 2 0 1 3

DEVELOPMENT OF C STRATEGY

• Unpredictable Consequences

• Inconsistent Care Giving

• Caregivers’ Responses Fluctuate

• Child Preoccupied with Caregivers’ State of Mind.

M A N E L A 2 0 1 3

Attachment Anxiety/Type C -Have self regulatory deficits that develop in the prefrontal cortex (Schore, 2001). Therefore, self soothing skills need to be taught.

For those high in anxiety attachment (Type C), relationships are associated with emotional dysregulation. (Lopez & Gormley, 2002)

M A N E L A 2 0 1 3

TYPE A (AVOIDANT) STRATEGIES:AVOIDANT OF NEGATIVE AFFECT

• Rely heavily on cognition.• Predictability.• Minimize negative feelings.• Do what is expected; avoid punishment.• Disorders of inhibition and compulsion.

M A N E L A 2 0 1 3

TYPE A (AVOIDANT) STRATEGIES (CONT.):

• Avoid disorganizing stimulation from mom.• Constant parasympathetic state.• Gaze aversion and passive avoidance.• Limited capacity to experience intense emotion.• “Over-regulation disturbances.”• Too much inhibition.

M A N E L A 2 0 1 3

TYPE A (AVOIDANT) STRATEGIES (CONT.):

• Over-thinkers.

• Avoidant of negative emotions and very predictable. False positive affect.

• Don’t trust their feelings.

M A N E L A 2 0 1 3

DEVELOPMENT OF “A” STRATEGIES:

• Dismissive caregivers

• Competitive caregivers

• Learns to repress negative emotion

M A N E L A 2 0 1 3

DEVELOPMENT OF “A” STRATEGIES (CONT.):

• Child remains distressed.

• Caregiver minimizes intimate interactions.

• Emphasis upon over-activation of child’s exploration and competence.

M A N E L A 2 0 1 3

All sensory experiences are emotional experiences.

Amygdale is the sensory center and emotions center.

M A N E L A 2 0 1 3

CHALLENGES WITH REGULATION MAY RESULT IN:• In-Attention to task• Poor Impulse Control• Limited Frustration Tolerance• Poor Balance of Emotions• Sleep Disturbances• Poor Self-Calming• Intolerance of Change• Anxiety• Feeding Problems• Mood Regulation Problems

M A N E L A 2 0 1 3

Secure Attachment correlates to lowerlevels of pain severity, depression, pain catastrophizing and anxiety (Tremblay & Sullivan, 2009).

Insecure Attachment- predicts lower pain threshold, lower perceptions for both pain control and ability to lessen pain, greater stress, depression, catastrophizing, substance abuse disorders, eating disorders and impulsivity.

M A N E L A 2 0 1 3

TECHNIQUES FOR REGULATION AND SECURE ATTACHMENT

M A N E L A 2 0 1 3

TWO MODES OF REGULATION

• Co-Regulation: Use of relationships.• Auto-Regulation: Ability to self-regulate independently.

M A N E L A 2 0 1 3

REGULATING STATE CHANGES

• Where are the child and I in the window?• What are the indicators?• How do I use this information to adjust my contact to be regulating?

M A N E L A 2 0 1 3

CO-REGULATING CHILD’S STATE OF AROUSAL

• Matching vitality of affect• Match tone• Match intensity• Match prosody• Don’t match the emotion

M A N E L A 2 0 1 3

READING THE MIND IN THE EYES

The eyes hold the information of affect.

M A N E L A 2 0 1 3

MAGIC OF CONNECTION

M A N E L A 2 0 1 3

Don’t Take Behavior Personally

M A N E L A 2 0 1 3

Regulate ourselves in the presence of chaos

“Stay in place”

M A N E L A 2 0 1 3

DEVELOPING MINDFULNESS• Staying present• Attunement• Self-Regulation• Compassion• Implicit Memory and Explicit Memory• Choosing our Words• Sensing into the Body

M A N E L A 2 0 1 3

The clinician’s mindfulness and its effects on the child's dramatic involvement with

emotions.

M A N E L A 2 0 1 3

ENVIRONMENTS THAT SUPPORT ATTACHMENT

The overarching term “environment” refers to the life experiences, family patterns and relationships that support healthy functioning.

M A N E L A 2 0 1 3

Activities for Therapists to Enhance the Development of Consistent Responses• Psycho-education• Modeling• Homework• Teaching reinforcement• Small steps• Successive approximations• Track progress

• Teacher training• Practice, role play• Teacher coaching• Start small, start easy• Address needs, not wants• Experiment• Predict pitfalls

M A N E L A 2 0 1 3

Activities to Enhance the Development of Routines

A Strategy• Encourage material choices.

• Encourage progressively more interactive play time, encourage choices.

• Develop ‘verbal blueprint’ of transition expectations.

C Strategy• Offer limited material choices.

• Structure play time, limit choices, alternate active games with self-regulation activities (blanket wrapping, play dough.)

M A N E L A 2 0 1 3

Activities to Enhance Mastery of Developmental Tasks

A• Teach social skills.• Consider settings that allow the child to play alone, then in pairs, then progressively with larger groups.• Progress from structured instructional time to more free play.• Encourage the development of skills: music, sports, art, etc. Start with quiet settings and move toward more interactive social settings.

C• Model social skills. Set limits.• Keep over stimulating environments to a minimum. Begin with opportunities for parallel play. Progressively move to settings with more children.• Progress from free play to more instructional time.• Encourage the development of skills by observing what the child does well and then systematically increase their time spent on those tasks in order to master them.

M A N E L A 2 0 1 3

Activities to Enhance Child Self Development/Identity

A• Encourage exploration and making choices, e.g. involve child in planning play time.• Ask child’s opinion in decision making, ‘what would you like to put on your project?’• Explain why things are done the way they are done. Encourage questions.

C• Ask child’s opinion, but limit options, ‘would you like to do your report now or after recess?’• Explain why things are done in short sentences. Cover one issue at a time. Answer questions when they are asked. Always reduce anxiety before attempting to explain anything.• Use concrete markers: height measures, life books.

M A N E L A 2 0 1 3

Strategies

• Use Connection• Work on Relationship, not Incident• “Draw out the Tears”• Draw out the tempering element

M A N E L A 2 0 1 3

Strategies (cont.)

• Scripting desired behavior

• Change environment

• Draw connections

M A N E L A 2 0 1 3

STRATEGIES TO TEACH PARENTS AND CAREGIVERS

• Teach that the paradigm can change• Awareness of intrinsic worth• Role play• Model appropriate attachment-related

behavior• Use of self-made movie clips and stories

M A N E L A 2 0 1 3

Adaptations for C’s in the Classroom

• Educators’ responsibilities to themselves.• Offer appropriate choices to share control.• Identify owner of problem.• Set limits with “thinking words” or

enforceable statements.

M A N E L A 2 0 1 3

Adaptations for C’s in the Classroom (cont.)

• Appropriate consequences

• Safe environment

• Punishment counterproductive

M A N E L A 2 0 1 3

• Tightly structured and loving environment• Slowly decrease structure• Conditional and reverse positives

M A N E L A 2 0 1 3

• Avoid Unconditional Negatives: “You never study!”• Avoid Unconditional Positives: “You are so smart!”• Avoid Conditional Negatives: “You did not study for the test!”• Conditional “yes” more often than “no.”

M A N E L A 2 0 1 3

• Acknowledge good behavior and decisions with specific language.• Allow natural consequences

• Consequences without anger.

M A N E L A 2 0 1 3

• Avoid lectures, sarcasm and comments such as, “I hope you learned your lesson.”

• Provide consequences the first time. Do not give the child a second chance.

• Avoid behavior modification strategies.

• Use one-liners as often as possible.

M A N E L A 2 0 1 3

THINK OF A PERSON THAT PUSHES YOUR BUTTONS

• What do they do that bothers you?• What are your judgments about the

behavior?• What do you do in response to the

behavior?

L A N N I G A N & M A N E L A 2 0 1 3

OCCUPATIONAL THERAPY COLLABORATION

•OTs and OTAs collaborate with other professionals, as well as with the children and those who care for them, to provide mental health services:•Children—to help develop performance skills in a variety of roles such as student, friend, team member, and family member.

L A N N I G A N & M A N E L A 2 0 1 3

OCCUPATIONAL THERAPY COLLABORATION (CONT.)

•Parents or care providers- to provide education about the social, emotional, sensory, and cognitive difficulties that interfere with a child’s participation in play, activities of daily living, and social activities; and to help develop emotional supports, structure, and effective disciplinary systems •Educators- to develop strategies for a child to successfully complete classroom, recess, and lunchroom activities, and to interact effectively with peers and adults.

L A N N I G A N & M A N E L A 2 0 1 3

•Counselors, social workers, and psychologists—to provide insights into the interpersonal, communication, sensory processing, and cognitive remediation methods that aid emotional and social development

•Pediatricians, family doctors, and psychiatrists—to support medical intervention for persistent mental illness and to provide a psychosocial and sensory component to supplement medical intervention

L A N N I G A N & M A N E L A 2 0 1 3

•Administrators- to develop programs that promote social competence and to train staff and families to help kids learn and maintain sensory self-regulation strategies•Communities- to support participation in community leisure and sports programs; to encourage education, understanding, and early intervention for children with mental health problems; and to develop advocacy and community programs for promoting understanding of the mental health diagnosis and decreasing stigma

M A N E L A 2 0 1 3

AROUSAL STRATEGIES AND TREATMENT

When it works, it’s treatment!

When it doesn’t, it’s assessment!

M A N E L A 2 0 1 3

DOWN-REGULATING TO A JUST RIGHT STATE

M A N E L A 2 0 1 3

UP-REGULATING TO A JUST RIGHT STATE

In order to find the ‘just right state,’ some individuals need to seek and energize their bodies to sustain alertness and produce adaptive responses.

M A N E L A 2 0 1 3

Rhythm provides structure for movement telling us how to move through time and space.

Speed of the rhythm can help either up-regulate or down-regulate dependent upon what is needed

M A N E L A 2 0 1 3

TOUCH IN REGULATION WORK

•Calming and grounding.•Creates a felt sense of safety.•Can also be triggering, thus one must possess the understanding of potentially traumatic effects of touch for dysregulated people.•Having caregivers present in the room helps increase comfort. (Calming Touch)

M A N E L A 2 0 1 3

DEEP PRESSURE TOUCH

When in doubt, use deep pressure!

Deep Pressure Activities

M A N E L A 2 0 1 3

Heavy Jobs

M A N E L A 2 0 1 3

ROUGH AND TUMBLE PLAYSoothing stimulation by caregivers and the self-stimulation rhythms of the infant are quickly replaced by peer play (rough and tumble play at the preschool age, and contact sports through grade school and high school).

M A N E L A 2 0 1 3

SCHOOL AGED TACTILE

M A N E L A 2 0 1 3

CONTACT SPORTS

M A N E L A 2 0 1 3

HOKKI MOVING STOOL

LINEAR VESTIBULAR STIMULATION

M A N E L A 2 0 1 3

ORAL STRATEGIES73

M A N E L A 2 0 1 3

Therap

M A N E L A 2 0 1 3

QUESTIONS?

M A N E L A 2 0 1 3

HAVE A WONDERFUL DAY

THANK YOU!76

M A N E L A 2 0 1 3

PHONE (917) 573-5540

FAX (973) 777-7411

EMAIL MIRIAM@OTTHRIVE.COM

WEB WWW.OTTHRIVE.COM

Miriam Manela OTR/LPediatric Occupational Therapist

M A N E L A 2 0 1 3

REFERENCESAyres, A. J. (1973). Sensory integration and learning disorders. Torrance, CA: Western

Psychological Services.

Ayres, A. J. (2005). Sensory integration and the child: Twenty-fifth anniversary edition. Torrance, CA: Western Psychological Services. (Original work published 1979)

Bradshaw, J. (2005). Healing the shame that binds you (Rev. ed.). Deerfield Beach, FL: Health Communications.

Brown, B. (2010). The gifts of imperfection: Let go of who you think you're supposed to be and embrace who you are. Center City, MN: Hazelden.

Carter, A. S., Ben-Sasson, A., & Briggs-Gowan, M. J. (2011). Sensory over-responsivity, psychopathology, and family impairment in school-aged children. Journal of the American Academy of Child and Adult Psychiatry, 50(12), 1210-1219.

Eisenberg, N., Thompson Gershoff, E., Fabes, R. A., Shepard, S. A., Cumberland, A. J., Losoya, S. H., . . . Murphy, B. C. (2001). Mothers' emotional expressivity and children's behavior problems and social competence: Mediation through children's regulation. Developmental Psychology, 37(4), 475-490.

Engel-Yeger, B., & Dunn, W. (2011). The relationship between sensory processing difficulties and anxiety level of healthy adults. British Journal of Occupational Therapy, 74(5), 210-216.

Field, T. (2000). Touch therapy. London, UK: Churchill Livingstone.

M A N E L A 2 0 1 3

REFERENCESField, T. (2003). Touch. Boston, MA: Bradford Books.

Francis, D., Kaiser, D., & Deaver, S.P. (2003) Representations of attachment security in the bird’s nest drawings of clients with substance abuse disorders. Art Therapy, 20, 125-137.

Goddard, S. (2005). Reflexes, learning and behavior: A window into the child's mind: A non-invasive approach to solving learning and behavior problems (2nd ed.). Eugene, OR: Fern Ridge.

Greene, R. (2009). Lost at school: Why our kids with behavioral challenges are falling through the cracks and how we can help them. New York, NY: Scribner.

Karp, H. (2003). The happiest baby on the block: The new way to calm crying and help your newborn baby sleep longer. Bantam Books.

Kawar, M. J., & Frick, S. M. (2005). Astronaut training: A sound activated vestibular-visual protocol for moving, looking and listening. Madison, WI: Vital Links.

Lopez, F.G., & Gormley, B. (2002). Stability and change in adult attachment style over the first-year college transition: relations to self-confidence, coping, and distress patterns. Journal of Counseling Psychology, 49, 355-364.

Maurice, C. (1994). Let me hear your voice: A family's triumph over autism. New York, NY: Random House.

M A N E L A 2 0 1 3

REFERENCESMelillo, R. (2010). Disconnected kids: The groundbreaking brain balance program for children with autism, ADHD,

dyslexia, and other neurological disorders (Reprint ed.). New York, NY: Perigee Trade.

Meredith, P., Strong, J., Feeney, J.A. (2006). Adult attachment, anxiety, and pain-self efficacy as predictors of pain intensity and disability Pain, 123, 146-154.

Perry, B., & Szalavitz, M. (2007). The boy who was raised as a dog and other stories from a child psychiatrist's notebook: What traumatized children can teach us about loss, love, and healing (Reprint ed.). New York, NY: Basic Books.

Ramacciotti, A., Sorbello, M., Pazzagli, A., Vismara, L., Mancone, & Pallanti, S. (2001). Attachment processes in eating disorders. Eating and Weight Disorders, 6, 166-170.

Schaaf, R. C., Miller, L. J., Seawell, D., & O'Keefe, S. (2003). Children with disturbances in sensory processing: A pilot study examining the role of the parasympathetic nervous system. The American Journal of Occupational Therapy, 57(4), 442-449.

Schore, A.N. (2001). Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal 22, 7-66.

Tremblay I., & Sullivan, M.J. (2009). Attachment and Pain Outcomes in Adolescents: The Mediating Role of Pain Catastrophizing and Anxiety. Journal of Pain 11, 160-171.

Van Hulle, C. A., Schmidt, N. L., & Hill Goldsmith, H. (2012). Is sensory over-responsivity distinguishable from childhood behavior problems? A phenotypic and genetic analysis. Journal of Child Psychology and Psychiatry, 53(1), 64-72.

Miriam Manela OTR/L Pediatric Occupational Therapist

Documents